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HiotDgiaphic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  MS80 

(716)  872-4S03 


4^ 


•%^ 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICIVJH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


Technical  and  Bibliographic  Notaa/Notaa  tachniquas  at  bibiiographiquaa 


Tha  inttituta  has  attamptad  to  obtain  tha  baat 
original  copy  availabia  for  filming.  Faaturaa  of  this 
copy  which  may  ba  bibliographicaily  uniqua, 
which  may  altar  any  of  tha  imagas  in  tha 
raproduction,  or  which  may  significantly  changa 
tha  usual  mathod  of  filming,  ara  chackad  balow. 


n 


D 


E 


1/ 


D 
D 


D 


□ 


Colourad  covars/ 
Couvartura  da  coulaur 


|~~1    Covars  damagad/ 


Couvartura  andommagAa 


Covars  restorad  and/or  laminatad/ 
Couvartura  rastauria  at/ou  palliculia 


I      I   Covar  titia  missing/ 


La  titra  da  couvartura  manque 


I      I    Colourad  maps/ 


Cartas  giographiquas  an  coulaur 

Colourad  ink  (I. a.  othar  than  blue  or  black)/ 
Encra  da  coulaur  (i.e.  autre  que  bleue  ou  noire) 


Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  materiel/ 
Rell6  avec  d'eutres  documents 

Tight  binding  may  cause  shadows  or  distortion 
along  Interior  mergin/ 

La  reliure  serrAe  peut  causer  da  I'ombre  ou  de  la 
distortion  la  long  de  la  marge  intArleure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanches  ajoutAes 
lors  d'une  restauration  apparaissent  dans  la  texte, 
mais,  iorsque  cela  6tait  possible,  ces  pages  n'ont 
pas  Mt  film6es. 


AdditionsI  comments:/ 
Commentaires  supplAmantaires: 


L'Instltut  a  microfilm^  la  mallleur  exemplaire 
qu'il  lui  a  4t*  poasibia  da  se  procurer.  Lea  details 
da  cet  exemplaire  qui  sont  peut-Atre  uniques  du 
point  de  vue  bibllographiqua,  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  mAthoda  normale  ua  filmage 
aont  indiqute  ci-dessous. 


I — I   Coloured  pages/ 


D 


Pages  de  couleur 

Pages  damaged/ 
Pages  endommagAes 

Pages  restored  and/oi 

Pages  restauries  et/ou  pelliculAes 

Pages  discoloured,  stained  or  foxe< 
Pages  dicoiortes,  tachetAes  ou  piquAes 

Pages  detached/ 
Pages  dAtachias 

Showthrough/ 
Transparence 

Quality  of  prir 

Qualit*  InAgaia  de  I'lmpression 

Includes  supplementary  materii 
Comprend  du  material  supplAmentaire 


|~~|  Pages  damaged/ 

I — I  Pages  restored  and/or  laminated/ 

r~n  Pages  discoloured,  stained  or  foxed/ 

I    1  Pages  detached/ 

[~n  Showthrough/ 

I      I  Quality  of  print  varies/ 

I      I  Includes  supplementary  material/ 


Only  edition  available/ 
Seule  Edition  disponible 

Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  ^o 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  ont  At  A  fiimAes  k  nouveau  de  fapon  A 
obtenir  la  meilleure  image  possible. 


Varioui  pagingi. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  filmA  au  taux  de  reduction  indiquA  ci-dessous. 


10X 

14X 

18X 

22X 

26X 

30X 

y 

12X 


16X 


20X 


24X 


28X 


32X 


Ills 

du 

difiar 

jna 

laga 


rata 
> 


alura. 


J 


32X 


Tha  copy  filmad  hara  haa  baan  raproducad  thanka 
to  tha  ganaroaity  of: 

University  de  Sherbrooke 

Tha  imagaa  appaaring  hara  ara  tha  bsst  qualify 
posaibia  conaidaring  tha  condition  and  lagibility 
of  tha  original  copy  and  in  kaaping  with  tha 
filming  contract  spacificationa. 


Original  copias  in  printad  papar  covars  ara  filmad 
beginning  with  tha  front  covar  and  anding  on 
tha  last  paga  with  a  printad  or  illustratad  impras- 
sion,  or  tha  back  covar  whan  appropriata.  All 
othar  original  copia*  ara  filmad  beginning  on  tha 
first  paga  with  a  printad  or  illustratad  impres- 
sion, and  anding  on  tha  last  paga  with  a  printed 
or  illustratad  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  -^  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  ara  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


1 

2 

3 

L'exempiaira  film*  f ut  reproduit  grAce  A  la 
gAn6rosit*  de: 

Univenit<  da  Sherbrooke 

Les  images  suivantas  ont  it*  raproduites  avac  la 
plus  grand  soin,  compta  tenu  de  la  condition  at 
de  la  nattett  de  rexemplaire  film*,  et  en 
conformity  avac  les  conditions  du  contrat  de 
filmage. 

Les  exemplairas  originaux  dont  la  couverture  en 
papier  est  imprimte  sont  filmte  en  commengant 
par  la  premier  plat  et  en  terminant  soit  par  la 
darnlAre  paga  qui  comporte  une  empreinte 
d'impression  ou  d'lllustration,  soit  par  la  second 
plat,  salon  le  cas.  Tous  les  autres  exemplairas 
originaux  sont  fiimte  an  commen9ant  par  la 
premiere  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  dfirniira  page  qui  comporte  une  telle 
empreinte. 

Un  dt^s  syml.toles  suivants  tiipparattra  sur  la 
derni*k«»  iir.age  de  cheque  microfiche,  seion  le 
cas:  le  symbols  — ►  signifie  "A  SUIVRE",  le 
symbols  V  signifie  "FIN". 

Les  cartes,  planches,  tableaux,  etc.,  peuvent  Atre 
fiimAs  A  des  taux  da  reduction  diffArants. 
Lorsqua  le  document  est  trop  grand  pour  Atre 
reproduit  en  un  seul  clichA,  il  est  film*  d  partir 
de  Tangle  supArieur  gauche,  de  gauche  d  droite, 
et  de  haut  an  bas,  en  prenant  le  nombre 
d'images  ndcessaira.  Les  diagrammes  suivants 
iilustrent  la  mAthode. 


1 

2 

3 

4 

5 

6 

I'noxTisriECK. 


I 


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Vrelcs.    2. 


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(/'"'  thldiln  fii   I'iij. 


,;/..',,'.) 


«J'i 


I 


AN    AMERICAN 

TH  XT- BOOK    OF 

OBSTETRICS 

FOR    PRACTITIONHRS     AND     STUDHNTS 

BY 

James  C.  Camiron.  M.I)..  HnwAun  P.  Davis,  M.l). 
RoBi-.KT  L  Dickinson,  M.D..  Chari.hs  Warkington 
Haki.i;.  M.D.,  Jamis  H.  HrHKRiDOh.  M.D.,  Hf.nry  J. 
(lARRiGiKs,  M.D..  Barton  Cookk  Hirst,  M.D. 
Charms  Ji-wktt.  M.D..  Howard  A.  Kki.i.y.  M.D. 
Richard  C.  Norris.  M.D..  Chaincf.y  D.  Pai.mfr,  M.D. 
THi:opH!i.rs  Parvin.  M.D..  Gkorgi-:  A.  Pii-rsoi..  M.D. 
Hdwari)   Rkynoios     M.D.,    Hi-nry    Schwarz.    M.D. 

Richard  C.  Norris.  M.D..  Hditor. 

ROBKRT    1..^  i^lCKINSON.    M.D.^AlCT    HdITOR. 

117/7/  X/ulRLV  U(}(i    COLORI'.n  AM) 

KUUATA. 

V\f   :i.'i  (p.  4;{|.    Th(>  laliolliiiB  on  the  cut  of  "axis  of  liriiii  "  shouUI  lio  •'pliiii«- 

11  liriiii." 

,  Kl^'  3.'i  (p.  48).    Ill  the  legend,  for  "luultiimrai"    read    "nullipaia'." 

Fii;.  209  (i>.  3,S.")).    In  the  legend,  the  (one-eixth  natural  size)    should  be  (fetus 
JiiciJixth  natural   sizf). 

riir.  211  (|>.  3>SS).    In  the  lesond,  for  "axis  of  inlet"  read  "plane  of  inlet." 

FiS.  2(!r»  (p.  4."»(!).    Thi>  fi«uiea  A  and  H  should  lie  leverst^d  to  a«ii'c  with  the 
k'l'ud. 

J  PI.  ISMp.  IGG).  The  legend  should  read  as  follows:  1.  The  nor-^ravid  womb 
lud  the  «ame  at  eight  months,  with  varying  heights  of  the  fundus  marked  in 
pek.s.    2.    Position  of  the  chiM   and  the  utoni'<  in  a  ease  of  pendulous  abdomen. 


PHILADELPHIA  : 

W.  B.  SAUNDERS 

92s    WALNUT  STREHT 


^1^^-A.^ 


:^ 


s^. 


MDCCCXCV 


BiBLlOTwrp,  ,r 


FROXTisriKrE. 


M 


Mr^iiil  x'ciiiiii  -.Imw  ill;;  tlif  icliii  i.iii  oi  tlir  vi-ii  rii  in  ilicii'  iiui'iiml  |Mi.sitiiiiis  '  liii'Uiiisiiii), 

(/!//■  ililnilf  I'll   I'iij.  ,'.'.  ji.  !,;.] 


h 


AN    AMERICAN 

THXT-BOOK    OF 

OBSTETRICS 

FOR     PRACTITIONERS     AND     STUDENTS 

James  C.  Camiron.  M.I)..  Hdwakd  P.  Davis,  M.D. 
RoBHKT  L.  Dickinson.  M.D..  Chari.ks  Wakrington 
Hari.k.  M.D.,  Jami-s  H.  Htheridgi:,  M.D.,  Henry  J. 
(lARRiGiKs,  M.D..  Barton  Cooke  Hirst,  M.D. 
Charles  Jewett,  M.D..  Howard  A.  Kelly,  M.D. 
Richako  C.  Norris.  M.D..  Chaincey  D.  Palmer,  M.D. 
Theophilis  Parvin,  M.D.,  George  A.  Piersol.  M.D. 
Edward    Reynolds.    M.[).,    Henry    Schwarz,    M.D. 

Richard  C.^ Norris.  M.D..  Editor" 

Robert   I..'  Dickinson.  M.D.^Aia  Editor. 

11777/  Xr.ARLY  000    COLORED  AND 
//AU'.fOXIi  //JJ'STRAThhVS. 


t 


PHILADELPHIA  : 

W.  B.  SAUNDERS 

92=5   WALNUT  STREET 


MDCCC.XCV 


^S^^^-A-^ 


fy     C>:^^ 


>  \ 


t^ 


BiBLlOTWrpi  ,r 


<'<'l'Ylil(,IlT,  ls;i,'),  KY 

W.    II.    S.\  (•  N  I)  K  US. 


WrSTCOTt    t,    THOMSON 
ILtCIHOTVMCHb      HH.LAU* 


PRFSS    Of 

W     B     SAUHUIHS     PHIL«D«. 


PREFACE. 


.\l>VAXCKs  in  the  science  and  art  t)f  ohstotrica  liave 
kept  jKice  with  the  advances  wliieh  liave  characterized  all 
hr.mches  of  medicine  and  snrjjjerv.  Althoufjh  nur  stand- 
ard text-l)(M)ks  of  ol)stetrics  have  <K'casionally  l)cen  rcrlKcit, 
an  entirely  new  text-l)(M»k  containing  the  writings  of  more 
than  one  individnal  has  not  a|)]H'ared  during  the  last 
decade.  The  Amkuican  TloXT-IiooK  ov  Omstktimcs  (»wes  its  existence  to 
the  fa(^t  that  it  seemed  pnicticahle  to  prodnce  a  work  which  should  not 
only  endxHly  the  teachings  <tf  several  prominent  American  obstetricians, 
thus  reflecting  all  recent  progress  made  in  the  theory  and  practice  of 
obstetrics,  but  should  also  l)e  a  standard  teaching-work  ft>r  students  and 
a  guide  for  practiti<»ners ;  for  this  pur|M»se  the  authors  selected  are  those 
possessing  experience  as  teachers  of  (»bstetrics  in  sevend  of  the  leading 
iuedi<'al  schools  and  hospitals  of  America. 

Tiie  especial  design  in  ])repariug  this  volume  was  to  make  clear  those 
departments  of  obstetrics  that  are  at  once  so  important  and  usually  so 
(»bscure  to  the  medical  student.  Therefore  the  ol)stetric  emergencies,  the 
mechanics  of  normal  and  al)normal  labor,  and  the  various  manipidations 
recpiired  in  obstetric  surgery  are  all  described  in  great  detail,  the  text 
being  elucidated  with  mnuerous  illustrations  and  diagrams  whicii  will  mate- 
rially assist  the  student  to  grasp  the  complex  problems  of  o|R'rative  obstet- 
rics. The  diseases  of  the  fetus  and  of  the  new-born  infant  are  given  sepa- 
rate secti<»ns  of  the  volume,  this  subject  being  discussed  more  frdly  than  is 
usual  in  obstetrical  works  in  the  Kuglish  language.  An  cft'ort  has  been  made 
t(»  render  attractive  the  sections  upon  Anat(»my  and  Knd)ryology. 

While  the  various  authors  were  each  assigned  special  themes  for  discus^-' 
sion,  nevertheli'ss  an  attempt  has  been  made  so  to  correlate  the  subject- 
matter  as  to  preserve  throughout  the  text  a  logical  sccpu'iice  not  always 
found  in  composite  publications.  The  writing  of  the  subjects  assigned  to 
Or.  Charles  Waniugton  Karle  was  only  fairly  begun  when  his  untimely 
and  widely-lamented  death  (M-curred.  The  Kditors  were  gratified  to  secure 
for  the  revision  and  completion  of  Dr,  KarK''s  manuscript  one  of  his  asso- 
ciates, Dr.  M.  J.  Mcrgler.  The  table  of  C'(»ntents  indicates  the  authorship 
of  each   section — a  feature  which  doubtless  will  give  sjitisfaetion. 

One  of  the  just  claims  of  this  text-book  to  originality  is  that  an  attempt 
has  been  ma<le  to  carry  out  systematically  the  following  ])riuciplcs  in  its 
illustration  :  All  figures  to  be  drawn  to  scale;  a  uniform  scale  to  be  adopted, 
usually  (Uie-third  or  one-sixth  life  si/e  ;  in  wigittal  sections  the  same  half 
always  to  be  shown  for  case  of  comparison ;  full  labelling  to  be  made 
tliret'tly  on  the  drawing,  to  which  should  be  given  as  much  artistic  treat- 

7 


'v'*f'«(»i'»*aii.|"* 


i'iii:i\[('i:. 


iiicnt  as  would  Ih'  coiiipiitiltlc  witli  clciiriM'ss  iiixl  witli  tciicliinj;  (|iiii1itv. 
Tlic  scale  »»!'  i\\v  cuts  in  iu«»st  previous  te.\t-l)ooks,  au<l  the  clioiee  of  the 
sajfittal  section — rijrht  or  left — have  varied.  In  this  hook  the  left  half  of 
the  section  has  prefer.ihly  heen  chosen,  hecause  it  is  the  (»ne  made  familiar  to 
practitioners  l>y  the  treatment  of  patients  in  the  latero-prone  posture. 

Kach  ixirrowed  cu^raviuf;  has  been  (-redited  t<»  its  sourci'  in  all  cases 
where  it  eoidd  he  tr.iced.  When  alterations  have  not  heen  extensive  these 
cuts  are  designated,  respectively,  as  "  redrawn  from  "  or  "  lutNliticd  from  " 
the  original.  When  such  corrections  and  additions  have  heen  inadi'  as  to 
eonstitut*'  practically  a  new  drawing,  the  origin  of  the  cut  is  nirely  in«licated. 
Where  there  may  seem  to  he  strong  resemltlant'c  to  older  work,  without 
credit,  it  will  he  found  that  new  pliotogr.iphs  or  sketches  are  the  hasis  of 
the  new  illustration.  The  htM'ntwcd  cuts  have  all  lu-en  redniwu,  excepting 
those  rcpHKhiced  from  the  i»ld  copper-plates  of  Hunter  and  Smcllie — a  stand- 
ard of  artistic  excellence  set  for  us  hy  the  most  fam<»us  engravers  of  Kngland. 
France,  which  has  furnished  our  specialty  with  its  stock-cuts  for  decades, 
gives  the  "American  'I'cxt-Hook"  many  suggestions  through  the  work  of 
Faniheuf  and  \'arnier.  To  (Jermany  ohstetrics  owes  much  gratitude  for  that 
aceuriicy  in  t(»pogr:iphical  anatomy  which  had  its  rise  in  the  heautifully  pic- 
tured sections  of  Bniun,  Schroi'der,  Waldeyer,  and  Zweifel  ;  while  we  thank 
Scotland,  through  the  atlases  of  Mart,  IJarhour,  and  Wehster,  for  the  know- 
ledge of  the  structure  of  the  pelvic  Hoor. 

Some  of  the  finest  pathological  specimens  illustrated  in  this  text-hook 
were  photogniphed  at  the  Army  Medical  Museum  at  Washington,  1).  ('., 
through  the  painstaking  ccairtesy  of  Dr.  I).  S.  Lamh,  while  Dr.  Farcpdiar  Fer- 
guson gave  access  to  the  New  York  Hospital  Cahinet,  and  Professors  Piersol 
and  Hirst  each  hrought  forward  some  of  their  most  striking  preparations. 

We  are  indehted  to  the  staff  of  artists,  Messrs.  Max  Colin,  W.  A.  ('. 
Pape,  H.  ('.  Lehmann,  F.  V.  Baker,  A.  W.  Doggett,  F.  Deck,  W.  H.  Richard- 
son, and  others,  hy  whose  skill  and  years  of  patient  labor  art  ha.s  been 
placed  at  the  servi<'e  of  scientitic  illustnitiim. 

Only  through  an  iniprecedentcd  liberality  on  the  ])art  of  the  jHiblisher  of 
a  medical  text-book  has  it  been  possible  thus  to  re-illustrate  an  entire  depart- 
ment of  medicine.  To  Mr.  W.  H.  Saunders,  for  his  imremitting  courtesy, 
patience,  and  generosity,  we  tender  our  thanks.  The  Kditors  desire  to 
acknov.ledge  their  indebtedness  to  Mr.  John  Vansant  for  valuable  assist- 
ance in  coiKhicting  the  mechanical  (h'tails  (tf  the  work  and  for  the  prej)- 
aration  of  the   Index. 

The  j)laii  of  this  text-book,  the  exposition  of  only  the  latest  ideas  in 
pathology,  the  es|H'cial  care  that  directions  for  treatment  shall  be  particular 
an<l  full,  the  avoidance  of  conHicting  statements,  and  the  wealth  of  illus- 
tration, are  (jualities  which,  it  is  hoped,  will  make  this  work  an  efficient 
guide   to   those  who  study   or   who   pr.U'tise   Obstetrics. 

lilCIIAKD  C.    XOHRIS, 
liOBEUT   L.    I)I(  KINSON. 


.I.CII.Vl 


.M:i 
KDWAl 


CONTRIIUFTORS 


J.  CIIALMKUS  CAMKUOX,  M.  J) 

MMtorni.y,  .„•.  ""siMtal,    I'l.ysiaan   Am.uchcM.r  t„   ti.e  M.mlreal 

KDWAHI)  1>.  DAVIS,  M.JJ., 

IVoCsscr  .,(•  ()l,s,etri..s,  JeHe.^,.,,   M^II^H  r    I       "^    "'''"'r''''''" ''"'-^^  <''i"iiMl 

f'l.ysic.i,n,  Cl.il.l.vn-.s  l>o,.art^K..u^I„^vard  li"  pul^ 'tl  '  "^  ""'''""''  ^■'''"'"^' 

UOIJEIITL.  DICKIXSOX,  M.  1,.,  ]{         - 

'"^ "-  ^-^  •" '-'  ^-^i^o'  <u..\..e^;;;;;;i;:;!;:::;:;::;;;:;;;t--'  ^^-i-.. 

t'lIARLKK  WAUKIN(}T()X  KARLK,  M.  J).,^ 

l-ate  I'rofi'ssor  of  <  )l)stHiii's  in  Hip  fnll,.,,,.     c  i>i      •  • 

•fAMKS  If.  KTIIElili)(;i.;:viD^ 

Professor  of  (iviii.i..il..<»»r  ....  i  /»i  .      .      .  'HCAfJO,  III. 

«>l<«.st  to  S,.  Jo,.p„-s  Hospital,  Chiea^a  ^^'•'^•^■"»n  "„s,„tal ;  ronsuI,i,.j,  ,iyne- 

IIKXRYJ.  (iAURKUKS,  IVI.  I)., 

IVofessor  of  ()|,sjt.t,.i,.s  ■„  ,|„.  V„„.  v     i    t.  ^"''^^^'  ^'<>RK. 

M-^s  nosp.,a.  a„..  ,0  „..  <i,r,na„   F>ispe„s^  '    '^    '^:':J'^  ^ '>^-"'"*^'^'  «'  «t. 
HARTOX  COOK,.:  HIRST.  M.  ,>., 

I'rofessor  of  ()bsfp(ri,Hi    r'  •        •  I*"I',AI)Kl.i>itrA. 

y  "-   r.vin.Mn   Charity  and   to    iJ   Preior  2      IT:"'    ''"'"""■"'^'  <  »>>stotrieian 
""**P""I.  i-U:  '"  "^^-"'"n  K^'feat;   (Jyncc-oloffist   t..   the  Howar.l 

("HAltLEs  JKWETT,  M.  I). 

I'rofeKsor  of  ( >l,st..tr'io.  a,„I  PoHi^.r,-       r  ,  ,  ^HOOKLYN,  N.  Y. 

'"  Kings  County  Hospital,  vU:  '"""^"'""ff  <  ■.vnec-olog.st  to  Htislnvick  Hospital  and 

HOWARD  A.  KKLLY,  M  D 

*  "oceasc<l. 


10 


voNTiiiiurrons. 


RICIIAIll)  ('.  NOUIIIS,  M.  I).,  l'nii,Ain.i,nMA. 

lA'ctiiriT  (111  Cliiiicnl  ami  <  )|K'riitiv»' Olwtolric's,  I'nivprsity  of  I'ciUHylviuiia  ;  Olmti-l- 
riciaii  in  Charge  of  llic  I'rcston  Hi-ircal,  l'liila<lfl|iliia  ;  NM^itinK  <  )l)stc(ri('iaii  to  the 
l'liila)lcl|iliia  IIiM|>ital;  (  iiiir>iil(iiiK  OltNti-triciaii  anil  <  iyiu-coloKirit  to  tin-  Soii|lieast«>m 
I>is|i('nr4an-  uiiil  IIos|iital  lor  Woiiicii  and  (  liililrcn ;  <  iyiifcoloKiNt  to  llii*  MotluNliHt 
K|iisco|ial  lloHpiial;  Follow  of  tlu'  Aiiii'rinui  t iyiu'foio>;[jca!  SiH-ii-ty,  vXv. 

CHAUNt'KY  1).  1»ALMKH,  M.  I).,  'im  ixnati,  Ohio. 

I'rofi-ssor  of  Ol>sli'lri(N,  of  Mcdiral  anil  Sur^fical  I )is«'ast's  of  Wonii'ii,  and  of  Clinical 
( iyni'«'olo>?y  in  tlu-  Mi-dical  ('olU'>;«'  of  Ohio;  Olistetrician  and  ( >yni'colo>{ist  to  tin-  Cin- 
cinnati Hospital;  Con.xuliiiiK  (iynecMilogist  to  the  tiernian  I'roteHtant  ami  I'reHhyterian 
Hospitals  in  Cincinnati,  etc. 

TIIEOPIlILrS  I'AUVIN,  M.  1).,  IMiii-adkmmiia. 

rrofrnMorof  Olwti'tricM  and  of  l>i.seiiMi>M  of  Women  andChildri'ii,  Ji'tlerson  Medical  Col- 
lege ;  Kx-1'resiilent  of  the  Indiana  State  Medical  Society,  of  the  Association  of  Ameri- 
can Medical  Jonrnalists,  of  the  American  Meilical  Ass<M'iation,  of  the  American  Academy 
of  Meiliciiie,  of  the  Philadelphia  Olistetrical  SH-iety,  anil  of  the  American  ( lynecolojf ical 
Society,  etc. 


(JEORGK  A.  IMKllSOL,  M.  1)., 

1'rofes.sor  of  Anatomv  in  the  I'niversitv  of  I'emisvlvania. 


I'IIII.ADKM'IIIA. 


EDWARD  REYNOLDS,  M.  D.,  HiWTux,  Mass. 

.Assistant  in  Olwtetrics.  Harvard  I'niversity  ;  Physician  to  < )nt-Patieii.t>  in  Hoston 
I.yin>j-iii  Hospital  ;  Assistant  in  ( Jynecolojry,  liostoii  City  Hospital;  Fellow  of  the  Amer- 
ican ( iynecoloj;ical  Society,  the  Ohstetric  Society  of  lioMon,  etc. 

HENRY  SCHWARZ,  M   D.,  St.  Lot  is,  M«). 

Professor  of  ( iynecology  in  the  St.  Tenuis  Medical  Collejie  (Medical  I>eparttncnl  of 
Washington  I'niversity)  ;  Consnitint;  ( iynccolojjist  to  the  Female  Hospital  ;  (iynecologist 
to  the  Kvan^elical  liiitheran  Hospital,  etc. 


i 


i- 


* 


mwil 


CONTENTS. 


f: 


I.  THE  GENERATJVK  OKCiANS. 

I.  Amitoiny  of  the  I'c'lvis(l>ioi>i()|) "^* 

II.  Anatomy  of  the  I<Y'nmIe(;   '/erative  Organs  (Piersol)  .   .   .  ,   .  ;,^ 

III.  I'liysiolofry  of  the  Female  «.Lnerative  Organs  (Piewol)  .   .   .   .   .   .     70 

II.  PREGNANCY. 

I.  Physiology  op  Pregnancy 

1.  Development  of  the  Emhryo  and  Fetus  (Piersol) 74 

±  Physiology  of  tlu»  Fetus  (I'jersol) '       ' 

.S.  Multiple  ('onfepti(«is(I»iorsol) ',,, 

4.  (-hanger  in  th(>  .Maternal    Organisms  induced  by  Pregnancv 
(I'lersol  and  Palmer*)    .  h  ^^ly^y 

lli» 

II.  Diagnosis  op  Pregnancy 

150 

1.  Symptoms  and  Signs  of  Pregnaney  (Palmer) j.-.n 

2.  Duration  of  Pregnancy  (Palmer  and  Piersol) .   .  m 

.'J.  Prolongation  of  Pregnancy  (Palmer)  ...  ,-q* 

1  /o 

m.  Hygiene  and  Management  op  Pregnancy  (Palmer)  .  .  .   i,so 

IV.  Pathology  op  Pregnancy  . 

INa 

1.  Diseases  of  the  Several  Systems  (Davis) jg- 

2.  General  Disorders  of  Pregnancy  (Davis) ifHj 

3.  Acute  Infectioni  dur.ng  l»regnancy  (Davis) 9.'}^ 

4.  Accidents  and  SurgicalOperations  during  Pregnancy  (Davis).       ^48 

5.  Diseases  of  the  Ovum  (Etheridge) .~r., 

G.  Abortion  («"theridg(>)  .   .  "'' 

"  '      2.(9 

7.  Extra-uterine  Pregnancy  (Kelly) ^-i 

8.  Disea.ses  of  the  Fetus  in  Utero  (lOarle  and  I^Ierglerf)    .   .   .   .  .   .    295 

*  "General  ChanRes"  (,,p.  ir,3-ir,9)  contributed  by  Dr.  Palmer 
t  The  manuscripts  of  Dr.  Earle  were  revised  and  completed  by  Dr.  M.  J.  Mergler. 

11 


^■w* 


mm 


m^mm 


■mp 


tm 


12  CONTENTS. 

III.  LABOR. 

PAOB 

I.  Physiology  op  Labor 318 

1.  Phenoiuemi  of  Normal  Labor  (Dickinson) 321 

2.  Clinical  Course  of  Labor  (Di<'kinson) 383 

n.  Conduct  of  Normal  Labor 341 

L  Antisepsis  (Jewett) 341 

2.  ]\[anagenient  of  Normal  I^abor  (Jewett) 349 

Obstetrical  Examination 340 

1.  Diagnosis  of  Fetal  Presentation  and  Position 3r)0 

2.  External  Measurement  of  the  Pelvis SHS 

3.  AiK'stlu'sia 3()2 

Examination  iluring  Labor 3(5r) 

Management  of  the  First  Stage 3(57 

Management  of  the  Second  Stage 3(18 

Management  of  the  Third  Stage 37() 

in.  Mechanism  of  Labor 384 

1.  Ciassitication  of  Jiabor  (Reynolds) 3SG 

2.  The  Fetus  (Reynolds) ■^*'l 

3.  Diagnosis,  Freciuency,  and  Prognosis  of  the  Several  Varieties  of 

Labor  (Reynolds) -^'^^ 

1.  Vkktkx  Pkkskxt-.tioxs  (Reynolds) -117 

A.  Mechanism  of  the  First  Stage  of  Labor *i-3 

li.  Mechanism  of  the  Second  Stage  of  Labor    .   .       -130 

C,  Mechanism  and  Management  of  the  Third  Stage  of  Labor  .  440 
1).  Mechanism  and   Management  of   Posterior    Positions  of 

Vertex  Presentations '"*- 

2.  FAfK  PuKsKxrATioNs  (Reynolds) "l^^ 

:Mechanism  and  >ranagement "^''^ 

3.  Huow  Pkkskntation's  (Reynolds)     ■!*'<» 

INIechanisiTi  an  1  Management ■**'♦* 

4.  Pkia'K-  Pkkskntatioxs  (Reynolds) "l^O 

Mechanism  and  Management *'" 

5.  FooTT>iX(i  Pkkskntatioxs  (Reynolds) ''^^ 

]Mechanism  and  Management ^^"^ 

C.  Thaxsvkksk  Pukskntatioxs  (Reynolds) "^^^ 

INIechanism  and  Management ^'^ 

7.  Pu(H-Al'SKl)  EXTUKMITIKS  (Reynolds) 492 


PAGE 

318 

321 
333 


.  341 

.  349 

.  349 

.  3r.o 

.  3r).s 

.  3()2 

.  365 

.  30)7 

.  3(18 

.  37() 

.  384 

.  386 

.  401 
)f 

.  407 

.  417 

.  423 

.  430 

•.  440 

if 

.  442 

.  458 

.  4()0 

.  4G6 

.  400 

.  470 

.  470 

.  4S7 

.  487 

487 

,  488 

,  492 


CO^^TENTS. 


13 


IV.  Dystocia  .  .  .  page 


1.   ANOMALU>.   ,N  THK   FoKCKS  OF  LaROH  (W^v.t) 

1    DeHeient  Power  of  the  Uterine  Muscle;  Inertia  Uteri  (ili.t) 

""Peril's"  """"""^"^ 

5.  ^tage.„e,U  of  Labor  Obstructed  by  the  Conunonest  l-^orn.; 
f  Contracted  Pe,vi,s:  a  Hin.p.e  Flat,  a  Rachitic  Flat,  and 

n  fwer.erally-coMtractetl  Pelvis  (Hirst) 
«.  Obstruction  to  Labor  on  the  Part  of  the  .S<,ftMaternal  Struc-' 

tures  ,n  the  Parturient  Canal  (Hirst) 

7.  Obstruction  to  Labor  on  the  Part  of  the  Fetus  (Hirst)'   " 
2.  Dystocia  lie  to  AccinKXTH  and  Diskasks 
I.  Accidents  to  the  Umbilical  Cord  (Parvin) 
^.  dystocia  due  to  Hemorrhage  (Parvin  and  Sclnv. 
■^.  Dystocia  due  to  Diseases  of  the  Mother  ^>nrv^n^ 


493 

493 
493 
497 

498 

510 


543 


.    54() 
.    501 

•  .    .    573 

•  .    .        573 
irz*)  ....    581 

Mother  (Parvin) (jo;} 

IV.  THE  PUERPERIUM. 

I.  Physiology  op  the  Puerperium  (Jewett) 

n.  Diagnosis  op  the  Puerperal  State  (Jewett) 

m.  Management  op  the  Puerperium  (Jewett) . 

IV.  Pathology  op  the  Puerperium t'l 

I.    IXUUn.>.    TO    T„K     (JKX.TAL    OUCAXH    KOLLOWIXf;"  LaHOK     ^'^ 

(hchwarzand  Norrisf) ^^aisok 

II.    I>IH>:ASKs  or  T„K  SKX.'AL  Okgav.S ''"" 

1.  Puer|)eral  Infection  ((Jarrigues)  ...  ^'^^ 

2.  Subinvolution  (Norris)  ....       ^'^"^ 

3.  Hf'"">rrhages  in  the  Puerperium  (Norris) 

4.  Anon.alies  of  the  Nipples  and  Hrea.sts  (Norris) 

.).  I>Jseases  of  the  Nipples  (Norris)     ....  

0.  I>i«^«isesof  the  Hrea.sts  (Norris).   .....  

7.  Arrest  of  Lactation  (Norris) 

H.  Anomalies  in  the  Milk-secretion  (Norris)  .   .   .    .   .    .    "   '    '       7,;^ 

III.    Diskasrs  of  THK   NOX-HKXUAI.  OWJAX.S  ... 


649 
65() 


/34 

7;J8 

745 
747 
751 
707 


1.  F.'ver  due  to  ("auses  other  than  Puerperal  Infection  (Norris) 
-*.  Intercurrent  Diseases  (Norris)  u^orri.s)  . 

3.  Diseases  of  the  Urinary  Organs  (Norris) 

4.  I>I«t"a><es  of  the  Nervous  System  (Norris)  

IV.  Ra,.„.  ok  Si^nnKx  I)fat„  ,x  thk  Pcikupkuum  (Norris) 


778 
778 
780 
785 
790 
801 


■■pav 


mmmm 


mumm 


1 1 


I 


14  CONTENTS. 

V.  THE  NEW-BORN  INFANT. 

PAOK 

I.  Physiology  op  the  New-born  Infant  (Etheridge) 807 

n.  Pathology  op  the  New-born  Infant  (Karle) 813 

1.  Medical  and  Surgical  Diseases  Incident  to  tlie  Birth  of  the  Child 

(Karle) 8i;i 

2.  Traumatic  Injuries  of  the  New-born  (Earle) 823 

3.  Deviations   from  Some  of  ttie  Physiological  Processes  which 

characterize  the  Pearly  Life  of  the  Infant  (Earle) 826 

4.  Infectious  Diseases  of  the  New-born  (Earle)     835 

5.  Geneml  and  Unclassified  Disejises  of  the  New-born  (Earle)   .   .    .  851 

6.  Hygiene  and  Therapeutics  soon  after  Birth  (Earle) 85!) 

7.  Premature  Infants  (Etheridge) 861 

VI.  OBSTETRIC  8URGERY. 

I.  Instrumental  Operations  (Cameron) 867 

General  Requirements  and  Preparation  for  Operation,  867— Pass- 
ing the  Catheter,  808— The  Doudie,  870— Curettage,  872— The 
Tampon,  874 — Episiotomy,  877 — Premature  Induction  of 
Labor,  878— Artificial  Dilatation  of  the  Via  Uteri,  882— The 
Forceps,  884— Sympliysiotomy,*  DO") — Cesannin  Section,  917 — 
I^apro-elytrotomy,  !)2r)— Craniotomy  and  Embryotomy,  !)2(). 

n.  Manual  Operations  (Dickinson) 941 

Vkhsion— Varieties,  !>41— Methods,  942— Indications  for  the 
Operation,  942— Contra-indications  to  Version,  943— Dan- 
gei-s  of  Version,  943. 

1.  External  N'ersion 944 

2.  Bipolar  Version 94(5 

3.  Internal  Version     951 

in.  Celiotomy  for  Sepsis  in  the  Child-bearing  Period  (Hirst)  968 
Index 977 

*  "Sympliysiotomy"  (pp.  905-917)  contributed  by  Dr.  Jewett. 


PACK 

807 
813 


813 

823 

826 
835 
851 
859 
861 


867 


AN 


AMERICAN   TEXT-BOOK 


941 


944 
94() 
951 


OF 


OBSTETPvIGS 


MM 


ANATOMY   (»F  TIIK   I'KLVIS. 


I'l-AIK    1 


'I'hi'  nliitliili  lii'twccii  .lie  inl\  is  mill  llir  inlvic  (irKMiis  iiiiil  I  lie  siiifiu'r  ciC  tlic  licidy  :  v.  iirmiiniitnry  of  tlio 
-iici'iiin  ;  s,  -.ymiiliysis  iMiliis  ;  i',  I'll  in  I  lis  ol'  llir  iilcrus ;  o.  tlic  nv.-iiy  iiiiliriiciil  liy  tlif  I'lilluiiiiiu  t\il)o;  tlio  lint' 
il'  till'  I'Siills  lllllsck'  lllilii'Mti'il  :    11,  till'  Irrllllll. 


Il 


ANATOMY  OF  TIIK   I'KLVIS. 


Plate  2. 


'-<r/'-v 


a 


m-x 


\  I 

IschiaC  N.^ 

r&litroyiiy    Ifansvense    \.        //  cot- 


*S,ii?^- 


\ 


^|N, 


'■•""■"'■"■••sn|-,,..lvisMll„i,n,vu,l,,nmsv..rs.ili,u.,li ..Urs,    , 


IS.     ■_'.   Hiiiiiutcrs  of  pelvic  milU't. 





m 


AX  A]MERICAX 


TEXT-BOOK  OF  OBSTETRICS. 


I.  THE  GENERATIVE  ORGANS. 


I.  Anatomy  of  the  Pelvis. 

Four  bones — the  two  ossa  initoniitiatd.  the  sucritm,  and  the  coccyx — tuke 
part  in  the  Ibrniation  uf  the  pelvis;  each  of  these,  in  tnrn,  is  composed  of  a 
nniuher  >>t'  segments  wliieh  in  early  life  are  distinct  and  unitC'l  by  intervening 
cartilane.  The  pieces  comprising  the  innominate  bone — the  Hiuin,  the  puhh, 
and  the  hch'uuii — earliest  unite,  although  the  imi(Hi  of  the  several  portions  of 
the  acetabulum  is  not  complete  until  from  the  eighteenth  to  tiic  twentieth  year. 
The  sacral  and  the  coccygeal  segments  fuse  still  later,  tho.se  of  the  coccyx  re- 


Fiii.  1.— Ki'imiK'  pelvis  (tino-tliini  natural  size). 

niaining  movable  until  middle  life,  while  the  attachment  of  this  bone  with  the 
.sacrum  occurs  late  in  life.  Diwing  the  usual  period  of  ehildbearing,  therefore, 
the  segments  composing  the  posterior  boundary  of  the  pelvis  arc  ununited,  and, 
in  the  lower  or  coccygeal  jiart  of  the  wall,  are  capable  of  yielding  to  the  demands 
of  parturition  for  increased  antero-posterior  or  conjugate  iK'lvic  diameters. 
The  pelvis  viewed  in  its  entiretv  presents  an  inverted  truncated  cone  (Fig.  1), 
2  *  17 


II 


'I 


18 


AMJJJi/CA.y    TKXT-JiOOK    OF    OUSTKTIilCS. 


sli^^litly  coniprcssod  trinn  heforc  backward,  mIioso  base  is  dinrtt'd  upward  and 
forward,  and  whose  sniallor  end  looks  downward  and  l)ac'kward.  Tlio  sacrum 
and  the  coccvx  occupy  a  median  j)osition  beliind,  an<l  contribute  tiie  posterior 
Mall,  the  innominate  bones  expaiuling  laterally  and  meeting  in  front  to  form 
the  pubic  arch  and  symj)hysis. 

The  space  include<l  within  these  bony  walls  is  divided  into  two  ])arts  l)y  a 
plane  passing  through  the  middle  of  the  sacral  promontory  behind  and  the 
up))cr  border  of  the  symphysis  jtubis  in  front.  The  portion  of  the  l)ody- 
cavity  lying  below  this  plane  constitutes  the  true  jtrfri>< ;  the  portion  lying 
above  this  j)lane,  included  within  the  widely  expanded  iliac  bones,  the  verte- 
bral column,  and  the  abdominal  pai'ietes,  constitutes  the  falne  pc/vin  and  be- 
longs to  the  abdominal  cavity,  to  the  contents  of  which  it  affords  support  and 
protection. 

The  true  or  /csnrr  pr/ris  is  a  short  curved  canal  whose  superior  xtriilf,  or 
inlet,  is  marked  l)y  the  brim,  a  bony  ring  defined  by  the  anterior  border  of  the 
])romontory  of  the  sacrum  behind,  the  ilio-pectineal  lines  laterally,  and  the 
j)osterior  margin  of  the  pubis  in  front.  The  plane  of  the  inferior  strait,  or 
outlet,  jtasses  through  the  tij)  of  the  coccyx,  the  tubera  ischii,  and  the  lower 
border  of  the  symphysis  pubis.  In  addition  to  the  foregoing  planes  marking 
the  upper  and  lower  boundaries  of  the  true  pelvis,  two  others,  corresponding 
with  its  widest  and  most  contracted  pai'ts,  are  recognized  with  advantage. 

The  j)lane  of  (jreatest  pelric  expanxion  extends  from  the  union  between  the 
second  and  third  sacral  vertebrie  behind  to  the  middle  of  the  symphysis  pubis 
in  front,  its  lateral  boun<laries  corresponding  on  either  side  with  the  mid-jioi:it 
of  the  imier  surface  of  the  acetabulum. 

The  plane  of  least  pelcie  diameter  lies  somewhat  lower,  being  defined  In- 
lines  passing  through  the  sacro-coccygeal  articulation,  the  ischial  spines,  and 
tlie  lower  third  of  the  symphysis  pubis :  this  plane,  marking  as  it  does  the 
point  of  greatest  permanent  constricticm,  really  constitutes  the  pelvic  outlet  in 
an  obstetrical  sense  more  than  do  the  lower  and  more  vielding  confines  to 
which  the  term  is  usually  apjjjied. 

The  superior  strait,  or  inlet,  of  the  true  pelvis  is  slightly  cordiform  in 
outline,  since  the  low-arched  jiosterior  border  of  its  generally  oval  figure  is 
encroached  ujion  by  the  sacral  promontory,  the  indentation,  however,  i)eing 
much  less  in  tiie  female  than  in  the  male  pelvis. 

The  dimensions  of  the  inlet  (PI.  2.  Fig.  1)  are  represented  by  the  antero-iv)s- 
terior  or  conjugate  diameter  of  11.5  centimeters  (4^  inches),  measured  from  the 
middle  of  the  promontory  of  the  sacrum  to  the  middle  of  the  upper  l)order  of 
the  symphysis  pubis,  and  the  transverse  diameter  of  l^J)  centimeters  (o| 
inches),  determined  by  the  greatest  distance  between  the  ilio-pectineal  lines; 
since,  liowever,  the  pubic  portion  of  the  pelvic  brim  lies  slightly  in  advance  of 
the  posterior  surfiice  of  tiie  pubis,  the  available  antero-posterior  diameter,  or 
obstetric  conjnf/ftte,  is  .somewhat  less  tlian  the  anatomical  dimension,  measuring 
11  centimeters  (PI.  2.  Fig.  2).  Su])plementarv  to  these  measurements,  the  ob- 
lique diameters  of  12.75  centimeters  (5|  inches),  measured  from  the  intersection  of 


4 


1 


AXATO-VV   or    Tin:   aKSKliATIVE   ()/,'(/ A xs. 


19 


the  siuTo-iliac  articiiIatioM  witli  the  ilio-pwtiiical  lino  to  tlie  \n\\>'w  spino  of  the 
ite  side,  are  usually  iioted.     The  HR'asiirciuciits  of  tho  jilaiif  of  i/initfut 


0|)|)0S 


orin  in 
<>uro  is 


iKMUg 


To-pos- 
(iin  the 
nlor  of 
crs  (o| 
linos; 
tmoo  of 
lotor.  or 
lasuring 
Itho  ob- 
;'tion  of 


'PI 
r.r]>(i)i.sioH  incliido  an  antoro-postorior  dianiotor  of  12.7->  coiitimotors  (o^  inches) 

and  a  ti'ansvei*8e  diameter  of  12.0  eentinietors  (o  inches).  Tho  jilmtr  of  hint 
(liinenxintix  possesses  an  aiitoro-posterior  diameter  of  11  tvnt i motors  (4iJ  inches), 
as  measured  between  the  end  of  tho  sacrum  and  the  ?'ummit  of  tho  ]»ubi(! 
arch,  and  a  transverse  diameter  of  11  contimeters  (4^  inches),  taken  between 
tho  inner  siu'faoe  of  tho  ischial  l)ones  near  their  posterior  border;  the  distance 
separating  tho  spinie  ischii  is  about  10.")  centimeters  (4J-  inches). 

Tho  infrrior  xfroif,  or  anatomical  outlet,  of  the  |M'lvis,  although  loss  regular 
in  outline  than  tho  inlet,  jutssossos  a  geiuM'al  ovate  form,  the  smaller  end  of 
tho  Hgure  being  <Iirocted  anteriorly,  while  its  larger  end  is  impressed  by  the 
prominence  of  the  coccyx  ;  in  addition  to  tho  latter  point,  two  other  osseous  pro- 
jections, the  tubera  ischii,  aid  in  defining  tiie  boundaries  of  the  outlet.     Between 


Fiii.  J.— Feninlo  iiclvis,  viewed  from  liel^w,  with  liniments  (oiu'-thircl  luitiirnl  sizeV 

those  tuberosities  in  front  is  included  the  subpubic  arch,  bounded  by  the  pubic 
and  ischial  rami,  while  behind,  between  them  and  tho  sacrum,  lie  the  deep  saero- 
si'iatic  notches,  which  are  bridged  over  an<l  converted  into  foranuna  by  the 
greater  and  lesser  sacro-sciatic  ligaments  (Fig.  2). 

The  d!memio)i.s  of  the  phntc  of  the  jiclrii-  out/rf  (1*1.  2,  Fig.  2)  include  the 
antoro-postorior  diameter  of  9  continietor-i  (."U  inches),  measured  from  the  tip 
of  the  coccyx  to  tho  summit  of  the  pubic  arch,  and  tho  transverse  «liametor  of 
11  coiitimotors  (4f  inches),  measured  between  the  middle  of  tho  i.schial  tuberosi- 
ties. It  must  be  reinembored,  however,  that  while  tho  antoro-j)ostorior  diame- 
ter under  ordinary  conditions  is  only  9  centimeters  (3^  inches),  tho  mobility 
of  tho  coccyx  is  usually  such  that  this  diameter,  or  obstetric  conjugate,  is 
increased  to  11  centimeters  during  parturition  (1*1.  2,  Fig.  2). 

The  carltif  of  the  true  ])elvis,  as  ap|)ears  from  tho  foregoing,  is  an  irregular 
cylinder  of  somewhat  varying  diameter;  the  imaginary  jjc/c/c  axis  is  producal 


20 


AMi:i<'/(A.\   THXT-IiOOK  OF  oiisrt:Tiiics. 


\\ 


II 


1)V  uniting;  tlie  coiitral  points  of  the  aiitt'r(>-|M)storic»r  (liaiiu'terfi  of  tlie  superior, 
the  iiifi-rior,  and  tiie  interinediate  plaiu's  above  dt'serilMMl.  The  pelvic  cavity 
is  enclosed  Ity  the  smooth  snrfac«'s  prescnteil  i)y  the  surrounding  l)ony  parts; 
its  anterior  wall,  foruiiKl  by  the  symphysis  and  the  bodies  of  tiie  pid)ic  bones, 
is  convex  and  shorter  tliaii  the  posterior,  measuring  but  little  more  than  4 
centimeters  (about  \\  inches)  in  depth  ;  its  {wsterior  wall,  inchuling  the  con- 
cave anterior  surfaces  of  the  sacrum  and  the  coccyx,  is  much  longer,  cxtoinl- 
iiig  ll.o  centimeters  (abitut  A\  inches)  from  the  sacral  pronumtory  to  the  end 
of  tiie  coccyx.  The  lateral  walls  correspond  with  the  broad  (piadrilateral  .sur- 
faces of  the  ischial  biKlies,  and  present  an  intermediate  depth  of  9  centimeters 
(3^  inches). 

The  j)onl(lon  of  the  pelvis,  evidently,  must  vary  with  the  changes  in  the 
j)osture  of  the  body.  In  the  erect  attitude  the  plane  of  the  inlet  of  the  true 
pelvis  is  well  elevated,  forming  with  the  horizontal  an  angle  of  about  55° 
(5U°  to  G0°),  the  inclination  being  generally  somewhat  greater  in  the  female; 
the  plane  of  the  outlet  coincides  more  closely  with  the  horizontal,  subtendinj^ 
with  the  latter  an  angle  of  about  11°  (Pi.  3,  Fig.  1).  In  the  erect  position  the 
planes  of  the  perpendiculars  let  fall  from  the  anterior  superior  iliac  spines  and 
from  the  symphysis  pubis  coincide  ;  the  base  of  the  sacrum  lies  about  9  centi- 
meters (3i  inches)  above  the  upper  border  of  the  symphysis,  the  tip  of  the  coc- 
cyx at  the  same  time  being  about  2  centimeters  (-J  inch)  above  the  summit  of  the 
subpubic  arch.  The  (ixin  of  the  pcfric  inlet  is  directed  forward  and  upward, 
toward  the  umbilicus;  if  pndongetl  downward,  it  strikes  the  tip  of  the  coccyx. 
The  axis  of  the  outlet,  naturally  downward  and  a  little  backward,  will  meet 
the  promontory  if  extendtKl  upward.  The  plane  of  the  symphysis  forms  un 
angle  of  from  90°  to  100°  with  that  of  the  pelvic  brinj. 

The  importance  of  obtaining  definite  information  concerning  the  dimensions 
of  the  pelvis,  but,  at  the  same  time,  the  impossibility  of  determining  many  of 
the  foregoing  measurements  on  the  living  subject,  has  led  to  the  substitution 
of  external,  readily  accessible  measurements  which  bear  a  direct  and  constant 
relation  to  the  internal  diameters.  The  most  useful  of  these  external  meas- 
urements include — the  distance  between  the  anterior  superior  iliac  spines, 
26  centimeters;  the  distance  between  the  iliac  crests,  29  centimeters ;  the  dis- 
tance between  the  greater  trochanters,  31  centimeters  ;  the  distance  between 
the  spinous  process  of  the  last  lumbar  vertebra  and  the  upper  margin  of  the 
jiubic  sym|!liysis,  or  external  covjuf/dte,  20J  centimeters ;  the  distance  between 
the  posterior  sui)erior  spinous  ]>rocess  and  the  anterior  superior  spinous 
jM'ocess  of  the  opjiosite  iliac  bone,  (»r  the  ohlhiue  diameter,  22  centimeters; 
the  distance  between  the  ischial  tuberosities,  11  centimeters.  These  external 
diameters,  which  are  readilv  obtained  bv  means  of  direct  measurements  bv  the 
pelvimeter,  bear  sufficiently  constant  relation  to  the  internal  diameters  to  make 
them  of  much  ])ractical  importance.  As  j)ointed  out  by  Klein,  however,  the 
antero-posterior  diameter  is  subject  to  considerable  normal  variation.  The  aver- 
age thickness  of  the  bony  walls  at  the  ])oints  of  measurement  being  known,  the 
subtraction  of  this  amount  from  the  ascertained  external  diameter  evidently 


J 


k\ 


ANATOMY    ()!•    IIIK    I'Kl.N  IS. 


I'LATK  ». 


itiition 

instant 

iiieas- 

dis- 

?t\voon 

lot"  the 

jtweeii 

[)inotis 

lietcrs ; 

:tornal 

DV  the 

make 

'f,  the 

aver- 
[n,  the 
flently 


I 


I 


i 


I 


pelvis,  shiiw  iiiii  iiiiiitt 


1.   Stljjittlll    StM'tiftU    l)f  it'inilii-    |u-i  \  ijN,  >in  n^  I  im    II  nil  11  >iii  II  ji  1    jiiiii    I II  iMfi  I  nil  i  1 1  iniiii' 

stnicliircs  ciiiiiiKisiiiu'  tlic  |ii'lvic  llonr:  1,  pi'lvii'  lii^-cin,  \\  liidi  iil  wliili' line  splits: 

(■-')  mill  nliluratnr  Ciiscia  ■  li,  ii  lliiii  inMitiiiiiiil  slii'ct,  tlic  .iiinl  l'as<'iii  i^li,  ciivcriiiu  tin  um-i  i.n  :.iii  im  i- m  mi 
li'Viiliir  inii  liiMscli';  ."i,  (l,  tlic  sin>riinr  iinil  iiifcrior  liiycrs  ul' tlu'  liiilliKUliir  li;.'aiiK'lit ;  7,  .s,  lU'cp  illiil  silpiT 
liciiil  liiyi'is  (if  till'  puriiit'iil  fasciii;  'J,  skin. 


iniiiil  anil  ulistitiical  iliaiiutiTs,    i  I)in>;niin  of  the 

into  rcctu-Yi'sical  fascia 

iiforior  surliicf  of  the 


f^ 


|;f 


AXATOMV    OF    TIIK    GENERATIVE    ORGANS. 


21 


supplies  (lata  comparable  with  the  recognized  average  of  the  internal  diniensionii 
Thus,  the  distance  between  the  lower  edge  of  the  spinous  process  of  tho  last 
hinihar  vertebra  and  the  middle  of  the  upper  margin  of  the  syni})hysis,  meas- 
twed  by  the  pelvimeter,  is  20  centimeters;  from  this  are  deducted  the  9  centi- 
meters which  represent  the  c()nd)ined  average  thickness  of  the  vertebral  bixly 
and  the  pubic  symphysis,  the  remaining  11  centimeters  corresponding  closely 
with  the  conjugate  of  the  superior  strait  as  determined  by  dirctt  measurement. 
The  size  of  the  female  pelvis,  although  presenting  many  individual  varia- 
tions, is  not  inifavorably  iuHuenced  by  stature,  since  short  women  often  rossess 
pelves  of  more  than  average  breadth.  The  distincftive  characteristics  of  sex 
are  acquired  after  puberty,  although,  according  to  Fehling,  indications  of  these 
peculiarities  are  present  ever,  at  biri'i.  Some  asymmetry  of  the  pelvis,  as  of 
other  parts  of  the  body,  is  usually  to  be  detected. 


Fio.  ;!.— Male  pelvis  (slifjlitly  less  tliim  uiietliinl  iinturni  size). 

The  following  table  exhibits  the  average  dimensions  of  the  ftdly  developed 
female  pelvis,  the  measurements  being  taken  from  the  dried  pelvis : 

Ceiuimeters. 
(ireatest  iHstaiKv  betwi'on  crests  of  ilia -JS 

I)ist;miv  lietweeii  :iiiterii>r  superidr  iliiic  spines -J.') 

l>i>taiii'e  between  last  Imiibar  siiiiu' ami  front  "I"  sviiiphysis  ]mi)is 'JO 

TiUK  Pi:i,vis. 

Antero-pnsterior  niaiiieter        Transverse  l>iiimeter        OMiciue  Diiuneter 
(Centinietors).  u'entiineters).  (.Centimeters). 

Plane  (if  (lelvie  inlet 11.  i:i,.")  l-J.") 

I'laiie  (if  presitest  expansion    ....  1'_>.7.')  \'1.'>0 

Plane  of  greatest  contrai-tion     ...  11.  11. 

Plane  of  iielvic  outlet l>.o    (increased  to  ll..')  em.    \\,  \\J^ 

liy  ilisphK'enieiit  of  eoeey.xi. 

The  (lifttiiu/ulfiliin;/  rlinrdcfn-isficK  of  the  femtde  pelvis  (Fig.  1)  as  C(mtraste<l 
with  the  corresponding  portion  of  tiie  male  skeleton  (Fig.  ;})  incliule  slighter 


99 


AMERICAN   TEXT-BOOK   OE   OBSTETRICS. 


'■^ 


bones  with  less  marked  imiscular  impressions;  less  height  of  the  entire  pelvis; 
greater  breadth  and  eapaeity  of  the  true  pelvis,  but,  owing  to  the  more  verti- 
eally  placed  iliac  bones,  relatively  and  absolutely  less  expansion  of  the  false 
l)elvis  than  in  the  male  (Thane).  l>oth  the  inlet  and  the  outlet  are  larger  in 
the  female,  the  outline  of  the  pelvic  brim  approaching  uu»re  nearly  the  circular 
form,  owing  to  the  slighter  ])roJection  of  the  sacral  promontory.  In  the  female 
pelvis  the  sacrum  is  broader  and  less  concave,  the  depth  of  the  symphysis  is 
less,  and  the  subpubic  arch  is  wider,  embracing  from  90°  to  100°  as  against 
70°  in  the  male. 

In  addition  to  individual  peculiarities,  the  iuHuences  of  race  markedly 
impress  the  general  form  of  the  pelvis,  particularly  tiie  relation  of  the  antero- 
posterior to  the  transverse  diameter :  the  broad,  cordiform  outline  of  the 
Caucasian  lemale  pelvis  is  replaced  by  one  nearly  circular  among  the  native 
Australians ;  among  the  Bushman  and  ^[alay  women  the  usual  ratio  between 
the  conjugate  and  transverse  diameters  becomes  so  altered  that  the  outline  of 
the  pelvis  is  an  upright  oval,  the  antero-posterior  dimension  surpassing  the 
transverse. 

Articulations  of  the  Pelvis. — The  comjionent  bones  of  the  pelvis  are 
united  with  one  another  by  four  articulations  (Fig.  4):  one  in  front,  between 


Fii:.  -4.— Wiimlo  jii'lvis  (viowoil  from  nbovo)  witli  linamoiits  (niic-tliinl  natural  size). 

the  two  pubic  bones  ;  two  behind,  between  the  iliac  bones  and  the  sacrum  ; 
and  one  between  the  sacrum  and  tiie  coccyx.  The  opposed  bony  surfaces  are 
closely  united  by  til  ro-cartilaginous  jtlates  and  external  ligamentous  bands, 
and  admit  of  very  limited  motion  ;  these  articulations,  tlieretbre,  are  usually 
classed  as  amphiarthroses  or  symphyses. 

The  pubic  articulation,  or  i^i/tnjihi/si.s  puhis  (Figs.  5,  6),  is  formed  by  the 
approximation  of  the  two  oval  articular  facets  occupying  the  mesial  borders  of 
the  pubic  bones,  which  are  connected  by  the  interj)osed  fibrous  disk  and  the  sur- 


t: 


ANATOMY    OF    THE    GEXERATIVE    ORGANS. 


23 


Ituiu  ; 
Ls  aro 

■iiially 

\y  the 
?rs  of 
sur- 


rounding external  ligaments.  The  slightly  convex  surfaces  are  covered  with 
i)lat('s  of  cartilage  which  fill  up  the  inequalities  of  the  bones,  the  opposed  sur- 
faces being  held  together  by  the  intervening  mass  of  fibrous  tissue  and  fibro-car- 


V*: 


'irptnr 


Fig.  ">.— Section  across  symphysis  pubis,  sliowing  interpubic  disli. 

tilage  constituting  the  interpubic  disk  (Fig.  o).  This  layer,  which  projects  ante- 
riorly and  posteriorly  beyond  the  adjacent  bony  margins,  is  thickest  in  front ;  the 
tlcrti'iency  of  the  intermediate  tissue  above  and  behind  sometimes  results  in  the 
formation  of  an  interspace  or  fissure.  The  fis- 
sure within  the  interpubic  disk  extends  usually 
about  half  the  length  of  the  cartilage,  and  is 
produced  during  life  by  the  absorption  of  the 
tlljid-cartilage :  it  aj)pears  after  the  seventh 
ycai',  and  is  of  larger  size  and  more  constant 
ill  tlie  female.  While  undue  tension  exerted 
upon  the  joint  during  labor  may  j>redispose  to 
tlic  production  of  this  fissure,  the  latter  is 
not  a  sequence  necessarily  of  pregnancy,  as  is 
siidwn  by  its  existence  in  pelves  of  males  and 
of  virgins.  A  slight  separation  of  the  pubic 
syiiipliysis  during  pregnancy  is  regarded  by 
iiKiiiy  as  probable;  this  tendency,  however,  is  reduced  to  a  minimum  through 
tlie  bracing  effected  by  the  decussating  fibres  i>f  the  oblique  muscles.  Tiie 
external  ligaments  which  additionally  strengthen  this  articulation  are  the  ante- 
ridi',  the  posterior,  the  superior,  and  the  inferior. 

The  (interior  pnlm  lir/ament,  of  considerable  thickness,  consists  of  several 
strata  of  interlacing  fibres,  the  deepest  of  which  passes  directly  across  between 
tlic  l)oiies  in  front  of  the  interpubic  di-k,  with  which  they  are  blended  ;  the 
superficial  layers  include  oblicpie  interlacing  fil'.res  continued  from  the  tendons 
(pf  tlie  external  oblifpie  and  the  recti  muscles,  and  of  the  more  superficial 
adductors  of  the  thigh. 

The  jtnxterior  piihic  lif/amext  consists  of  a  few  sparingly  distributed  fibres 
which  unite  the  bones  behind,  and  it  is  little  more  than  the  somewhat  thick- 
ened ])criosteum. 

The  Kiiprrior  pxhic  lif/atnent  is  represetited  by  a  meagre  bundle  of  fibres 
occupying  the  upper  surface  of  the  articulation. 


Fiii.  (■).— Frontiil  soctidii  tlirnuch 
syiui>liysis  pubis,  oxpusiiiK  interpubic 
cleft  (Fnrabcuf). 


^T* 


24 


AMERWAN   TEXT-BOOK   OE    OBSTETRICS. 


The  inferior  or  subpubic  lif/avienf,  on  the  contrary,  is  thick  and  triangular 
in  form,  and  it  contrihtites  the  smooth  boundary  to  the  summit  of  the  sub- 
pubic arch.     Througliout  the  middle  of  its  span  the  ligament  is  closeh'  united 


Sufifrior 
peh'ic  h[^at'tent. 


Inferior 
pubic  ligiinit'}it. 


Fig.  7.— Anterior  view  of  synipliysla  iml)is. 


i 


1(5 


\i\  1 


with  the  interpubic  disk,  being  attached  at  the  sides  and  below  to  the  descend- 
ing pubic  rami  (Fig.  7). 

The  sdcro-iliac  articukdion  (Fig.  8)  lies  between  the  lateral  surfaces  of  the 
sacrum  and  the  ilium ;  the  rough  articular  surfaces  of  both  bones  are  covered 

by  thin  plates  of  cartilage,  that  on  the 
sacrum  being  thickest.  With  the  ad- 
vance of  age  these  cartilages  often  be- 
come roughened  and  partially  separated 
by  spaces  containing  a  glairy  fluid. 
Not  infrequently  the  apposed  bones 
are  united  by  intervening  bundles  of 
fibrous  tissue,  these  bands  constituting 
the  intei'osseous  ligament.  The  prin- 
cipal bonds  of  union  are  the  anterior 
and  posterior  ligaments. 

Tiie  anterior  sdcroiliae  lir/ament 
comprises  :i  nundxT  of  thin  irregular 
fibrous  bundles  stretching  between  the 
front  of  the  sacrum  and  the  adjacent 
border  of  the  iliac  bone.  Associated  with  the  upper  and  lower  margins  of 
this  ligament  are  thickened  bimdles  of  fibrous  tissue  that  spread  over  the 
ilium  respectively  as  far  as  the  ilio-peetineal  line  and  the  posterior  iliac  spine; 


Fig.  8.— Section  tlirouuli  tlic  Kit  Micro-iliiic  iirtiiu 
lution  il.usi'liku). 


A.YATOJrV   OF   THE    GEXERATIVE   ORGANS. 


25 


4 


these  bands  constitute  tlie  supe)'ior  and  the  inferior  sacro-iliac  ligaments  sonio- 
tiraes  described. 

The  posterior  sacro-iliac  lir/ament,  which  is  of  jrreat  strength,  extends  be- 
tween the  back  of  the  sacrum  and  the  posterior  border  of  the  iliac  crest.  The 
general  direction  of  the  fibres  is  downward  and  inward  from  the  ilium  ;  some 
of  the  fasciculi,  however,  pass  almost  horizontally,  while  a  special  bundle 
extends  nearly  vertically  from  the  posterior  superior  iliac  spine  to  the  third 
and  foiirth  sacral  segments,  and  forms  the  obli(iHe  sacro-iliac  li(/ament. 

The  sacro-coccygeal  articulation  includes  the  oval  fawt  at  the  end  of  the 
sacrum  and  the  base  of  the  coccyx,  and  it  corresjiontls  in  its  ligamentous  struct- 
ures with  the  intervertebral  joints,  to  which  series  it  belongs.  The  bones  are 
united  by  the  anterior,  the  posterior,  and  the  lateral  bands  as  well  as  by  the 
interposed  intervertebral  disk. 

The  anterior  sacro-coccygeal  ligament  is  the  continuation  of  the  anterior 
common  ligament  of  the  vertebrae,  and  it  consists  of  a  few  irregular  bands  of 
fibrous  tissue  that  pass  from  the  anterior  surface  of  the  sacrum  to  that  of  the 
coccvx  to  blend  with  the  periosteum. 

The  liosterior  sacro-coccygeal  ligament,  stronger  than  the  preceding,  is  the 
prolongation  of  the  posterior  common  ligament,  and  it  descends  from  its  attach- 
ment around  the  lower  orifice  of  the  sacral  canal,  the  lower  hind  wall  of  which 
it  lartjoly  forms,  to  the  posterior  surface  of  the  coccyx. 

Additional  posterior  bands  descend  from  the  sacrum  to  the  coccyx  as  con- 
tinuations of  the  interspinous  ligaments  intimately  blended  with  the  aponeuro- 
sis of  the  erector  spinse ;  the  lateral  expansions  which  connect  the  corinia  of 


the 
,ered 
the 
ad- 
?n  be- 
rated 
luid. 
)ones 
of 
:uting 
pr  in- 
terior 

amcni 
>gular 
Ml  the 
jacent 
us  of 
■r  the 
pine ; 


'xM 

ii 

'im 

M 

fe 

1 

w 

'.^ 

iH 

-{,''■ 

M 

'■Jj 

Fiii.  9,— Variation  in  sacral  curves  (Hirsf) :  P,  jironiontory  of  sacrum  ;  C.  coccyx. 

the  last  sncral  segment  to  the  coccygeal  cornua  constitute  the  supracornual  or 
lateral  liga,nents.  The  intertransverse  ligament  is  reprcsentod  by  fibrous  bands 
wliicli  pass  tVom  the  lower  lateral  angle  of  the  sacrum  to  the  transverse  pro- 
cess of  the  firsi  piece  of  the  coccyx. 

The  Intervertebral  dixk  is  a  rudimentary  member  of  the  series  of  fibro-car- 
tilagiiious  plates  interposed  between  the  vertebrie  ;  a  distinct  cavity  sometimes 
exists  within  this  disk  (Cruveilhier),  especially  mIicu  tiie  coccyx  is  freely 
movable;  this  mobility  seems  increased  during  pregnancy. 


2G 


AMEIilCAy    TEXT-BOOK    OF    OBSTETRICS. 


The  coccviroai  sct;iiioiits  lire  lield  togetlier  In-  the  extensions  of  the  anterior 
ami  posterior  li^iunciits  and  In*  the  rndinicntary  intervertebral  disks  which  lie 
between.  The  indivi»hial  pieces  remain  distinct  in  the  t'eniale  dnring  early 
adolescence,  bnt  become  nnitcd  bv  tiie  close  of  the  childbearinj;  period  ;  in 
later  lite  ossification  l)et\vecn  tiic  sacnnn  and  the  coccyx  sometimes  takes 
place. 

Closely  associated  with  tiie  boundary  of  the  true  pelvis  are  the  important 
sacro-sciatic  ligaments. 

The  gmd  or  pontcrior  sacro-f<ciatic  lit/amoif  extends  from  the  posterior 
inferior  spine  of  the  ilium,  the  lower  tubercles  of  the  sacru?n,  and  the  inferior 
portion  of  the  lateral  border  of  the  sacrum  and  the  coccyx  ,'o  the  inner  mar- 
gin of  the  ischial  tuberosity,  whence  tiie  fibres  are  continued  along  the  inner 
edge  of  the  adjoining  ramus  as  the  falciform  process,  the  concave  border  of 
which  aftords  attaelimeiit   for  the  obturator  fascia. 

The  IcKscr  or  anterior  f<(a'ro-sci<ttic  h'f/ament,  triangular  in  form,  passes  from 
its  wide  attaciiment  on  the  lateral  margin  of  the  sacrum  and  the  coccyx  to  the 
spine  of  the  ischium,  thus  dividing  the  large  space  enclosed  by  the  great  sacro- 
sciatic  ligament  into  an  upper  larger  oj)ening,  the  great  sacro-sciatic  foramen, 
and  a  lower  smaller  aperture,  tiie  lesser  sacro-sciatic  tbramen.  The  anterior 
boundaries  of  these  foramina  are  respectively  the  greater  and  lesser  sacro- 
sciatic  notches  of  the  innominate  bone. 

Muscles  of  the  True  Pelvis. — The  osseous  and  ligamentous  framework 
of  the  true  pelvis  is  supplcmeiiti'd  by  muscles  and  fascia  which  complete  its 
boundaries  as  well  as  somewhat  lessen  its  cajiacity,  these  structures,  iiowever, 
being  so  located  that  they  but  slightly  diminish  the  size  of  the  parturient 
canal.  In  order  to  facilitate  a  study  of  the  faseiie,  a  consideration  of  the 
muscles  related  to  the  cavity  and  floor  of  the  true  ptlvis  first  claims  attention. 
These  muscles,  on  each  side,  are  four  in  number — the  obturator  internus,  the 
pyriformis,  the  levator  ani,  and  the  coccygeus. 

The  obturator  intrrntiK  muscle  (1*1.  3,  Fig.  2)  comes  in  close  relation  with  the 
jielvic  cavity  throiigluiut  a  considerable  part  of  its  extended  origin,  which  in- 
cludes almost  the  entire  part  of  the  |)elvis  contributed  liy  the  innominate  bone. 
The  muscle  arises  from  the  inner  surface  of  the  obturator  membrane,  except  at 
its  lower  part,  the  fibrous  arch  completing  the  canal  for  the  obturator  vessels  and 
nerve,  and  the  inner  surtace  of  the  innominate  ixme  anteriorly  and  internally 
between  the  obturator  foramen  and  the  margin  of  the  piibie  arcli,  and  poste- 
riorly and  externally  from  the  foramen  as  far  as  the  ilio-pectineal  line  above 
and  the  sacro-sciatic  notch  behind.  The  external  surface  of  the  muscle  rests 
upon  the  hip-bone  and  the  obturator  memiirane;  its  inner  or  jiel vie  aspect  is 
covered  by  the  obturator  fascia,  the  continuation  of  the  |)elvic,  and  comes  in 
relation  with  the  internal  piidie  vessels  and  aceompanying  nerve. 

The  piirljitrinix  muscle  arises  by  digitations  from  the  second,  third,  and 
fourth  sacral  segments  between  and  external  to  the  anterior  sacral  foramina, 
from  the  ilium  below  the  interior  posterior  spine,  and  from  the  great  sacro- 
sciatic  ligament.     In   its  course  to  the  great  sacro-sciatic  foramen,  through 


i 


ANATO.)fr   OF   THE    GEXEItATIVE    ORGANS. 


27 


which  tlie  niiisclo  oscapcs  to  seek  iiif«ortion  into  the  lemur,  its  fan-shaped  mass 
aids  in  forniing  the  posterior  and  outer  wall  of  the  pelvie  cavity. 

The  remaining  two  uuisdes,  the  levator  ani  and  the  coecygeu.s,  are  of 
especial  interest,  since  they  largely  sui>plement  the  fascia*  in  the  formation  of 
the  septum,  or  pdrlc  <li(ij)lu-<if/ii},  which  stretches  across  the  bony  canal  and 
materially  aids  in  supporting  the  vagina  and  the  rectum  and  in  the  constitution 
of  the  floor  of  the  pelvis. 

The  /cvdhr  ani  (Figs.  10,  11),  the  most  important  muscle  of  the  pelvic  dia- 
phragm, in  general,  with  its  fellow  of  the  opposite  side,  presents  the  form  of  a 
horseshoe,  open  in  front,  rather  than  that  of  a  funnel,  as  very  commonly  stated. 
The  true  relations  of  this  nuiscle  have  especially  been  emphasized  by  Luschka 


ten 


th  the 
cli  in- 

bone. 
cei)t  at 

Is  and 
nally 

poste- 

above 
le  rests 
?pect  is 
jmes  in 

rd,  and 
ramina, 
t  sacro- 
hrough 


Fiii.  111.— Femnle  polvis,  shewing  tlio  foriii  iiml  attac'linu'iits  of  the  leviituros  ani  muscles  (Dickinson). 

ami  liy  Dickinson,  whose  descriptions  are  here  utilized.  These  two  nuiscles  con- 
stitute a  sling  attached  to  the  pubis  in  front,  and,  sweeping  almost  horizontally 
backward,  embrace  the  vagina  and  the  rectum  and  become  attached  posteriorly 
to  tlic  coccyx.    While  fuliilling  the  function  indicated  by  its  name,  the  action  of 


rill.  U— FomaU'  lu'lvis,  sliDwIng  tlii'  lovatort's  ani  nuisflt's  fruni  liofcuv  anil  bolow  (Dickinson). 

the  levator  ani  is  especially  to  drag  the  lower  ends  of  the  vagina  and  rectum 
furwju'd  to  the  level  of  the  symphysis.  The  mu,<cle  consists  of  numerous  thin 
flat  bmidles  often  separat(!d  from  one  another  by  intervals  filled  bv  comiective 


TT" 


28 


AMEIiK'AX    TEXr-nOOK   OF   OBSTETRICS. 


w 


m 


;i:< 


i! 


'i    ;■ 


li 


tissue,  by  moans  of  wliidi  all  arc  united  into  a  nieinbranoiis  sheet.  The 
origin  of  tiie  levator  ani  is  partly  luiny  anil  partly  fascial.  The  bony  origin 
provides  for  the  ant«'rior  and  ])osterior  j>ortions  of  the  nnisdo,  the  intervening 
and  most  extende<l  part  arising  from  the  tendinous  arch  which  bridges  over 
the  obturator  interims. 

The  anterior  portion  takes  origin  i)rincipally  from  the  horizontal  ramus  of 
the  ]>ubis,  about  1.25  <'enti meters  (|- inch)  from  the  middle  of  the  symphysis, 
and  3.5  centimeters  (If  inches)  below  the  ujiper  Ixmlcr  of  the  ramus. 

The  pnxterior  portion  is  narrow,  l>ei!ig  little  over  .5  centimeter  (about  -} 
inch),  and  arises  from  the  inner  side  of  the  ischial  spine  in  front  of  the  origin 
of  the  coccygeus. 

The  broad  intcrreninrf  portion  of  the  muscle  springs  from  fascia  along  a 
curved  line  extending  from  the  back  of  the  pubis  to  the  ischial  spine,  the  low- 
est point  of  its  sweep  lying  5.5  centimeters  (2^  inches)  below  the  ilio-pcctineal 
line.  This  curved  line  of  tendinous  origin  closely  corresponds  with  the  posi- 
tion along  which  the  division  of  the  j)elvic  fascia  divides  into  the  inner  recto- 
vesical lamella  and  the  obturator,  the  line  of  separation  being  marked  by 
thickening  of  the  fascia  which  produces  the  tendinous  marking  or  the  "  white 
line."  The  origin  of  the  muscular  fibres  is  by  tendinous  bands,  which  may 
not,  however,  although  closely  ass(X'iate<l,  be  directly  connected  with  the  line. 

The  course  of  the  fil)res  of  the  various  parts  of  the  muscle  varies :  stretch- 
ing down  and  back,  the  fibres  divide  into  unequal  portions,  of  which  one 
))asses  to  the  anterior  aspect  of  the  rectum,  another  to  its  posterior  and  lateral 
surfaces,  while  the  fibres  attachiMl  to  the  pubic  i)one  extend  along  the  vagina, 
with  which  they  are  united  by  strong  connective  tissue,  but  do  not  terminate 
within  its  walls.  Tiie  belly  of  the  muscle  sweeps  backward,  almost  horizon- 
tally, surrounding  the  rectum,  the  margins  or  edges  of  the  muscular  band  being 
often  especially  thickened  ;  when  hypertropliied,  as  this  portion  of  the  muscle 
sometimes  is,  severe  vaginismus,  dyspareunia,  and  dystocia  may  result.  Accord- 
ing to  the  observations  of  Dickinson,  the  inner  edge  of  the  levator  ani  lies 
about  1.5  centimeters  from  the  vaginal  orifice,  the  position  of  the  nuiscle  being 
indicated  by  a  sharply  defined  double  band.  Contraction  of  the  muscle  causes 
the  U])])er  end  of  the  vaginal  canal  to  rise  from  15°  to  20°  toward  the  pelvic 
brim.     The  average  muscle  exerts  a  j)owe?'  of  ten  j)ounds. 

The  insertion  of  the  post-rectai  part  of  the  levator  ani  varies  with  its  ])osi- 
tion  :  the  posterior  and  smallest  part  is  attached  by  tendon  to  the  front  of  the 
fourth  coccygeal  vertebra ;  the  middle  part  becomes  aponeurotic  and  joins  its 
fellow  at  the  tip  of  the  coccyx  ;  and  the  anterior  and  largest  part  unites 
directly,  without  tendinous  structiu-e,  with  the  muscular  bundles  of  the  oppo- 
site side. 

The  cocoi/f/citi^  muscle  supplements  the  levator  ani  behind,  jiresenting  a  tri- 
angular sheet  which  ])asses  from  the  ischial  spine  to  the  adjacent  surfaces  of 
the  coccyx  and  the  sacrum.  The  muscle  arises  by  its  ajiex  from  the  spine  of 
the  ischium  and  from  the  inner  surface  of  the  pelvic  fascia,  and  expands  to  be 
inserted  by  its  base  into  the  lateral  margin  of  the  coccyx  and  the  lower  jiart 


f 


A.XATO.VV    OF    THE    dEXEliATIVJ':    OliGAXS. 


20 


of  tlio  sacrum.  The  pelvic  (surface  of  this  muscle  aids  in  supportinj^  the  rec- 
tum, anil  its  external  surface  is  closely  relatetl  with  the  lesser  sacr.  <ciatic 
ligament. 

PascisB  of  the  Pelvis. — The  pelvic  fascia  is  the  direct  continuation  of 
the  iliac  and  transversalis  fascial  sheets.  It  is  attached  laterally  along  the 
pelvic  hrim  and  around  the  origin  of  the  obturator  internus,  and  behind  it 
extends  over  the  pyrifonuis  ami  the  adjacent  nervous  trunks  as  far  as  the 
sacrum  ;  anteriorly  it  closely  follows  the  outline  of  the  obturator  internus,  aids 
in  bounding  the  inner  opening  of  the  obturatt»r  canal,  and  at  the  h)wer  part 
of  the  pubic  symphysis  becomes  attached  to  the  anterior  pelvic  wall. 

A  thickened  band  of  light  colored  fascia,  the  so-called  "  white  line"  (see  p. 
28),  which  extends  from  the  lower  part  of  the  posterior  surface  of  the  symphy- 
sis to  the  ischial  spine,  indicates  the  position  along  which  an  inner  or  visceral 


tg  a  tn- 
faces  of 
line  of 
Is  to  be 
[er  part 


Fiii.  ]J.-Sas;ittiil  se('ti(  III  showing  rulatiuns  of  the  several  layers  of  fascia  withiii  tlio  pc'lvic  fl()or  (Dickinson). 

lamella,  the  rcctn-rcsical  faxcia,  diverges  from  the  parietal  or  main  pelvic 
sheet ;  the  latter,  which  adheres  t(»  the  ])elvic  wall  and  covers  the  obturator 
internus  muscle,  is  now  known  as  the  ohtumtnr  fascia  ;  the  latter,  therefore, 
is  that  part  of  the  parietal  lamella  of  the  j)elvic  fascia  that  lies  below  the 
"white  line"  and  forms  the  external  fascial  investment  of  the  ischio-rectal 
fossa,  the  deep  triangular  recess  included  between  the  ischial  tuberosity  and 
the  contiguous  parts  of  the  innominate  bone  and  the  external  and  inferior  sur- 
face of  the  muscles  of  the  pelvic  diaphragm.  A  thin  sheet  given  off  from 
the  parietal  layer  or  obturator  fascia  below  the  "  white  line"  covers  the  under 


•ST" 


30 


AMKlilCAX    TEXT-liOdK    OF    Oli.STKTJilCS. 


iTr 


^l 


siii'tiK'C  of  the  levator  ani  niii.solt'  and  coiistitntcs  {\wuu<il  nv  isr/iio-rrHa/  funvia. 
Tiie  internal  pndie  Iddod-vessels  and  the  aceoinpanyinir  nerve  in  tlieir  conrse 
across  the  onter  wall  of  the  isehio-reetal  fossa  are  invested  l»y  an  additional 
special  layer  of  the  ohtnrator  fascia,  which  thus  separates  the  vessels  from  the 
fossa  and  encloses  them  within  Aleuck's  canal. 

The  viHccral  (lonclld,  or  the  ncto-irsmil  fdncht,  is,  as  ])()inted  out  l)v  Wehster, 
a  structure  of  great  imj)ortance  in  enabling  the  pelvic  floor  to  resist  inter- 
abdominal  pressure  at  the  jx'lvic  outlet.  .Springing  from  the  parietal  layer 
along  the  "  white  line,"  the  recto-vesical  fascia  covers  the  inner  and  ujtper  sur- 
face of  the  levator  ani  and  continues  over  the  muscle  to  the  bladder,  the  vagina, 
and  the  rectum,  where  it  divides  into  four  layers — the  vesical,  the  vesico-vagi- 
nal,  the  recto-vaginal,  and  the  rectal. 

The  irslcal  liii/rr  expands  over  the  lower  lateral  aspect  of  the  bladder, 
forming  of  that  organ  the  lateral  true  ligaments,  which  become  greatly  thinned 
out  as  they  pass  over  its  walls.  The  anterior  part  of  the  visceral  lamella  on 
each  side  is  attached  to  the  back  of  the  lower  part  of  the  pubis  in  front,  lat- 
erally to  the  symj)hysis,  and  behind  passes  to  the  anterior  surface  of  the  bladder 
to  become  the  anterior  true  ligament  of  this  organ  :  the  .space  between  these 
bands,  the  pubis,  and  the  bladder,  sometimes  called  the  "space  of  Retzius,"  is 
occupied  by  the  retropubic  tix.'^uc,  consisting  ]>rincipally  of  adipose  and  areolar 
tissue. 

The  vmco-vcKjinal  Inner  extends  between  the  bladder  and  the  anterior 
vaginal  wall,  and  aids  in  coimecting  these  )>arts  by  its  firm  union  with  both, 
blending  with  the  attachment  of  the  j)osterior  ])art  of  the  bladder  to  the 
uterine  cervix. 

The  recld-vtif/iiial  layer  passes  between  the  vagina  and  the  adjacent  wall  of 
the  lower  part  of  the  rectum  ;  the  union,  except  l)ehind  the  U])per  part  of  the 
vagina,  is  very  intimate,  while  below,  this  layer  is  contimious  with  the  fibrous 
tissue  of  the  jH'rincal  body. 

The  rccff/l  hii/er  extends  behind  the  rectum  and  is  attached  to  its  walls, 
becoming  continuous  with  the  corresponding  layer  of  the  opposite  side. 

The  Pelvic  Floor. — The  exact  structures  which  should  be  regarded  as 
taking  ])art  in  the  constitution  of  the  pelvic  floor  has  occasioned  nnich  dis- 
cussion, since  by  some  authors  its  constituents  are  limited  to  those  structures 
which  directly  contribute  to  the  c'ontinuity  of  tlie  se|)tum  closing  in  the  jielvic 
outlet,  while  by  others  all  ])arts  directly  or  indirectly  contributing  to  the  sup])ort 
of  this  septum,  as  the  bladder,  the  upper  part  of  the  vaginal  canal,  the  uterus, 
and  the  rectum,  are  included  within  the  category  of  the  floor. 

In  the  present  consideration  of  the  ])elvic  floor  only  those  structures  will 
be  included  that  directly  contribute  to  its  formation,  thus  excluding,  with 
Symington,  tlie  bladder  and  the  uterus,  and  reckoning  as  belonging  to  the  floor 
only  those  ])ortions  of  the  walls  of  the  vagina  and  of  the  rectum  that  lie  inti- 
mately united  with  the  septum.  The  close  relation  which  these  excluded 
organs  bear  to  the  ])elvic  floor,  howev(>r,  must  not  be  overlooked,  since  by 
their  intimate  connection  with  the  tissues  of  the  floor,  on  the  one  hand,  and  by 


^ 


A^^ATOMV   OF    TJII-J   GENEltATIVK    OliGANS. 


31 


lall  of 
of  the 
fibrous 

walls, 
<1(>. 
rdod  as 

•h  dis- 
Kictiiros 

polvio 
.ii]>]H)rt 

uterus, 

i'os  will 
with 
111'  floor 
|io  inti- 
ceUulocl 
|nce  by 
ind  bv 


I 


tiieir  suspensory  ajiparatus,  on  the  other  hand,  they  exert  an  important  influ- 
ence, as  eniphasizeil  by  Webster,  in  supportinjj  the  tissues  closing  the  outlet 
of  the  pelvis. 

The  pehlc  floor,  in  the  sense  here  accepted,  is  bounded  externally  by  the 
skin  and  internally  by  the  peritoneuni,  and  includes  the  several  intervcninjj; 
structures  which  stretch  across  between  the  ossei»-Iiganientous  boundaries  of 
the  pel 


VIS 


and  enclose  the  irregular  outlet  of  its  cavity.  Viewed  in  mesial 
sa<''ittal  section,  the  floor  is  seen  to  be  divided  by  the  vaginal  slit  into  two 
portions,  an  anteri<»r  and  a  posterior,  which  have  been  designated  by  JIart, 
respectively,  as  the  pubic  and  the  sacral  segments. 

Tile  (inferior  or  juihit-  wijmenf  appears  triangular,  being  attached  to  the 
pelvis  in  front,  and  including  the  structures  lying  between  the  symphysis  and 
the  vaginal  orifice ;  the  urethral  and  the  anterior  vaginal  walls,  together  with 
the  dense  intervening  fibrous  tissues,  contribute  largely  to  this  portion  of  the 

floor. 

T\\c  posierlor  or  sacral  fief/mcnf  includes  the  structures  between  the  vaginal 
orifice  and  the  posterior  bony  pelvic  wall,  to  the  sides  of  which  it  is  closely 
attached.  The  portion  of  this  segment  interposetl  between  the  vaginal  slit  and 
the  anus  constitutes  the  inijiortant  perineal 
body  (Fig.  13),  whose  elastic  yet  resistant 
tissues  enable  the  septum  to  undergo  great 
distention  during  labor.  The  perineal  body 
is  triangular  in  sagittal  section,  and  its 
boundaries  are  the  posterior  vaginal  wall 
in  front,  the  anterior  wall  of  the  rectum 
bchiiul,  and  the  integument  between  tiie 
vaiiina  and  the  anus  below.  The  base  of 
tlie  perineal  body  measures  about  2.G  cen- 
timeters, and  the  height  from  30  to  36 
centimeters.  In  addition  to  the  strong 
bnudles  of  fibro-elastic  tissue  and  invol- 
untary muscle  that  constitute  the  body, 
it  is  traversed  by  the  muscles  which  join  in  the  common  tendinous  perineal 
centre. 

The  female  perineum  proper — by  which  term  is  to  be  understood  the 
anterior  portion  of  the  pelvic  floor  included  between  tlie  iscliio-j)ul)ie  rami  as 
far  back  as  a  line  drawn  through  the  tubera  iscliii — corresponds  in  general 
with  the  similarly  situated  structures  in  the  male,  subject  to  the  modifica- 
tion brought  about  by  the  mesial  cleavage  of  the  jnirts  by  the  vulvo-vaginal 
opening.  The  perineum  must  be  distinguished  from  the  perineal  body,  the 
latter  iiu'luding  onlv  the  limited  tissues  interveninii  between  the  vasxina  and 
the  anus. 

As  in  the  male,  so  also  in  the  female  ])erineum,  the  fascia?  constitute  im- 
portant and  resistant  structures  (Figs.  14-10).  (^f  these  structures  there  are 
three :   the  deep  layer  of  the  superficial   fascia  (corresponding  with  Colics' 


OftA  NAVl  CUUOMf 
^  Levator  fbscia  • 
.Ifiansuiar  Lifmtt 
jupfrnciiUliyer. 

•Sup-Perintal  faidi 


j/<irJ 


Fig.  1:'..—Siii.'ittiils('ctinn  of  llic  perineal  hi  Illy, 
sli(iwiiij.'it.-ciiiiii"inoiit.>itrii(  turi's  (lilVsizi'V 


tvi 


AMKIilCAX    Ti:XT-l}f>f)K    OF   fHiSTF/PlilCS. 


fiiscia),  the  superficial  or  inferior,  and  the  deej)  or  superior  layer  (»t'  the  trian- 
^liilar  li;;anient.  'I'liese  f;i>eial  layers  are  attaelietl  at  various  levoiis  to  the 
is«'hio-pul)ic'  rami  anteriorly  and  laterally,  and  eonverge  as  they  pi'oeeed  baek- 


/'.rtei  Hill  iiifir/icial 

/"•  t  ith'iil  >rrf:-i\ 
/iitiriiu/  su/'iificial 

/l<  ilHul  IlilVC. 

Su/'i>fUitil  /'vrinfal 
iH/.iy. 

/'i/'i  y/,>y  />tii/t'tu/ii/ 
Me>-  c. 


l'iu/i\'  iwrff. 

luliinal  f'lulic 
artery. 

In/vriiir  lumor- 
rhoiiliil  artery. 

htjeri,  r  lt>  nio}  - 
rh.i/ttal  nerT'i'. 

/*'«*// ;/('WA  iiHtit'  of 
f>t  riiu'UHl. 


ni'ii 


Yw..  11.- 


r,v..f.i- 
-ninTticiiil  stnu'turi'S  of  tlu'  fiiniiU'  in'riiifuin  (Wt.'issiO. 


ward  to  lieeoine  continuous  at  the  jwsterior  free  bonU'r  of  the  so-oall(Hl  "peri- 
neal shelf,"  the  middle  of  which  marks  the  j)erineal  etiitre. 

The  interval  enclosed  between  the  superficial  fascia  and  the  su{)erfieial  or 
inferior  laver  of  the  triangular  li"ament  is  divided  l>v  the  irenital  orifice  into 
two  trianLiular  spaces  which  toj;ether  correspond  with  the  nupirficiid  pcrhiati 
intii-HiKicc.  The  various  strovtures  contained  within  this  space  include  the 
crura  of  the  clitoris  witl)  tlic  a^•(K•iat(•d  ischio-eavernosus  muscles;  the  bulbi 
vesti!)uli,  with  the  spariiitily  developed  constrictores  vajrinse,  the  homolojiues 
of  the  l)ull)o-cavernosiis;  rlie  Miperficial  traiisversi  periniei ;  the  tjlands  of  Bar- 
tholin ;  toirether  with  the  superficial  perineal  vessels  and  nerves. 

( )n  removal  of  the  skin  and  the  superficial  fascia  the  ixcliio-cdi'irnoHUH  muscles 
appear  as  slender  hands  which  arise  from  the  inner  surface  of  the  tuberosities 
and  rami  of  the  ischium  and  the  pubic  rami,  and  conver<je  toward  the  anterior 
commissure  of  the  <renital  fissure,  to  be  inserted  into  the  cavernous  bodies  of 
the  clitoris,  these  muscles  correspondinu:  closely  with  those  of  the  male  except 
in  size,  their  reduced  dimensions  aifreein»«;  with  the  diminutive  clitoris. 

The  hii/hn-cdrcnioxiis,  or  cnnxfrh'tor  v(i(/i)i(t'  muscle,  is  represented  l)y  atten- 
uated fibres  which  pass  on  either  side  of  the  vairinal  orifice  over  the  bulbi  ves- 
tibidi  and  the  slender  stalks  conneetini;  them  with  the  clitoris.  The  action  of 
these  fibres  seems  to  be  laruiely  confined  to  exerting  pressure  upon  the  adjacent 


I 


A\ATit.)/y  OF  Tin:  (;/:\/:/i'Ai7\'/-:  oav,m.v\. 


33 


triun- 
to  the 
I  baik- 


niasscs  of  crcctilf  tissue,  witli    little,  if  any,  tlirect   role  iis  ('(nistrietors  of  tl 


iUf't-rftcial 
.iif'ryfii.iiil 
il  /'!>  infill 

(•iiiliiiilit! 


)■■ 

■  /i,  iiior- 
:,/  artt-ry. 
r  //.  nil')- 
'a/  iie'Ti'- 

,tlis  i  I  lit  1 1-  of 
'Clllll. 


ed  "  peri- 


ii'i' 


ticial  or 
itice  into 
pir'nicdl 
liulo  tlu" 
the  bulbi 
inoh>^tit'!^ 
Is  of  Bar- 


((«  nuipclos 
iherositics 
10  anterior 
bodies  of 
ale  except 
oris, 

by  attcn- 

Hilbi  ves- 

aetion  of 

le  adjacent 


I 


va;iiiia,  conipressioii  o 


f  thi- 


d  I 


eanal   heiiiir   exerc 


iscd, 


al 


reativ  s 


tate« 


tl 


contractions  of  tlie  anterior  pnitioiis  df  the  levator  ani   innsi-le. 

The  Kiini I'ticidl  frininirrMii.s  /nrinn i  imiseles  elosely  resemble  those  of  the 
male,  beiiij;,  however,  redneed  in  >i/.e.  They  arise  from  the  imier  snrface  of 
the  tidierosities  and  rami  of  the  ix-hinm,  in  close  relation  with  the  origin  of 
the  ischio-eavcrnosi,  and  extend  inward  towaril  the  perineal  centre,  where  they 
blend  with  the  fd)res  of  the  sphincter  ani  and  the  constrictores  vajrina'. 

The  roof  of  the  snperticial  interspace  is  formed  by  the  inferior  or  >i>iperfiri(d 
Uiijcr  of  the  trianjfidar  ligament,  the  somewhat  thickened  anterior  part  of  tjie 


Ilorsai  T4'in  of  clitoris. 


Ditisitlii  rtiiy  of  clitoris. 

Inferior  f<uilenilal 
nerve. 

Artery  of  hiilh. 


Puiiic  ntr-ie. 
Internal /•Uilic  artery. 

Inferior  licinorrhoiiiat 

artery 
Inferior  heinorrlioidal 

nerve. 


Teni/inous  /lerineal 

centre. 

Su/ieeticiat  traH.^7'ersHS 
/fcrimri  inusc/e. 


FliJ.  l.i.— r>i.«si'('tliiii  111'  fi'inaU'  |«'riiU'Ui"  :  nii  tlic  left  siiU'  tlu'  piiiimil  iiiiisclts  an-  cximihimI  ))y  the 
nllioliiiii  uf  tlu'  pi'i'iiii  111  liix'iu  :  mi  lln'  rifjlit  sido  tlii'  iiiiisclo  mid  tlu'  suiiirliciiil  InyiT  oI'IIk'  liiiiii'^'uliir 
li^Hiiiriit  liiiVL'  tii'i'ii  ri'iiiuMil,  tluTi'liy  <.'.\|nisiiii,'  till'  (k'l'ii  Iiiyir  nl'  tlu'  liKiiiiu'iit  iiinMlilioil  riniii  \Vl■i^.sL'l. 

(l('('|)  fascia  of  the  perineum.  This  layer  is  utta«'lu'd  antero-laterally  to  the 
jMiho-ischial  rami  above  the  line  of  attachment  oi'  the  stiperticial  fascia,  and 
stretches  almost  horizontally  across  the  snbpnbic  arch  to  the  posterior  perineal 
border,  where  it  fuses  with  the  other  layers  takin>i-  part  in  the  perineal  ledt>e. 

The  superior  or  <leejt  Itti/er  of  the  triangular  ligament  is  a  resistant  fd)rous 
scptmn  which  expands  inward  on  each  side  from  its  line  of  attachment  ahnig 
the  ischio-pnbie  rami  and  constitutes  the  Hoor  of  the  anterior  extensions  of  the 
ischio-rectal  fossa\  at  the  posterior  margin  of  the  ])erineal  ledge  joining  the 
superficial  layer  in  the  conunon  fusion  of  the  fascial  layers  occurring  at  that 
point.  This  layer  may  be  regarded  as  a  rcHcetion  deriveil  from  both  the 
obturator  and  the  reeto-vesical  fascia,  since  the  septum  is  forme<l  by  the  union 
of  the  contribution  given  otf  laterally  from  the  obturator  fascia  with  that  sup- 
3 


34 


AMEIilCAX    TEXT-JiOOK    OF   OBSTETJilCS. 


m 


'A 


!'? 


pliod  niosially  by  the  iccto-vcsical  fania  :  tliis  relation  is  c's|K't'iaIly  evident  in 
frontal  sections  passinu'  tlirontrh  the  iseliial  tuberosities. 

Tlwdicj)  pcfiiiad  iiifcrsjKWc  lies  between  the  interior  and  superior  layers  of 
the  triansrnlar  liuainent,  and  it  contains  within  its  wedii'e-shaped  area  the  urethra 
and  tile  surronudinti'  venous  plexuses,  the  internal  pudic  artcM'ies  and  acconi- 
]>anyin<;  veins  and  (h>eper  nerves,  and  the  fibres  of  the  deep  transversus  ju'ri- 
n;ei  nniscle,  liere  divided  by  the  ifcnital  fissure,  and  represented  by  thin  trronps 
of  variable  muscular  tissue  surroundinii'  the  urethra. 

On  riMuovinii;  th(~  skin  and  fascia,  that  part  of  the  p(>lvic  floor  lyinsr  ]>oste- 
rior  to  the  perineum  j)roper  is  divided  by  a  median  ridye  extendinj^  from  the 


■ 


i 


5 


i'      1 


Fk;.  ir.,-Iiissi(lin!i  of  fcmiilc  pcriiii'iiin.  slinwiii',-  tlir  lici'iicr  >tnuturc~  iiftir  r'lnnvnl  (if'tlir  hviitur  iiml 

>pllill(tr|-  lllli  imiM'lo  illlllrll  UKiililkil  llnlll  Wi'isM'i, 

jierineal  centre  to  the  tip  of  tlie  coccyx,  that  consists  of  the  lower  end  of  the 
rectum  surrounded  by  the  tleep  nniscnlar  band  of  the  KjJiiiirtn-  aiu  r.iiiriniN. 
Tiiis  muscle  comprises  voluntary  fiiscicidi  wiiich  extend  from  .he  perineal 
centre  in  front,  where  they  blend  with  the  fd)res  of  the  superficial  transverse 
jH'riucal  and  va<iinal  ctmstrictor,  t-  the  ti|)  ol"  the  coccyx  bi'hind,  eneIosiiij«'  the 
anus  in  their  course.  Su|ierticially  the  anal  s]»hiiicter  is  closely  related  with 
the  int(^iiment,  deeply  with  the  levatorcs  ani  and  the  internal  sphincter;  the 
nuiseular  tissue  of  the  rectum  is  closely  related  to  the  <'xterual  sphincter,  since 
numerous  bauds  of  the  former  blend  with  the  encirclini;  fasciculi  of  the 
s^)hiucter.  Externally  the  anal  spliiucter  comes  in  contact  in  it-<  deeper  parts 
wish  the  tissue  occupyiuLi'   the  iscliio-rectal   fossa';  the  latter  extend  as  two 


I 


AXATO.Vr   OF    TIIH    GLWKRAT/ 1'/-:    OAV,'.LV,s'.  3.') 

deeply  rcci'dinu;  spaces  whose  siii)erioi'  IniiiiKlarv  follows  the  lower  surlaee  of 
the  levatores  aiii. 

The  isclii'o-n'ctal  fossce  arc  continued  anteriorly  and  posteriorly  within  the 
pockets  situated  respectively  above  the  triansiular  lii>'ainent  and  the  sacro-sciatic 
ligaments.     Viewed   in   sagittal   sections  passing  through   these  recesses,  the 


;l  of  the 
•.r/c/'/C'.v. 
Iperineal 
Inisverr-e 
[sing  the 
led  with 
jter;  the 
|er,  since 

of  the 
|)er  parts 

as  two 


I'p..  iT.-lii.^sc'clidii  i>r  liiiiiilc  iHTiiR'nni.  sliDwiii!;  sn|M'rli(iiil  liloud-vi'sscls  ntul  iicrvi's  'SnvaEri'):  C, 
clil.iri-;  1/,  :iU'iitiis  iiriimriiis  ;  T.  v:i'^iiial  ii|-ilicc;  .1.  iniu>  ;  ",  ruccyx:  T.  Iiiliri'  i>chii;  /.,  Micin-M'iiilic 
liiiiiiiH'iil ,  1, 1',  iiiti'i'iiiil  imilii'  nrtrry,  iiiviiitr  <ilV  its  iiilcrinr  liciiinrilinicliil  ''-'o,  ciitiiin'niis,  iiml  iiiiiMiilar 
linniilus  ' ',  I);  'i,  suiuTliciul  in'riiiciil  ;  s,  lutiry  nf  Imlh-  ~.".  tcnjiliiiil  hnuirlH's  u'oiiiix  tn  ilni-siiin  iiiiil 
CMViiiiHiis  liudifs  nf  clituris;  in,  pin  lie  lU'lVi';  II,  lu'iuiMrliiil  jl  iiii.l  iiiuscMiliir  .  IJI  liniuclu'S  :  1;'.,  1 1.  iiiliT- 
iial  ami  I'xurniil  suiHTlicial  inTincjil  lU'rvcs  :  l."i,  comiiiiiiiicaliinis  willi  iiiUrinr  innlciiilal  iicrvi'  iliu  ;  17, 
rciiitimiatinii  III' lU'cp  liraticli  nf  lunlic  iutvi',  tcniiiiiali.iL'  is  ilursnl  iicivi-  nl' flituvis  1 1"'' :  I'.i,  hriniiial 
lu  i'js  111'  ilii)  inniiiiinl  iioi'vo  ;  jn,  siiinll  sciatii' ;  'Jl,  cii'  'iic m  ^  liranrlics  :  n.  cut  Mirlncr  nl'  i;luti'i\s  niaxi- 
iiiiiv;  ^,  ^iiliiiii'tcr  ani  ;  c.  U'vatnr  aiii :  il.  tniiis  versus  |H',iMi'i ;  ' ,  li\illiii-(avi'riin>us  ;  ,;',  ^.-racilis  ;  <i.  isrliui- 
cavi  riiHMis  ;  //,  I'xivaiisiiai  of  cnis  I'lituriilis  ;  /.  ailiiui'tu  ■  ma^iinis, 

is(  liio-re(  lal  fossa  presents  an  oudine,  as  descril)e<'.  hy  Anderson,  not  unlike 
tiiat  of  an  anvil.  In  frontal  ft"  )ns  the  fossa  appears  as  an  opi'U  A-shaped 
nrcss  except  at  its  extreme  lads,  where,  as  just  desciihed,  the  perineal  k-dge 
and  the  sacro-seiatic  liganivr.t?    close  in  the  space  helow. 

The 'V(K)(^ir.s•^'(/.s■  (<!  the   ?>"lviv'  H  lor  include  the  arterial  brai  ehes  derived 


fkMif 


3(5 


AM  Eli  IVAN    TEXT-BOOK   OE    OBSTETRICS. 


:l 


I 


\  ! 


■( 


(lifcctly  (ir  iudirictly  iioiii  the  aiitorior  division  of  the  internal  iliac,  and  the 
vcnons  trunks  accoiupanyinir  the  arteries,  as  well  as  the  venous  plexuses  occur- 
riiiLT  in  close  relation  with  the  vesico-vauinal  walls  (Fi>r.  17). 

The  iiill'rior  vesical  and  the  vaginal  arteries,  touether  with  twigs  from  the 
external  pudie,  siippU'ini'nt  the  branches  derived  troni  the  internal  pudic,  of 
which  the  inlerior  hemorrhoidal  and  the  superficial  j)erineal  especially  supply 
the  muscular  structures  connected  with  the  pelvic  Hoor,  The  superficial  peri- 
neal artery  pii'rces  the  superficial  fiiscia  and  gains  the  superficial  jierineal 
interspace,  supplying  the  contiguous  structures  and  giving  off  the  transverse 
perineal  branch. 

Tile  eontinuatit)n  of  the  internal  ])udie  artery  maintains  a  more  deeply  situ- 
ated course,  lying  along  the  lateral  boundary  of  the  deep  perineal  interspace 
between  the  two  layers  of  the  triangular  ligament.  In  this  position  are  given 
off  the  arteries  of  the  vestibular  bulbs  and  of  the  crura  of  the  clitoris,  '"^he 
internal  pudic  terminates,  after  piercing  the  anterior  layer  of  the  triangular 
ligament,  as  the  dorsal  artery  of  the  clitoris,  from  whicli  twigs  extend  ♦•»  the 
corpus  cavcrnosuin,  the  glans,  and  the  prej)uce. 

The  n///N  of  the  |)elvie  floor  consist  of  the  trnidvs  which  dose'v  cdrrespond 
with  the  arteries,  of  which  veins  the  most  important  ari'  the  tributaries  of  thn 
pudic  vein  and  those  which  pursue  an  independent  course  and  take  part  in  the 
formation  of  the  rich  vesico-vaginal  and  hemorrhoidal  ])lexuses. 

The  iniTcti  sup|tlying  the  structures  of  the  Hoor  are  derived  principally 
from  branches  of  the  sacral  nerves,  either  directly  or  after  their  formation  of 
the  plexus,  snpplementeil  i)y  some  few  filaments  from  the  ilio-inguinal  as  well 
as  Ity  nuiucnuis  l)ranches  from  the  neighboring  hyjxigastrie  ]>lcxus  of  the 
sympathcti<'  (IM.  4). 

Th(>  anterior  division  of  the  fourth  saoral  nerve  supplies  important  nniscu- 
lar  structures,  including  the  levator  ani,  the  sphincter  ani,  and,  in  conjunction 
with    the  fifth   sacral,   the  coeeygcus. 

'i'he  <upcrlicial  perineal  branches  of  the  jMidic  and  the  inferior  pudendal 
brani  li  of  tii(>  small  sciatic  nerve  chiefly  provide  for  the  integument  and  tli'- 
nioi'e  -nperticial  structures  of  the  pelvic  Hoor,  including  the  perineal  miiscle.- 
(ihe  ix'hin-cavernosi,  the  constrictor  vagiiuv,  and  the  transvcrsi  pcriinei)  and 
the  more  external  portions  of  th<'  genitalia;  the  ilio-inguinal  contributes  fila- 
ments to  tlie  Ial)ia.  The  terniiuation  of  the  pudic  nerve  ])asscs  forward  as 
the  diminutive  dorsal  nerve  of  the  clitoris.  Sympatlu'tic  filamcMits  from  (he 
hvpoga>tric  plexus  are  additionally  distributed  to  those  part 
abundant  vascular  tissue. 


contaiuMii; 


11.  Anatomy  of  the  Female  Generative  Organs. 

'i'he  structures   coii-iituting   the    female   reproductive  apparatus  consis,  ^>i' 

thi'ce   group. (1)    the   external,   (_)    the   intermediate,    and    (.'>)   (he   interna! 

generative  organs. 

1.  External  ■  rgaiis  of  generation  (I'!  o),  ,^r  he  i/n.'!"!l(i,  include  the 
mon-  veneris,  (he  labia  maioia  and   minora,  the  i''ti  r!      l!)-  ;■■  >tibule  with  the 


d  the 

occur- 

)ni  the 
lie,  of 
supply 
1  pcri- 

ClilK'ill 

iisvcrse 

Iv  sit\i- 
ei^pacc 

0  given 
;.  'Hie 
angular 

1  ♦..  the 

■s  of  thc^ 
It  in  the 

incipally 
lation  of 
I  as  well 
s  of   the 

niuscu- 
unt'tinn 


->u* 


londal 

nid  til" 

nuiscU' 

luei)  and 

)utfs  lila- 

•ward  .IS 

roni  the 

()ntainiii;j; 


UdUSlS,    >'! 

intt'rn;i' 

icluth'  llie 
with  tlie 


ANATOMY    <»F   TllK    I'KIAIC    IT.OOi;. 


I'l.ATi.;   1. 


'J 

■/. 

:, 

^ 

■r. 

U 

i~ 

t~ 

7. 

,i^ 


^"^ 


H 


I,  St 


W^ 


4- 


ANATOMY   OF   THE    GENERATIVE    ORGANS. 


87 


meatus  iirinariii.s,  and  the  vaginal  orifice.     These  parts  are  collectively  known 
as  the  vulva  or  pmkmJum. 

The  mons  vcnerk  presents  an  eminence  surmounting  the  pubes  in  advance 
of  the  vulva,  and  is  composed  of  stout  integument  abundantly  supplied  with 
crisp  hail's,  and  a  thick  cushion  of  subcutaneous  adipose  and  areolar  tissue 
upon  which  the  rounded  contour  of  the  part  depends. 

The  labia  niajora,  the  homologues  of  the  scrotum  in  the  male,  arc  two  con- 
sj)icuous  longitudinal  folds  of  integument  extending  from  the  mons  veneris 
downward  and  backward  to  within  about  2,5  centimeters  (1  inch)  in  front 
of  the  anus.  The  elongated  fissure  included  between  these  folds,  the  uro- 
f/cnital  orifice,  occupies  almost  a  horizontal  position  in  the  ertKit  posture,  and  is 
limiteil  by  the  anterior  and  the  posterior  commissure,  formed  by  the  union  of 
the  labia  in  front  and  behind.  Immediately  within  the  posterior  commissure 
a  crescentic  fi)ld  extends  transversely  and  constitutes  the  fourchette  ;  the  space 
between  the  latter  and  the  posterior  commissure  is  the  fossa  navicularis. 

The  labia  majora  are  continuous  anteriorly  with  the  mons  veneris,  and  are 
thicker  in  front  than  behind  ;  they  present  the  usual  ai)pearance  of  integument, 
being  covered  on  their  outer  surfaces  with  scattered  hairs  and  pigmented 
epidermis;  their  protecte<l  inner  surfaces  are  more  delicate  in  texture  than 
their  outer  surfaces,  and  where  least  exposal  they  partake  somewhat  of  the 
character  of  a  nuicous  membrane. 

The  tegmental  fold  of  each  labium  includes  areolar  tissue,  some  involun- 
tary muscle,  and  a  considerable  mass  of  fat  which  receives  the  distal  end  of  the 
round  ligament  of  the  uterus.  Descent  of  the  ovary  into  the  labium  occurs  in 
very  exceptional  cases,  the  displac(xl  organ  following  the  round  ligament  and 
taking  up  a  position  within  the  labium  after  traversing  the  inguinal  canal. 
'I'he  labia  in  the  young  and  wcll-developfKl  subject  are  closely  approximated 
and  occlude  the  vaginal  orifice. 

The  labia  minora,  or  the  nymphm,  are  two  thin  diverging  folds  of  delicate 
skin  that  lie  protected  within  the  greater  labia,  so  that  their  arched  free 
borders  are  often  completely  covered  and  not  visible  externally ;  luiless  arti- 
(iciall"  separated  their  mesial  surfaces  lie  in  dose  contact.  The  nymphse 
are  subject  to  great  individual  variation  in  size,  in  s(mio  cases,  as  conspic- 
Mt)usly  seen  in  Hottentot  women,  reaching  excessive  dimensions;  usually  they 
extend  downward  and  backward  from  the  clitoris  (about  3,5  centimeters) 
along  the  genital  fissure,  iadiiig  away  at  the  sides  of  the  vaginal  orifice. 
Directly  continuous  with  the  lai)ia  majora  externally,  their  smooth  iiuier 
siu'fiices  pass  directly  into  tlie  mucous  membrane  of  the  adjacent  vestibule, 
which  they  closely  resemble  in  appearance  and  structure,  Vascidar  papilhe 
and  well-developed  sebaceous  fi)llicles  are  common  to  both  surfaces  of  the 
nympha^,  but  sweat-glands,  hairs,  and  fat  are  wanting,  Tiie  interior  of  ciicii 
fold  contains  abundant  venous  spaces,  which,  in  (onnection  with  the  uustriped 
muscle  pres(>nt,  produce  a  structure  resendding  erectile  tissue. 

The  converging  and  often  unsynunetrical  lal)ia  min(»ra,  just  l)efore  meeting 
anteriorly,  separate  into  two  divisions,  the  outer  and  nj)per  Itaflets  continuing 


mm 


h 


38 


AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 


;U 


5  :    « 


^1 


»;  !  i 


\ 


1 1 


||  : 


11 


ovor  tlio  clitoris  to  unito  to  form  tlio  prcjuifiinn  vlitoridis,  tlio  lower  or  inner 
lamina'  joininii:  Ih'Iow  tlic  jilands  to  eonstitutc  the //■(■/(» m  c/i(ori(liK. 

The  f//7o/7.s',  the  homoloyiK'  ol"  the  penis,  presents  i^reat  similarity  to  the 
male  orojan,  possess  ins;  all  the  parts  of  the  latter  rethieed  in  size  and  inllneneed 
l)v  the  absenee  of  the  urethra  and  by  the  cleft  and  nuxlitied  condition  of  the 
corpns  spon<::iosnm  as   represented   l>y  the  hnlhi  vestihuli. 

The  somewhat  laterally  eom])ressed  hody  of  the  clitoris  consists  of  the  dimin- 
ntive  corj)or(t  cdrcriKmi,  which  diveriic  behind  and  are  attached  by  their  ernra 
alono;  the  pnbic  and  ischial  rami,  the  snspensory  lij^ament  aiding  in  niaintain- 
ijiu:  the  })osition  of  the  origan.  In  front  the  cavernons  bodies  are  capped  by  the 
rounded  i//ini><  c/ifnridis,  wlii<'h  contains  papilhe  occupied  by  arterial  tufts  and 
the  peculiar  special  nerve-endings,  the  (jctiitnl  vorjuixch'n.  The  nerves  of  the 
clitoris  are  relatively  better  developed  than  the  corrcsjiondinir  ones  of  the 
penis,  the  organ  beinii  the  especial  seat  of  voluptuous  sensation.  Sebaceous 
follicles  surround  the  glans,  and  they  are  also  present  in  the  outer  layer  of  the 
prepuce,  being  almost  wanting,  however,  on  the  glans  itself.  These  follicles 
secrete  s.il -tances  prone  to  decomposition  and  to  the  production  of  a  jteculiar 
odor.  The  erectile  tissue  constituting  the  dimimitive  corpora  cavernosa  and 
the  glans  eovresvonds  in  structnr(>  with  similar  tissues  within  the  jtenis.  Two 
small  nnisei.'s,  (he  ischio-cavernosi  or  ercctorcs  clitoridis,  extend  from  the 
ischial  tuberosities  to  be  inserted  in  the  crura  of  the  clitoris,  and  correspond 
with  the  homologous  muscles  of  the  tnalc. 

The  vcslihiilc  includ(>s  the  triangular  space  lying  between  the  clitoris  in 
front,  the  vaginal  orifice  behind,  and  the  nymph.'c  at  the  sides.  Its  smooth 
mucous  surface  is  broken  by  (he  urethral  o])eniug,  the  lorafus  KriiKiriiis 
being  situated  in  the  mid-liiic  of  (he  j^osterior  v(>stibnlar  wall  about  2  to 
2.5  centimeters  (1  inch)  behind  the  clitoris,  slightly  in  advance  of  the 
orifice  of  the  vagina. 

The  iifliuti'i/  iiic(tti(s  varies  in  form,  but  oftenest  appears  as  an  ov(»id  cleft, 
frequently  presenting  short  irregular  lateral  branches,  surrounded  by  a  border 
of  .'^lightlv  corruirated  elevated  iiiiicoiis  membrane,  due  to  the  encircling  ring 
of  muscular  fibres  (PI.  o). 

The  /)ii//>l  vrsfihiili  are  two  elongated  leech-shaped  masses  (about  '2.5  centi- 
meters in  length)  situated  on  cither  side  of  the  vestibule  a  little  behind  the 
nymjiha',  and  attached  above  to  the  crura  of  the  clitoris  by  means  of  a  con- 
tracted iutermediate  portion,  the  y^^/z'N  iittcniicilid/ix.  They  are  composed  prin- 
cipally of  close  and  intricate  venous  plexuses  eorrespouding  with  the  tissues  of 
the  male  corpus  spongiosum,  of  which  part  the  biilbi  vestibuli  must  be  regarded 
as  the  cleft  hoiiiologue.  The  eoiistrictores  vagina'  muscles  lie  in  close  relation 
with  the  bulbs,  and  by  their  contractions,  as  during  sexual  excitement,  com- 
press the  venous  cliaiiiicls  and   render  the  tissue  turgid  aiid  erect. 

The  ghivdx  of  ItdrfJkol'nt,  the  homolognes  of  Cowpers  glands,  are  two 
ronn<l  or  oval  yellowish  bodies  (about  1  eeiitimeter  in  diameter)  which  lie  on 
either  side  of  the  lower  part  of  the  vagina.  These  bodies  are  less  deeply 
situated  than  the  corresponding  structures  in  the  male,  being  eontaincHl  within 


(;KNi;i!Ai'l\  I".   <)lHiAN> 


I'l.ATi; 


ccilti- 
iiil   the 

a  <'()n- 
il  priii- 

<I1('S  of 

ji'ardctl 
'lation 
,  coni- 


V  fwo 

lie  on 

Ip('|tly 

within 


lUniHl.v.'s^.'N  of  Ihr  \'v]\\-  iliourL't'i-y  .-in.!  .lac.l.i ;  tln'  lUitriiMr  pnrt  of  (lir  |  .'h  i-  lui-  1 ii  ivmnviM.  Mini 

tlicMiiiMrr  mi.l  llir  ;nii.ii,,r  va-lnal  w.-ill  \\:i\<-  hv,\\  iwirlinlly  .ul  «»iiy.     Iliv  uhtu-  i~  .Iniw  n  up  iiml  tlic 


'^w^ 


r  i 


*!, 


'•'.  §il 


■'il  {:' 


I 


mmrr  ■  i      -^.- 


(iKNKHATlVK  (>U(iANS. 


I'LATK   H. 


I'l'lvic  (iririitis  in  silii  nf  ii  yniiiitf  wuiimii  nf  sixteen  yeiirs  ;  scon  from  ntiovo  after  eii refill  removal  nf  the 
interlines  \v  itjiiiiit  ilisliirliiii'/tlie  reliitiniis  :  .(,  iiliilniniiial  aurtii ;  \'i  \  inferior  Venn  eava  ;  /'.-■.  psnas  niannus  ; 
I'l.  iMnninMlory  of  .".aenitii  ;  /.'.  ent  reetiun  :  /»,  |i.  neli  nf  limmliis  ;  /.'/  ,  hi.dy  of  nierns  ;  /T.  I'lnnius  of  nterus  ; 
/;  ,  M.iilder:  '),  ovary;  7',  l'iillo|iian  lulie;  /,'/ ,  roiiinl  liLiiiineiil ;  (V,  nivter-  ii.\,  uNarian  aitery  ireilrawii 
IVoni  Walilevi'n. 


ffT^- 


^li 


M: 


J 


l!i 


'Mil' 


ri 


MXTKKN'AI.  GKNEUATIVK  ORGANS. 


I'l.ATi:  'i. 


M!flJ!lV\l(A  '■ 


DlAGPAVi 


1.  \'iri;iii  liyiiHti.  J.  ('hiinii'ti'ri>tii'  hyiiu'ii  iiiiil  I'lHirclu'tlr  of  n  nmrrinl  unin.iii:  \:iv^r  u  linkli'il  luliiii 
iiiiiioia  Mild  |iri'|iiici'.  :i.  Miilliiunii.  slmu  in-;  I'l'iiuiiml  nl' liyiiirii,  iH.uchiiiL;  Miilrri..i-  .iikI  |m.-i  Mmiiiicl  uiill, 
si'iii-  ill  |>i  riiii'iiiii,  liil'^r  l:ilii:i  mil Ji ii;i.      1.    |li)if,'nilM  nil  a  ililViTrlit  ^ciilr  IViiin  Ihr  I'n'ii.HiiLi  li.;iirf>. 


w 


%\\ 


i;\i'i;i:N.M.  (ii;M:i;ATi\  !■;  ()1;(;a.ns. 


l'U\TE  0. 


I      I  <i 


)  .' 


1 

a 


> 


/     > 


a 

I 

i 

-•a 


yr  ^^ff-.  i*» 


■"-v;*:.v^-; 


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i 


A^ATO^fV   OF    THE    GENERATIVE    01i(,'AJV,S. 


39 


the  superficial  perineal  interspace,  and  not  between  the  two  layers  of  the  tri- 
angular ligament.  They  arc  niuco-serous  racemose  glands,  and  pour  their 
secretion  upon  the  mucous  membrane  by  long  slender  ducts  which,  after  an 
oblique  course,  open  into  the  vestibule  just  external  to  the  vaginal  orifice. 


Dorsiil  L  rvi  of 

liitor  is. 
/>.>r.\u/  tirti-ry 

of  c/itt'ih. 

rtt'yy  o/iorplts 

i'a7't'rn<>sutn. 
Deep  f^et  iiwtil 

artery. 


Artery  i>/  lulb. 


Tentlit'ous  peri- 
neal eentre. 


Kic.  IS.— nissc'cHcm  of  foniale  perineum,  Rhowlnp  the  vestibular  bull)  and  tin?  clitoris  (Weisse). 

TIk!  liymen  consists  of  a  thin,  usually  cre-soentic  duplicature  of  mucous 
niendjrane,  strengthenetl  by  fibrous  tissue,  stretched  across  the  posterior  part  of 
the  vaginal  opening,  which  it  i)arHy  occludes.  The  hymen  varies  greatly  in 
form  and  in  extent,  at  times  being   represented  by  a  slight  semilunar  Ibid 


Fiii.  111.— Kroclik'  strut'tures  of  tlio  fi'malo  K'l'iiitalia,  iiarticularly  tlic  liiK'lily  vascular  bullii  vcslibuU 

(Kobelt). 

whose  concavity  looks  upward  toward  the  pid)es,  at  other  times  forming  almost 
a  complete  and  imperforate  membranous  septum.  The  variations  in  the  shape 
and  extent  of  the  fold  and  its  (srifice  ine'ude  the  circular,  cleft-llk(>,  cordiform, 
cribriform,  and  other  types,   well   illustrated   on    Plate  (J.     Uupture  of  the 


hi* 


'.1 1  ^  i 


I!H .  }l 


40 


AMERICAN    TEXT- BOOK    OF   OliSTETElCS. 


hynieu  usually,  but  by  no  moans  necessarily,  occurs  durinj]j  the  first  sexual 
intercourse ;  in  rare  cases  the  septum  persists  until  the  event  of  parturition. 
In  women  who  have  borne  children  the  orifice  of  the  vagina  is  surroundeil  by 
irregular  j)apillary  elevations,  the  cavuncalce  myrtiformes :  these  are  the  remains 
of  the  ruptured  hymen,  but  are  usually  present  only  after  labor  has  taken 
place,  since,  as  established  by  Schroeder,  the  rent  hymen  is  converted  into  these 
eminences  as  the  result  of  the  pressure  incident  to  chiklbeariug,  and  not  to  coitus. 


Dorsal  neive. 

Poisal  artiiy. 
Porstt/  7't\'/i   of 
clitoris. 


Moatus  uri- 
>uirii4s. 

Art,-ry  of  /'l<ll\    jt. 
Artery  to  gland.  jj_^ 


/  'hho-iuiginal 

I  'itl7'o-vai;inal 

Jiut. 
Lt~ihitor  fascia. 


Frohe. 


Pef/i  perineal  iinisele. 
Sn/'ey/itial  l<:yer  of  triitn- 

git/itr  lii:ament  relh\led. 
Peep  layer  of  supet/ieial 

perineal  fascia  rejlecteil. 


Tendinous  centrr    '..-''' 
of  perineum. 

Flo.  'JO.— |)isso('<ii)ii  ol"  fomnle  poriiu'iim,  showing  stnicturos  within  tho  dcop  intLTfa.scinl  perineal 
intiTspuco;  tlii'  vnlvn-viifiinal  f;lan(ls,  liowovcr,  lu'lonj^  to  the  snpi'rlieial  spaee,  but  arc  sliown  resting  on 
tlie  lieeper  stnictiires  (Weissc). 

The  /(7»<//c  urethra  (Fig.  21)  is  short,  being  only  about  4  centimeters  in 
length,  and  lies  beneath  the  .symphysis  pidjis,  firmly  imbedded  within  the  ante- 
rior vaginal  wall.  It  descends  from  the  neck  of  the  bladder  to  the  vestibule 
almost  vertically,  presenting  usually,  however,  a  slightly  marked  d()id)le  or  sig- 
moid curve,  or  at  least  a  curvature,  forward.  Its  vestibular  orifice,  the  meattin 
iiriiKirln.'i,  is  indicated  usually  by  an  elevation  of  the  mucous  membrane  situated 
from  2  to  2.0  centimeters  behind  the  clitoris.  The  meatus  marks  the  most  con- 
stricted part  of  the  canal,  the  average  diameter  of  which  is  about  .(J  centimeter. 
Owing  to  the  elastic  character  of  its  ti&sues  and  to  the  yielding  nature  (»f  the 
surrounding  structures,  the  female  urethra  is  ca])al)le  of  great  distention,  a 
matter  of  importance  in  examination  of  the  bladder. 

The  walls  of  the  urethra  comprise  a  nmcous,  a  subinucou,'^,  and  a  nuiseular 
layer.  Tiie  nuico.si  is  covered  by  stratifie<l  .stpiamous  or  transitional  epithelium 
directly  continuous  with  that  of  the  bladder;  tubular  glands  oecnir  near  the 
vesical  end  of  the  canal,  where  tho  mucous  mend)rane  is  soft  and  .spongy. 
Skene  has  called  attention  to  the  existence  of  two  small  tubes  (from  10  to  20 
millimeters  in  length)  which  lie  within  the  nuiseular  walls  of  the  female 
urethra  and  which  open  by  minute  orifices  situated  about  3  to  4  millimeters 
within  or  above  the  meatus.  These  tubes  probably  represent  the  remains  of 
(Jiirtner's  duct  derived  from  the  fetal  WoltHan  duct. 


ANATCnfV   OF    THE    aENERATIVK    OlidANS. 


41 


sexual 
iritioii. 
dwl  l)y 
oinain.s 

taken 
o  these 
'  coitus. 


The  .suhmueous  stratum  contains  much  elastic  tissue  and  a  rich  venous 
plexus.  Tlie  muscular  tissue  of  the  hUwUler  is  continued  over  the  urethra  as 
an  inner  longitudinal  and  an  outer  circular  layer,  in  addition  to  which  the 
tube  receives  an  investment  between  the  layers  of  the  triangular  ligament 
from  the  compressor  urethne  or  deep  transverse  perineal  muscle.  The  muner- 
ous  blood-vessels  and  nerves  of  the  female  urethra  are  derived  from  the  same 
sources  as  those  of  the  vagina. 

The  female  bladder,  relatively  broad  and  capacious,  bears  important  rela- 
tions to  the  vagina  and  the  uterus.  When  empty  and  relaxed  the  organ  lies 
entirely  within  the  true  pelvis,  Iwhind  the  pubes  and  usually  to  one  side;  the 
fundus  is  then  greatly  flattened  out  and  somewhat  indented,  so  that  the  cavity 
of  the  bladder  and  the  urethra  together  a})pear  Y-shaped  in  section  (Fig.  22),  the 
widely-separated  hinder  limb  and  the  corresponding  posterior  vesical  wall  lying 
against  the  upper  part  of  the  vagina  and  the  lower  segment  of  the  uterus ; 


Km 


Jl.— Siinittii;  .section, showing  ri'Intionsiuul  form  I'siK'i'iiiUy  of  tlii' bladder, un'thrn, anil  vayiiia  (Hart): 

[',  r,  urethra;  li,  li,  blatUlor. 


sometimes,  however,  the  emi)ty  organ  is  strongly  contracted,  the  cavity  of  the 
bladder  then  presenting  a  slit-like  lumen.  Maxinnim  distentii>n  carries  the 
bladder,  together  with  the  peritoneum,  well  above  the  pubes,  with  the  conse- 
(pient  tendenty  to  backward  displacement  of  the  uterine  fundus. 

77ic  Fniudc  Ureter. — The  urt>ter  in  the  female  (IMs.  7,  8)  presents  peculiar- 
ities in  its  relations  within  the  pelvis  tiiat  deserve  notice.  After  the  usual 
relations  of  tiie  abdominal  portion  of  its  course — proceeding  downward  and 
inward  uj)on  tlie  i)soas  muscle  and  its  fascia,  being  erossetl  by  the  ovarian  ves- 
sels, and  crossing  the  iliac  vessels  about  1.5  centimeters  below  the  division  of 
the  common  iliac  artery — the  ureter  passes  into  the  true  pelvis  in  front  of  the 
sacro-iliae  synehondrosis,  thence  upon  the  cjbturator  interims  muscle  and  its 
fascia  toward  its  termination,  rmming  beneath  the  root  of  the  broad  ligament. 

About  opposite  the  origin  of  the  vesical   and  uterine  arteries  from   the 


yt 


42 


AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 


internal  iliac,  the  nreter  forms  a  sweeping  curve  which  is  most  pronounced 
where  tiie  uterine  artery  crosses  the  ureter,  about  on  a  level  with  the  os  exter- 
num. The  ureter  crt)sses  the  uterus  at  a  point  closely  corresponding  with 
the  position  of  flexure  of  the  uterine  body  upon  the  cervix,  here  lying  between 
the  vesical  venous  plexus  laterally  and  the  utero-vaginal  venous  plexus  and 
the  uterine  artery  internally. 

The  h)wer  part  of  the  ureter  passes  at  first  at  the  side  of  the  upper  thinl 
of  the  vagina;  it  then  reaches  the  vesico-vaginal  septum,  within  which  it  lies 
for  1.5  to  2  centimeters  before  entering  the  bladder-wall. 

The  ureter  does  not  extend  lower  than  about  the  middle  of  the  anterior 
wall  of  the  vagina;  as  it  rests  directly  upon  the  latter,  it  is  encloscHl  for  a 


:y 


Promontory. 


,..' 


■X 


hi. 


.cS> 


..c»- 


Ovario-pelvic 
ligament. 

— Tube. 

-Ovary. 

Broad  ligiimcnl. 


Uterus. 


^' 


I'c^^' 


^.^Hetropiibu 
'         triangle. 


Bladder. 


X 


I ;  I  ,     I  •^■s^"'  „„„„ 


I        ! 


'    I  '  I  N        '' 

I  '  Inrernal  sphincter  anl.  ""n 
1  I       r       '  / 


•W 


I       I 


lUilho-caTcrih  <s//s. 


\Lev)ftor.\ 


'•'J'  E.\ter)iat  spluncter. 

Klii.  22.-Mi'siiil  sictidii,  slmw  iiij;  llic  rcliitiiiii  nf  tlu'  x  isccni  in  llu'ir  imrinHl  |»isiti(iii  (Uickiiisuii). 

short  distance  (about  1  centimeter)  within  a  distinct  fibrous  sheath  continuous 
with  the  bladder-wall  (Waldeyer). 

The  course  t)f  the  tircter  within  the  vesical  wall  is  obliquely  downward 
and  inward  for  a  distance  of  al)out  1.5  centimeters.  The  lower  part  of  the 
tube,  from  its  investment  by  the  above-mentioned  sheath  to  its  termination,  is 
cylindrical  in  form,  in  contrast  with  the  remaining  fiattened  portions  of  the 
canal. 

2.  Intermediate  Organ. —  Thv  V(uihia. — Tlie  nuiseido-mend)ranous  canal 
of  the  vagina  fi)rms  the  intermediate  tract  connecting  the   internal  and  the 


A» 


ANATOMY   OF    THE    GENERATIVE    ORGANS. 


43 


external  organs  of  generation.  Piercing  the  pelvic  floor  with  its  lower  end,  it  lies 
chiefly  within  the  cavity  of  the  pelvis,  in  relation  with  the  bladder  and  the  urethra 
in  front  and  with  the  rectum  behind,  the  vcdco-vaginnl  and  the  redo-vaginal 
fiej)fa  intervening.  The  axis  of  the  vagina  (Fig.  23),  while  corresponding  in 
general  with  that  of  the  pelvic  cavity,  resembles  that  of  the  urethra  and  the 
rectum  in  i)resenting  a  double  or  S-like  curvature.  The  axis  of  the  lower  third 
of  the  vagina  corresponds  closely  with  the  plane  of  the  pelvic  brim  ;  that  of  the 
upper  two-thirds  lies  parallel  with  the  axis  of  the  lower  third  of  the  rectum, 
forming  almost  a  right  angle  to  the  axis  of  the  anal  extremity  of  the  gut. 
The  two  jirincipal  vaginal  walls,  the  anterior  and  the  posterior,  ordinarily 
lie  in  contact  except  at   the  sides,  where  the  lumen  of  the  canal  laterally 


\ 

Fig.  2.'!.-SiiKittal  section  of  fi'iiiiilo  yiolvis,  shinviiif;  axis  of  the  vngina. 

expands.  In  cross-section,  therefore,  tiic  vaginal  passage  under  normal  con- 
ditions appears  H-shaped  (Fig.  24) ;  when  distended  it  is  club-shaped,  being 
more  capacious  above  than  below,  where  the  entrance  marks  the  least  diameter. 
The  shorter  anterior  wall  (Fig.  25)  extends  from  the  vaginal  entrance  to 
the  apex  of  the  corresponding  utero-vaginal  recess  or  anterinr  fornix,  and 
measures  aboiit  6.5  centimeters,  or  about  2}j  inches;  seen  from  behind,  this 
sin-face  appears  triangular  in  its  g(>ueral  form,  the  base  being  above,  corre- 
sponding witii  tile  greater  sui)erior  diameter  of  the  canal.  Tiie  anterior  wall 
is  very  conspicuously  marked  by  transverse  /vff/"'  (Fig.  20),  wliich  are  especially 
promiiienl   in  tlic  virgin;  an  additional   vertical  fold,  the  anterior  co/Hmn,  is 


■^"K 


44 


AMERICAN   TEXT- BOOK    OF   OBSTETRICS. 


'J 


pn  sent  at  the  lower  part  of  tlie  passage,  where,  also,  this  wall,  distinctly 

thicker  than  its  fellow,  is  most  robust. 

riie  posterior  wall,  nuieh  the  longer,  extends  from  the  vaginal  orifice  or 

the  hymen  to  the  apex  of  the  dcc\)  poderior  fornix  (Fig.  25)  or  retro-cervical 

fossa ;  it  lies  in  front  of  the  anterior  rectal 
wall,  with  which,  thronghont  its  lower 
two-thirds,  it  is  united  by  areolar  tissue. 
The  posterior  wall  measures  about  9  cen- 
timeters, or  about  S^  inches,  in  length, 
being  broader  above  than  below  ;  its  supe- 
rior third  receives  an  imperfect  covering 
of  the  peritoneum  which  forms  the  most 
dependent  portion  of  the  anterior  wall  of 
Douglas's  pouch.  While  distinctly  less 
corrugate<l  than  the  anterior  wall,  the  pos- 


Fk;.  2(.— Sfctioii  illiistriitiiiK  the  chariiptoristic         Fig.  25.— SiiKittiil  section,  showinK  vn(;iniil  wnlls 
form  of  till'  viiniiml  clfll  (Ut'iilc) :    Tn,  urolhra  ■  nnil  roliition  of  cervix  uteri  tskuiie). 

IVi,  viitfiim  ;  ],,  levator  aiii ;  Ji,  rcctuiu. 

terior  surface  in  the  virgin  possfct;ses  numerous  transversely  disposed  ruga;  as 


Fill.  ■Jf).— Sntfitfiil  section  of  viifiinii  of  a  virgin,       Fio.  '27.— Suuittnl  section  of  vagina  of  a  multipara, 
stiowiii;.'  rufjous  (iiiiilitiou  of  walls  ami  ciilarKeJ  oiie-lialf  natural  size  (Hart), 

iiliper  extremity  (Hart). 

well  as  a  vertical,  and  sometimes  double,  posterior  column.    Siibscfpient  to  the 
dilatation  incident  to  parturition  the  vaginal  nigte  are  much  less  conspicuous 


'^ 


■■>^/ 


AXATOMV   OF   THE    GENERATIVE    OBGAXS. 


45 


^/ 


(Fi<'.  27),  tluiso  on  till'  posterior  wall  often  alino.'^t  ciitirt'ly  disappearing,  leav- 
ing^the  .somewhat  pouched  surface  relatively  smooth  ;  the  folds  of  the  anterior 
wall  are  retaine.1  to  a  much  greater  extent. 

Ill  ,sfn(rfiiir  the  walls  of  the  vagina  consist  of  a  mucous  membrane,  a  nius- 
c:ilar  coat  and  a  Hhrous  tunic.  The  mucosa  is  covered  by  a  thick  stratified, 
squamous  epithelium,  and  possesses  numerous  papilla.  The  rugic  include 
within  their  structure  not  only  the  tissues  t»f  the  mucosa,  but  also  bundles  of 
involuntary  muscle  and  large  veins.  True  (jlawh,  if  found  at  all,  are  repre- 
sented bv  a  few  sparingly  distributed  tubular  structures  within  the  upper  part 
of  the  vairinal  mucous  membrane,  the  acid  secretion  which  bathes  its  surface 
beiii"-  the  iiroduct  of  the  general  mucosa.  The  deepest  part  of  the  mucous  mem- 
brane that  corresponds  with  the  submucous  layer,  is  succeeded  by  the  iims- 
cular  coat,  composed  of  an  inner  circular  and  an  outer  longitudinal  stratum 
of  u list ri pod  muscle. 

The  fibrous  tunic  consists  of  a  dense  coat,  rich  in  fibro-elastic  tissue,  which 
is  derived  as  a  prolongation  of  the  recto-vesical  fascia  and  materially  con- 
tributes to  the  strength  of  the  vaginal  wall.  The  lower  extremity  of  the 
canal  is  encircled  by  a  thin  plane  of  muscular  fibres  constituting  the  con- 
strictor vatiiiiic  muscle,  and  is  closely  attached  to  additional  bands  derived 
from  the  levator  ani. 

Bhod-vcsscls  and  Xerves. — The  vascular  and  nervous  supplies  of  the  vagina 
arc  verv  <>;enerous.  The  arteries  are  derived  from  the  vaginal,  the  internal 
pudic,  the  vesical,  and  the  uterine  branches  of  the  internal  iliac.  Correspond- 
iiif  veins  return  the  blood  to  a  large  extent,  in  addition  to  which  the  vaginal 
plexus  surrounds  the  lower  part  of  the  canal  and  communicates  freely  with 
the  iieiirliboriug  vesical  and  hemorrhoidal  plexuses.  The  urethral  plexus 
around  the  upper  jiortion  of  the  urethral  canal  receives  the  dorsal  veins  of  the 
clitoris.  Witiiin  the  submucosa  large  and  plentiful  venoirs  radicles,  together 
with  b;ui(ls  of  involuntary  muscle,  give  this  layer  the  charaftter  of  erectile  tissue. 

Till'  hjinphatics  of  the  vagina  constitute  two  groups,  those  from  the  lower 
and  the  upper  portions  of  the  canal.  The  former  join  the  lymphatics  of  the 
external  genital  organs  and  end  within  the  superior  or  oblique  set  of  inguinal 
glands  ;  the  latter,  together  with  the  vessels  from  the  lower  part  of  the  uterine 
body  and  the  cervix,  proceed  outward  Avithin  the  broad  ligament,  joining  with 
the  lymphatics  from  the  oviduct  and  the  ovaries,  and  terminate  in  the  lumbar 
glands. 

The  nerves  of  the  vagina  are  contributions  from  both  the  symjiathetie  and 
tiie  corcbro-spiual  system.  The  branches  of  the  former  are  derived  from  the  infe- 
rior hypogastric  |)lexus,  those  of  the  latter  from  the  fourth  sacral  and  the  pudic 
nerve.     The  sympathetic  fibres  are  largely  distributed  to  the  vascular  tissues. 

."5.  Internal  Organs  of  Generation. —  The  Uterus. — The  uterus,  the  thick- 
ened and  specialized  segment  of  the  generative  tube  for  the  reception,  the  reten- 
tion, the  development,  and  the  final  expulsion  of  the  product  of  conception,  in 
its  mature  liut  virgin  condition  is  a  slightly  pyriform  body  whose  thick,  dense 
walls  enclose  a  narrow,  cleft-like  cavity.     The  organ  lies  within  the  pelvis, 


46 


AMKIilCAX    TEXT- BOOK    OF   OBSTKTIiTCS. 


li' 


w^ 


I.  « 


lickl  by  sii|)i)ortiiii>'  ptTitoiical  folds  and  niiisi-idar  hands  oxtoudinii;  between  tlio 
bladder  in  front,  the  reetuni  and  the  sacrinn  behind,  an«l  the  j)elvie  walls  at 
the  sides;  the  most  (le{)endent  porticm  of  its  lower  and  smaller  segment,  the 
cervix,  projeets  within  the  upper  part  of  the  vagina. 

The  rit'f/in  uterus  (Figs.  28,  2!>)  measures  about  7.5  eenti meters  (about  3 
inehes)  in  length,  4  centimeters  (about  H  inches)  in  its  greatest  widtli,  and 


Tn/v. 

I\ouui/  h'^ti' 
ment. 


ffriionium. 


Fundus. 


Hotly. 


Internal  its. 


Ct'irix. 


Exttiiial  OS.  — 


Anterior 
surjuee. 


Fl(i.  2f<.— Anterior  vii'W  of  vir^'in  utiriis.  sli(i«  -  Fni.  2(1.— Sniiittnl  section  of  virgin  litems,  show- 

inpr  reliitioiis  of  cervix  to  eorpiis  iittri  and  ivllee-  iiif;  ]>ositioii  of  os  internum,  fusiform  cliiiriieter  of 
tiou  of  i>eritoneum  nt  istlinuis.  tlie  cervical  canal,  iintl  relations  of  the  peritoneum. 

about  2.5  centimeters  (1  inch)  in  thickness  ;  of  the  entire  organ,  approxi- 
mately three-fifths  belong  to  the  body  and  two-fifths  to  the  neck,  the  latter 
being  relatively  much  longer  in  the  nulliparous  adult  than  after  pregnancy  has 


^i  1 


^  PORTlOtI/ 

VflCIN/lL 
PoRTIOHl, 


Fio.  30.— Diiieram  illiistrntin!.'  the  reliitiuns  of  the  uterus  lo  the  vni.'inn,  hladder,  nnd  peritoneum. 

occurred.  The  division  of  the  uterus  into  body  and  neck  is  indicated  exter- 
nally by  the  con.stricted  ixihuutx  uteri,  which  is  situated  about  midway  in  the 
organ  ;  internally,  hoAvevcr,  this  botuidary  is  uncertain,  since  the  contours  of 
the  cervical  mucous  membrane  gradually  pass  into  those  of  the  general  uterine 
lining. 


A.yATO.W    OF    THK    (! EXFIiATI  VE    OlidAXS. 


47 


,cen  tlie 
wallt?  at 
,cnt,  the 

(about  3 
ilth,  ami 


Anh-rioy 
sui/itce. 


,  uterus,  show- 
1  clmnutor  uf 
If  juTitoiiuum. 

},  approxi- 

the  latter 

inancy  lias 


|H' 


ritoneum. 


oatcd  oxtcr- 
(hvay  in  the 
contours  of 
leral  uterine 


,1 


5! 


The  pvritoriu  I'ndi/  is  almost  flat  on  its  anterior  surface,  hut  i)osteriorly  is 
(11  sti net Iv  convex  ;  its  superior  and  anterior  arched  border  is  thick  and  rounded, 
and  passes  over  into  the  slightly  convex  lateral  borders  at  the  superior  antrles. 
The  upper  part  of  the  orgiui,  includinjj  its  superior  arched  border,  constitutes 
the  fumhis  and  is  completely  invested  with  peritoneum.  The  serous  covering  of 
the'anterior  surface  extends  oidy  us  far  as  the  isthmus,  whence  it  is  reflected  to  the 
nei'^hborino;  vesical  wall.  I'he  peritoneum  on  the  posterior  wall  is  complete, 
since  the  serous  membrane  is  prolonged  downward  and  backward  about  2.5  cen- 
timeters bevond  the  cervix  upon  the  posterior  wall  of  the  vagina  before  passing 
to  the  rectinn.    The  later.'-.l  borders  mark  the  attachment  of  the  broad  ligaments. 

The  ccrri.r,  sli<rhtlv  spindle-form  in  general  outline,  may  be  divided  into 
three  portions  or  zones  (Fig.  30),  the  supravaginal,  the  intermediate,  and  the 
intravao-inal.  The  first  of  these  zones  occuines  the  upper  half  of  the  cervix, 
extending  somewhat  farther  forward  along  the  anterior  surfaee,  where  it  comes 
in  relation  with  the  bladder,  than  posteriorly,  where  covered  by  the  peritoneum 
of  Douirlas's  jiouch.  The  intermediate  ])ortion  includes  the  zone  of  vaginal 
attachment,  hence  it  is  narrow  and  oblique,  extending  higher  behind  than  in 
front.  The  intravaginal  segment,  or  o.s  uteri,  projects  within  the  vaginal  canal 
in  such  manner  that  its  axis  is  directed  toward  the  posterior  wall,  and  it 


/■'nni/lis  split  I'pi'lt. 


Funtfus. 


Ihtrn. 


\thiiii  ///i  titw. 


Fl(i.  81.— Cnvity  uf  utorus  disiiluyud  by  ri'nidvttl  uf 
iintorior  wall. 


/  'ti^i^in.i 

Fii;.  oJ.— Vir.L'in  \iti'rus  laid  ii|n'ii,  slidwitiir  the 
I'uguu.s  foiKlitidii  uf  tin.'  ct'rvi.v. 


presents  the  transversely  oval  orifice  of  the  cervical  cavity,  bounded  by  the 
rounded  and  prominent  anterior  and  po.<terior  lij)s  or  labia,  the  anterior  of 
wliieli  is  somewiiat  the  thicker  anil  shorter.  The  proportion  between  the  body 
and  the  cervix  varies  with  ay-e :  in  the  vouny;  virgin  adidt  the  uterus  is  about 
ecpially  divided  between  these  segments ;  in  early  life  the  cervix  greatly  pre- 
])on(lerates  over  the  imperfectly  developed  fundus;  while  after  childbirth  the 
fundus  never  returns  to  its  former  size,  always  remaining  enlarged  and  nearly 
twice  its  original  length  (Fig.  31).  With  the  advent  of  old  age  the  entire 
organ  suffers  marked  atrophy. 


48 


AMKllKAX    TEXT-liOOK    OF    OliSTr/riilCS. 


I  1 


;i  A   .1 


H 


4  f 


m\'''^ 


if 


Tlu^  cdritif  of  till-  riri/lii  uterus  is  very  narrow,  tlic  iippositioii  of  the 
iiiitcrior  aiul  jjostcrior  walls  of  its  liody  reducing  tlw  space  to  littlo  more  than 
a  lonjfitu«liiial  cleft,  as  .seen  in  mesial    sagittal   .sections  (Fig.  21)).      Viewed 


Ku..  :'.S.— Casts  (if  tlu'  cavitiis  of  uttTi  (if  viiricms  iikos  niid  coiKlitidiis  (inoditk'd  from  lliini'iimini) . 
2,  ;i,  liiuii  iinilliiniin'  (if  fif,'lit(.'t.ii  mid  twciity-fdur  years;  4,  fniiu  u  wdiiinn  of  forty-i'iKlit  yi'ais  who  had 
(iiR-  cliild  liftcrii  years  iirevious. 

from  in  front,  the  uterine  cavity  is  triangular,  the  expanded  base  extending  be- 
tween the  orifices  of  the  oviducts,  and  the  ai)ex  corresponding  with  the  inner 


Kl(i.  Ii"i.  — Kiniit  mill  )ir(>- 

lile  views  of  easts  of  the 

l"i(i.  :U. -Casts  (if  tlie  eaviliis  of  uteri   frmii   i"i)  a  uulliiiara  of  sixty         uterine  eavity  of  a  iiew- 

ei'.'hl  years,  mid  K'n  from  a  iiarmis  siilijeet  of  seventy  years  iiiiodilied  from        liorn  infant  (modilied  from 

Jla;,'eiiiaiinl.  HaKeiiiann). 

opening  of  the  cervical  canal.      On  account  of  the  encroachment  of  the  uterine 
walls,  the  cavity  of  the  uterus  between  the  angles  presents  concave  outlines. 

The  vdvUji  of  fhe  cervix  is  fusiform,  being  of  larger  diameter  at  its  niiddh: 
than  at  the  vmh,t\H'  "■•<  inlcnunit  and  the  o.s  (wtcnniin.  Theos  internum,  which 
marks  the  point  of  greatest  contraction,  possesses  a  lumen  of  circular  outline;  the 


AXATOMV    OF    TJll-:    (1  KNKIiATI  Vl-l    OlidANS. 


4!> 


1  ol'  the 

ore  than 

Vicwwl 


llaci'iiiinnil- 
I'lirs  who  had 


(Midinj;  l>f- 
i  the  inner 


l-l'nint  mill  )>r(v 
I'  (•ii>l>  iif  Ihf 

ity    111'  II    IH'W- 

(iiiuiliUcdl'nim 


the  uterine 
I  outlines. 

its  niiddU: 
hnini,  which 
Lutline;  the 


OS  externum  heforf  i)r(\LMiaucy  appears  as  a  narrow,  lransver>ely  phiced  oriliee. 
Tlie  antcriiir  ami  posterior  walls  of  the  virgin  eervical  eaiial  exhihit  coiispic- 
u.iMs  plications  (lepeiitlinii'  upon  the  arruntreinent  of  the  hundles  (if  inuseular 
ti-.<ue-  these  Y\\\ivc  are  arranj>eil  asprin<'ipal  loiijiitudinal  l"olds,  the  anterior  and 
posterior  eohunns,  from  whieh  seeon<lary  plications  extend  laterally.  These 
eorrn-iatious  collectively  form  the  nrhor  rihr  (Fij;.  85)  of  the  uterus,  being  hest 
marked  in  the  virgin  and  being  etVaced  by  repeated  jjarturitions. 

Striichiir. The  uterine  walls  include  a  mucous,  a  nniseular,  and  a  serous 

coat.  The  miifnsa  consists  of  a  tiuiica  jn-opria  of  delicate  bundles  of  tibm- 
elastic  tissues  covered  by  an  epithelium  c<-v<posed  of  a  single  layer  of  ciliated 
culunmar  n'lls.  Numerous  wavy  tubular  depressions,  the  ntfrliir  tjUinilx  (Fig. 
;}(')),  are  also  lined  by  the  ciliated  epithelium.     Since  a  subnuicous  layer  is 


Flii.  oi'i.- Scctiiiii  iif  Iniiium  iitrnis,  iiiclmlinu'  iiiiiciisu  m)  anil  ailjacciit  iiiusciihir  tissiu'  (M  ;  c,  I'liithi'- 
lium  c'f  I'liT  Mnliicc  mill  tulailar  utiriiii'  k'hiiiIs  c/i  :  .;',  ilcrpcst  hiyer  nf  iiuicusn,  (iiiitiiiiiiiig  riuiiU  uf 
ghiiiils;  /i,  .slnuids  of  uuu-stripcil  iiiusrlr  pi'lR'trHting  witliili  thu  mucosa  U'l'-'i'sol). 

wautino',  the  blind  and  often  forked  extremities  of  these  glands  abut  directly 
upon  the  muscidar  tissues. 

The  ccrriatl  nuicosa  differs  from  that  of  the  body,  being  thicker  and  tinner, 
sup[)lied  with  papilhe,  and  covered  with  stratified  s(piamous  epithelium  within 
the  lower  third.  In  the  upper  half  or  two-thirds  of  the  cervix  the  e])itheliiim 
is  ciliated  colninnar,  similar  to  that  of  the  body.  In  addition  to  the  tidtular 
follicles,  the  representatives  of  the  usual  uterine  glands,  numerous  short,  widely- 
expanded  nuicous  crypts  lie  within  the  cervical  mucosa.  Retention  of  the 
.secretion  of  some  of  these  mucous  sacs  often  takes  place,  the  resulting  greatly 
distended  cysts  appearing  as  translucent  yellowish  vesicles,  the  so-called  oridiv 
Nnhuthi.  In  its  meagre  su]>ply  of  glands  the  mucous  nuMubrane  of  the  lower 
part  of  the  cervix  still  further  resembles  that  of  the  adjacent  vaginal  surlace. 

The  mitsmldr  coat  (Fig.  37)  of  the  uterus  consists  of  bundles  of  luistriped 
nuiscle  (Fig.  38)  .separateil  by  bands  of  connective  tissue  and  surrounding  vas- 
cular channels.    Although  irregularly  arranged,  the  muscidar  tissue  is  disposed 


no 


AMi:iil<'A\    TEXT- HOOK   OF    OUSTKTltWS. 


I 


in  tliree  geiuTal  .strata — an  inner,  :i  niiihllc,  and  an  uutcr  layer.     'J'iie  inner  layer, 


Yvi.  :'.T.— Arruiimiiuiit  of  uturiiu'  iniisiU',  us  f,vv\\  from  in  fnmt  after  rcmovul  of  siTcms  coat  (llulii'i. 

composed  prineipally  ut"luiigitiKlinal  biiiKlles,  is  in  direct  contact  with  the  nni- 


Fi(i.  :;>.— A,  i.suliitfil  iiaisi'li-'ck'iiu'nts  <if  tlic  iiiiii|ir(.'L:iiiiMt  uttTus  ;  li,  culls  fmiu  \\w  orjjuii  sUditly  nftt'r 

ili.'liviTV  iSiippfy ,. 

cosa,  and  issometinies  regarded  as  belonging  totliatlayer,  as  being  a  hypertrophied 


r  lavor, 


^m 


AXATOMy   ()/'    Till':    GENEliATIVK    <)/{(; A. \S. 


51 


niiiscularis  nuu-osfp.  TIjc  iiiiddN'  layer  is  most  robust,  and  tonus  the  <rroater 
part  of  tlif  iiiiisciilai-  coat,  foiisistiii-,^  i-hicHy  of  himdli's  liaviii^^  a  general  circii- 
lar  disposition.  'I'liis  layer  is  also  distinj^iiisiicd  by  tiic  niiiiicroiis  lar<;c  venous 
cliaunels  enelosed  between  its  bundles,  lienee  the  ivahh;. '<li(ifinii  vdnru/ari:  Tiio 
outer  lavcr  ineliKle-;  botli  eireidarand  lon<;itndinal  bundles,  the  latter  predoini- 
natiu"- and  lvin<;'  in  elose  relation  with  the  superimposed  serous  coat.  Mimy 
binidles  of  tlie  tiMter  layer  pass  into  the  broad  li<j;ameuts  ;  .some  of  these  enter 
the  round  lijianients  and  aeeompany  the  areolar  tissue  and  the  blood-vessels 
eoniposinji'  these  strnetures  toward  the  ^roin,  while  others  extend  alonj;  the 
oviducts  and  ovarian  lijiaments.  Mnseidar  l)ands  pass  also  from  the  uterus 
into  its  siipportintj:  folds,  the  saero-uterine  band  bein<>:  |)articidarly  robust.  The 
nmsculatnre  ol'  the  cervix  is  distinj;uished  by  greater  regularity  in  its  arrange- 


,  (Hc'lio). 

the  mu- 


1 


'^lisM*"' 


roaiiJKrnmcnt. 


X.,. 


^-'t*-- 


I'lDidus, 


l-'ii.,  :;'.i.— lir.iiiil  li^'iiMicnts  viewed  IVdiii  the  piisterini  .-iirl'iice,  sllll\vin^'  uterus,  nviiliU'ts,  ami  ovaries  ; 
tile  iiiitunil  |iipsitiiiii  nC  tlie  latter  has  beeu  ili.stiirlieil  iu  eciiiseiiuenee  nf  tlie  separation  (if  lliu  supiiortiug 
atlaeluiieiits. 


Iiurtly  after 

•rtroi)hied 


mont,  which  includes  a  distinct  inner  longitudinal,  a  middle  eircnlar,  and  an 
outer  longitiulinal  layer. 

'Pile  ticroiiH  ciHit  of  the  utenis  comprises  the  usual  constituents  of  the 
peritoneum. 

Lir/ainctitK. — The  supporting  aj)paratus  of  the  uterus  consists  of  two  parts, 
the  folds  of  peritoneum  and  the  muscular  bands  which  extend  froiii  the  uterus 
to  adjacent  structures.  The  first  group  includes  two  anterior,  two  lateral,  and 
two  posterior  ligaments  ;  the  second  group,  the  so-called  "  muscular  ligaments," 
is  represented  by  the  utero-inguinal,  the  ntero-ovarian,  the  utero-pelvie,  and 
the  utero-sacral  imiscular  bands;  the  last  of  these,  the  utero-sacral,  are  included 
within  the  posterior  jieritoneal  folds;  the  remaining  ones  lie  between  the  layers 
of  the  lateral  or  broad  liiraments. 


52 


A^n^:/i'/(•A^'  thxt-book  or  onsTETiucs. 


V 


I      ; 


TliL'  atitirior  /if/(iiiuit(f<  inv  two  iiK-()ii.<picuon.s  semilunar  jwritoncal  folds  wliidi 
pass  hctweon  the  ujtpL'i-  part  of  tiio  cervix  on  each  siile  to  the  adjacent  posterior 
surface  of  the  hlachlcr,  and  bound  the  vex ico- uterine  pouch. 

The  latend  or  broad  (ii/tnnotts  (Fig'.  '59),  as  implied  by  their  name,  are  two 
wide  duplicatures  of  peritoueiun  that  extend  from  the  sides  of  the  uterus  and 
the  vagina  to  be  attached  to  the  lateral  wall  and  the  Hoor  ol'  the  jH'lvis.  Kach 
of  these  broad  folds  j)resents  four  borders,  tlu;  suj)erior,  the  inferior,  the  inter- 
nal, and  the  external ;  of  these  but  one,  the  sujjcrior,  is  free,  the  t)thcrs  being 
intimately  joined  with  neighboring  j)arts.  The  siijierior  or  free  border  encloses 
till'  oviduct,  whose  tortuous  course  it  follows  as  far  as  the  tind)riatetl  end  ;  at 
this  point  the  ])lication  diverges  toward  the  j)elvie  wall  and  forms  the  hij'iot- 
dibido-pelvie  I'Kjdinent,  which  fold  connects  the  end  of  the  tube  with  the  side  of 
the  pelvis  and  transmits  the  ovarian  vessels.  The  inferior  border  is  united 
with  the  recto-vesical  fascia  covering  the  levator  ani,  the  subperitoneal  tissue 
intervening  between  its  diverging  lamclhe  giving  transit  to  bhtod-vessels  and 
nerves  as  well  as  to  the  ureter.  The  intenud  border  is  attached  to  the  sides 
of  the  uterus  and  the  vagina,  the  blood-vessels  and  nuiseular  bands  passing 
into  the  tissue  of  the  broad  ligament  lu'tween  its  divergent  layers.  The  external 
border  comes  in  relation  with  the  obturator  fascia  and  affords  transit  Ibr  the 
uterine  vessels  and  the  round  ligament. 

The  broad  ligaments  enclose  Avithin  their  serous  folds  structures  of  import- 
ance (Fig.  40).     Along  their  unattached  superior  nuu'gins  lie  the  oviducts ;  a 


TUBE 


UrrfE 


Kii;.  10.— Dianniniinatic  >uction  nf  liroiul  lit-'iiiiu'iit,  showing  ri'latimis  of  tlio  u>     uitiit.'(l  stnicturos. 

little  lower  and  anti-riorly  an'  siliiatctl  the  round  ligaiucnls  ;  jiosteriorly,  the 
ovaries  and  their  muscular  attachments  ;  numerous  blood-vessels,  nerves,  and 
lymphatics,  together  with  the  parovarium,  the  ))aro(>phoroii,  and  the  utero-pel- 
vic  bundles  of  involuntary  muscles  which  ])ass  from  the  uterus  and  the  vagina 
to  the  obturator  fascia,  are  additional  structures  inchi<led  within  these  folds. 

The  roinul  //V/ro/Kvi/.v  (Fig.  41)  are  two  llattened  cord-like  bands,  from  10  to  12 
centimeters  in  length,  attached  to  the  upper  segment  of  the  uterus  in  i'ront  of 
the  oviducts,  and  extending  from  this  ]ioint  downward,  outward,  and  forward, 
winding  round  the  deep  cjiigastric  artery  on  the  inner  side  of  the  external  iliac 
artery,  to  the  internal  orifii'cs  of  the  inguinal  canals,  through  which  they  pass 


.1X1 70.1/ r    OF    THE    (iKNKRATIVK    OlidA^XS. 


O.i 


Uls  which 
posterior 

'?,  arc  two 
itorus  and 
is.      Karh 
tlio  iiiter- 
K-rs  bi'injj; 
'/•  encloses 
i\\  end  ;  at 
the  iuj'iin- 
he  side  of 
is  united 
neal  tissue 
essels  and 
1  the  si(U's 
ds  passin;j: 
lie  external 
iisit  for  the 


to  hlend  with  the  tissues  of  the  labia  niajora.     'i'he  round  lijranient  possesses  a 
eoveriui.;  of  peritoneum,  and  in  the  yoinij;  subject  a  funnel-like  depression  marks 


of  import- 
)viduet.s ;  a 


Y'Ui.  11."  liisM'ilinM  iilllu'  pelvic  Drains,  ^llll^^  ini;  llii'  n'liilinii  nl'tlic  nlHldiiiiiiiil  piirictcs  liitlu'  numil  liuii- 
iiuMls  :iiicl  I  lie  liliiiMir:  l,:i.  till'  ulililcriitfil  liyiui^'ii^tric  nrtrru's  ;  -J,  llu'  urni'liiis  i  Knur^'cry  iiinl  .liu'nln. 

a  tubular  extension  of  the  peritoneal  sac^  alouij  the  cord  as  it  leaves  the  abdomen  ; 
this  extensiiiii  eoiistitutes  the  ccuud  of  Xiick,  ami   is  homoloijous  with  the  pro- 


I 


stnicluros. 

1 

eriorly,  the 

nerves,  and 

e  utero-ju'l- 

the  va<i:na 

esi'  folds. 

•omlOtol2 

in  front  of 

nd  forward, 

xternal  iliac 

■h  they  pass 

i 

l''|ii.  I'.'.- I'lisU'iini'  vifu  orilie  iiliTus  mill  oviiriiv,  u  idi  ih,.  |„Ti|niiciil   fiil.N  (■i>iii|i..-iiiu  iIh- l.ioail  li(;ii- 
lurlll--  mill  llic  lltcrii  rrrtlll  I'uxmi  <  liimliliril    IViilil  lliiilu'i'l. 

ccssiis  vaii'iiialis  of  the  male,      it  is  ii-iially  (.blitrratcd  after  earlv  life,  but  iiiav 
jicrsist,  and,  in  I'arc  rases,  be  accompanied  !      an  abiK.niially  descended  ovarv, 


••^m 


54 


AMERICAN    TEXT- BOOK    OF    OnSTETRIVS. 


which  then  occiipios  a  position  within  the  hibia,  behind  the  peritoneal  sac.  In 
structure  the  round  lii>'anient  consists  of  bundles  of  connective  tissue  and  blood- 
vessels, together  with  plain  ninsenlar  tissue  derived  from  the  uterus. 

The  jtosfcrinr QV  ircto-u((fi)ie.  VKjimivHtH  are  two  peritoneal  folds  which  pass 
backward  from  the  cervix  and  the  upj)er  part  of  the  vagina  to  become  con- 
tinuous with  the  serous  covering  of  the  second  portion  of  the  rectum.  The 
deep  fossa  included  between  these  folds  laterally,  the  uterus  anteriorly,  and 
the  rectum  posteriorly  constitutes  the  poKch  of  J )oiigl<tfi  (Fig.  42),  wiiich  is  fre- 
quently occupied  by  coils  of  small  intestine.  lietween  the  layers  of  the  posterior 
ligaments  flat  bands  of  involuntary  muscular  tissue,  the  so-called  tifcro-mcraf. 


tl!  S ' 


I 


l:):.i  ! 


.!'     f;     it 


mi  i' 


Vu..  l;'..— Siifiitliil  scctidii  III'  I'ciiiiilc  iiflvis,  sliuwiiiir  tlir  ulcrcisiicnil  lifjaiiu'iits  susiicinUn).'- tlic  uti'i'us,  nlsii 
till'  iPiiliic  si':_'iiK'iit  imrt  III'  Ilir  --uiiiiipiliML'  iipinii'atiis  of  tlu'  utiTUs  (Dickinsdiii. 

ligdiiK'tits  (Fig.  43),  extend  on  each  side  from  tiie  highest  segment  of  the  cervix 
to  the  sides  of  the  sacrum,  at  tlie  level  of  the  sacro-iliac  juncture.  These  bands, 
among  the  most  important  parts  of  the  supporting  a])paratus  of  the  uterus,  are 
intimately  related  witii  tlie  muscular  coat  of  the  rectum,  which  tube  they 
encircle  near  the  union  of  its  tii'st  and  second  ])arts ;  laterally  and  anteriorly 
they  are  in  close  relation  with  the  pouch  ol"  Douglas. 

The  y>o.s///rj*(  of  the  norma!  uterus  (Fig.  22)  during  life  has  received  considera- 
tion from  many  investigators,  whose  conclusions,  however,  have  been  s(»  contra- 
dictory and  uncertain  that  almost  every  situation  of  the  organ  has  in  turn  been 
regarded  as  representing  its  normal  relation.  This  discrepancy  has  been  due 
in  large  measure  to  the  methods  of  examination  employed,  which  include 
observations  on  the  cadaver,  biniMMual  examination  of  the  pelvic  organs  of  the 
living  subject,  and  I'ro/.en  sections  of  tlie  parts  shortly  alter  death. 

The  examination  ol'  the  viscera  in  the  cadaver  in  the  usual  way,  even 
when  carried  out  with  -kill  and  j)reeaution,  nui.-t    necessarily  be  untrustworthy 


JXATO^Vr   OF    THE    (lEXERATIVE    ORGANS. 


55 


sac.    In 
id  blood- 

lich  pass 
jiue  con- 
111.  The 
jrly,  and 
c'li  is  fre- 
postorior 
•ro-sdcnil 


'I 


Tt 

'';(-- 


as  to  the  details  of  topos^rapliical  relations,  on  account  of  the  uncertainty  in- 
trodiicwl  bv  icason  of  the  unavoidable  post-mortem  alterations  and  ine\  itable 
distortions  affecting  the  organs.  The  apparent  exactness  of  the  method  of 
fro/en  sections  likewise  is  iiiifavoral)]y 
influenced  by  the  relaxation  after  death 
of  the  sui)porting  bands  which  during 
life  maintain  tlic  positions  of  the  organs  ; 
it  follows,  therefore,  that  the  testimony 
of  sections  cannot  be  accepted  as  unim- 
peachable evi(l(>nce  as  to  relations  during 
life,  since  the  relations  presers'cd  are 
oiilv  those  existing  at  the  time  of  fix- 
ation;  likewise,  the  possibility  of  en- 
countering the  effects  of  pathological 
chansres  in  fro/en  s(>ctions  must  also 
be  appreciated.  The  testimony  of  the 
most  competent  and  careful  investiga- 
tors points  to  the  conclusion  that  the 
most  valuable  and  trustworthy  observa- 
tions as  to  the  norn;.d  position  of  the 
uterus  are  to  be  gathered  from  careful  examinations  of  jiroporly  ])reserved 
bodies,  where  the  organs  have  been  hardened  in  situ  immalidtc/i/  after  death. 
The  results  of  such  investigations  closely  agree  with  the  opinions  of  tiie  most 
expert  observers  derived  from  repeated  examinations  on  the  living  subject. 


Fig.  44.— DiiiKnuiis  illustratinK  rniifro  df  va- 
rintiou  in  ])i).sitiuii  of  uterus  as  nllVctcd  liy  ilis- 
tontlon  of  the  bladder  (Van  do  Warker). 


the  cervix 
;e  bands, 
Items,  are 
tube  they 
anteriorly 

eiiiisidera- 

■o  conlra- 

tiirii  been 

s  been  due 

li    include 

fans  of  the 

way,  even 
•ustworthv 


Fn;.  4ri.-  T.ciimitudinal  portion  of  iMiUopiaii  tulic,  expivsimr  llu'  coiiipliciiti'd  loiiL'iludiiiiil  plications  of 
tlie  iii.H'osa  wliicli  e.Npami  into  tlie  liuilniie  (.Sappeyj. 

In  accordance  with  the  conclusions  ba.><ed  on  suHi  grounds,  the  normal  uterus 
most  ])robal)iy  occupies  a  position  almost  horizontal  in  the  upright  posture: 
the  lundiis,  ustiiiUy  slightly  to  one  side  of  the  mid-line,  r(>sts  on  the  bladder 
and  is  directed  forward  and  upward,  while  the  cervix  forms  a  slight  deflt>ction 
with  the  axis  of  the  uterine  bodv  and  looks  down  and  backward  auaiii.^^t  the 


riC, 


AM  hi? /('AX    TKXT-JIOOK   OF    OBSTETRICS. 


%i 


I 


*     i-; 


i 


i  -  ^ 


III 


I  I 


\  \ 


posterior  vaginal  wail.  Wliotlu'r  tiic  uterus  lies  most  frequently  to  tlic  right 
or  to  the  left  of  the  mid-line  is  still  in  dispute;  the  latter  position,  to  the 
right,  is  probahly  most  usually  encoinitored  (His),  although  the  opposite  con- 
dition, as  shown  on  IMate  8,  is  certainly  uot  uncommon.  The  topographical 
relations  between  the  uterus  and  tiie  bladder  are  so  close  that  the  position  of 
the  womi)  is  materially  iuflnenced  by  vesical  distention.  The  range  of  varia- 
tion in  tiie  position  of  the  normal  uterus  is  diagrammatically  represented  by 
Figure  44. 

The  ofi<li(cf,s,  or  F((//(tj)i<in  UiIx'k  (Fig.  •■>8),  the  representatives  of  the  un- 
united portions  of  the  fetal  Miillerian  ducts,  extend  from  the  superior  rounded 
angles  of  the  uterus,  within  and  along  the  free  upper  margin  of  the  broad 
ligaments  for  a  distance  of  from  10  to  12  centimeters,  to  the  vicinity  of  the 
t)varies,  wiiere  each  terminates  in  an  expanded  fumiel-shaped  orifice,  the  pavil- 
ion or  i)ift(n<lil))ilinn,  surrounded  by  a  series  of  fringed  processes,  tho  Jitiibrue 
(Fig.  45).  P^xamined  in  carefully-preserved  specimens  retaining  the  typical 
])o>ition  of  parts,  the  tube  at  first  passes  outward  closely  related  with  the  pelvic 
Hour;  it  then  turns  ujnvard  along  the  altached  anterior  border  of  the  ovary, 
when,  after  reaching  the  upper  pole  of  the  gland,  the  tube  bends  downward 
upon  the  free  posterior  border  and  the  inner  surface  of  the  ovary  (Figs.  22, 
41),  which  are  by  this  means  partly  masked  (Waldeyer). 

The  oviduct  commences  at  the  iinier  attached  extremity  as  a  narrow 
tube,  the  istlnnus,  about  2  millimeters  in  diameter;  during  its  further  slightly 

wavy  course  it  gradually  gains  in 
width  until  the  tube  measures  4 
millimeters  or  more,  when  it 
again  becomes  somewhat  nai'- 
rowed,  but  beyond  the  ovary  it 
rapidly  expands  into  the  ampulhe 
and  the  fimbriated  extremity  (Fig. 
4G).  The  lumen  of  the  tube  is 
narrowest  at  its  inner  end,  where 
it  opens  into  the  cavity  of  the 
uterus  by  a  minute  orifice,  the 
osfhtm  infcrinoi},  which  scarcely 
admits  a  bristle  ;  the  diameter  of 
the  canal  gradually  increases  until 
it  presents,  just  l)efore  its  fnial  ex])ansion  into  the  fimbriated  orifice,  a  distinct 
opening,  the  oxtimn  (thdoinind/c  (from  4  to  tJ  millimeters  in  width),  situated  at 
tiie  bottom  of  the  cleft-like  (le[)ressi()n  leading  from  the  attached  border  of 
the  fimbriated  exj>ansion. 

Sfriichiir. — The  ovichict  consists  of  three  coats — an  inner  nuicous,  a  middle 
muM'ular,  and  an  outer  serous.  The  iini<'fiitf<  lining  presents  numerous  longi- 
tudinal folds  (Fig.  47)  ;  these  become  more  consj)icuous  within  the  inf"undibu- 
hnn,  where  they  greatly  increase  in  size  and  complexity  and  terminate  in  the 
sinuous  border  of  the  fimbriie.     All  parts  of  the  canal,  including  its  ex](anded 


ri'..  Ii'i,— I'liiti^n  nl'liri)H(l  li!.'iuiifiit  stri'tcli'"'  '-■■ :  Imw 
tlio  imnivnrimii  (i>i  lyiiin  ln'twci'ii  Um.-  fulils  lunl  I'oi  -  .stiiiK 
or  the  lioini-tuli(.'  and  fi'oss-Hiliuk'S  (lii'jioiibiuir). 


AXATOJfV   OF    TIfl':    GENERATIVE    ORGANS. 


hi 


niitor  (-11(1,  :uT  clothed  by  a  .single  lavor  of  ciliated  columnar  cells,  whoso  ciliary 
current  sweeps  from  the  fnnhriic  toward  the  uterine  end  of  the  tube.  At  the  free 
cdce  of  the  fimbria}  the  columnar  epithelial  cells  give  place  to  the  low,  i)late- 
lil<('  elements  of  the  peritoneum  covering  the  exterior  of  the  tube.  (Jlands 
are  al)sent  within  the  nuicons  membrane  of  the  ovi(hict.  The  viKscnhir  fiuiic 
includes  a  i)rincipal  inner  layer  of  circularly-disposed  bundles  of  involuntary 
jcle  and  a  sii'ditly-develoj)ed  outer  layer  of   longitudinal    binidles.     The 


muse 


a  middl(> 
lis  longi- 

lundibn- 
ite  in  the 

xpanded 


1 


Fir,.  I".— Traiisvt.Tsi'  si^ction  i>f  l-'iillnpinn  tiiln',  slKiwiiiir  the  ciiiiiiiliciitcil  nrrniiKcmcnt  fjf  tlic  I<ingitii(liniil 
jilicatiiiiis  wliicli  iiri.'  licii'  rut  acniss  (Mnrtin). 

f<erous  enat  consists  of  the  fibro-elastic  stroma  and  endothelium  of  the  general 
periton(\il  investment  contributed  by  the  broad  ligament. 

The  />/o«(/-C('.s.s(7.s  of  the  oviducts  arc  branches  from  the  ovarian  and  the 
uterine  arteries  and  the  corresponding  veins,  the  arteries  possessiug  an  tunisu- 
ally  tortuous  course.  The  ncrirn  are  derival  from  the  ovarian  and  uterine 
plexuses,  and  consist  of  both   meduUated  and  ])ale  fibres. 

TItr  OvdricK.  —  Each  ovary  jireseuts  a  flattened  ovoid  mass,  somewhat 
almond-shaped,  which  appears  as  an  appendage  of  the  posterior  surface  of  the 
broad  ligament  (Fig.  'V,)),  to  which  the  organ  is  attached  by  its  straighter  anterior 
l)order.  The  dimensions  vary  with  the  individual  as  well  as  with  the  condi- 
tion of  function:il  aetivitv  ;  the  longest  diameter  usnallv  measures  about  3.0 
oontimcters,  the  width  about  2  centimeters,  and  the  thickness  a  little  ov«'r  1 
centimeter.  The  weight  of  the  ovary  is  ordinarily  between  (!  and  7  grams, 
the  right  being  eoiniuouly  slightly  heavier  and    larger  than  the  left  ovary. 

The  anterior  border  alone  is  attached  ;  the  arched  posterior  border  and  the 
broad  surfaces  arc  free  and  are  covered  with  modilicd  peritoneum,  the  f/enninal 


^^"9 


58 


AMERICAN    TEXT-nOOK   OF    OBSTETRTCS. 


;    '^ 


epithelium,  directly  coiitinnous  with  tlio  serous  eoverinj;  of  the  broad  ligament. 
The  position  of  the  ovaries  in  fiita  (PI.  8;  Fij;s.  22,  41)  and  <lnrinf;  life,  at 
least  before  the  permanent  displacement  attending  jm^gnaney  has  taken  place, 


/'UHtft/\  of  uttrus 


I'/i'ro-tT'tir/'itn 


l-'io.  4s.— Ovury   natural  sizt').^\ith  tin'  Kalln])ian  Uihv  \n  relative  iiositiun,  nCa  wnniaii  Iwenty-thrcu  years 

of  age  (Sutttm). 

is  probably  such  that  the  long  axes  of  the  organs  are  nearly  vertical  (Wal- 
deyer,  His,  Cunningham)  and  correspond  closely  with  the  sagittal  ])lane,  so 
that  the  broader  surfaces  may  be  spoken  of  as  internal  and  external  rather 

{/inibritP)^. 


I 'milium. 


-■^   ihuirian 

i         MIL. 


I  tirus. 


/^^f 


ih..,i,/ 


Round  lii;ti}uent. 
Fiii.   I'.i.— Oviiriiin  sac  nr  nccss  oii   tlie  jHisti'iior  iispi'd  uf  the  broiKl  ligament  inidiiilioil  from  Iticlmrd 

Ijy  lilaml  Siittciiii. 

tlian  as  antorior  and  jxjstcrior.     Tlio  ))()siti()n  of  the  riiiidiis  uteri  i.s  a  faetor 
ot'  luumout  in  deteniiiiiing  tiie  ovarian  axis,  .>^ince,  as  pointed  out  by  Ili.s,  the 


f ,: 


AXATOMV    OF    THE    GEXERATIVI':    ORGANS. 


59 


igamcnt. 

rt  life,  at 
en  place, 


null  of  the  uterus  when  not  occupying  a  mesial  position  predisposes  to  increased 
ol)li(luitv  of  the  ovarian  axis  of  the  opposite  side. 

The  smaller  and  lower  end  of  the  ovary,  or  the  uterine  pole,  points  toward 
the  uterus  witii  which  it  is  united  by  means  of  the  fil)ro-muscular  bands  consti- 


Fuflihfi  of'  iltrrus. 


y-thrcf  years 

cal  (Wal- 

])lane,  so 

lal  rather 


rum  Kiclmnl 

-  a  factor 
His,  tlie 


I 


CoilToiiiti::/  tul'i\ 


()ritry.        CV;T7*.r. 
Fiii.  .'ii,— rtcnis,  tiiln's,  mill  uvurii's  (if  ii  fliilil 

(SuUolll. 


Yfi..  ,'.11— Ovary  mid  tiilic>  iimtiiriil  size)  nt'  ii  wnii      .  of  sixty-riiilit  yi'iirs  (SiittmO. 

tutiii"'  the  (iriiridu  /If/dinent ;  the  uj>per  and  blunter  end,  or  the  fiibol  pole, 
after  being  embraced  by  the  arching  oviduct,  receives  the  lower  border  of  the 
finiiiriated  extremity  of  the  Fallopian 
tube,  and  is  further  connected  to  the 
wall  of  the  pelvis  by  the  nntfio-pelvic 
folil  of  the  j»eritoneuni.  The  ovary 
lies  within  a  ])eritoi)eal  recess,  the_/b.s'.sa 
onirii  (dandius),  which  occu})ies  the 
posterior  part  of  the  side  wall  of  the 
pelvis,  usually  boimded  by  the  internal 
iliac  aitcry  and  the  ureter  behind  and  the  obturator  vessels  and  nerve  in  front. 
i>oth  the  anterior  an<l  posterior  borders  of  the  gland,  as  well  as  its  inner  sur- 
face, are  closely  related  to  and  are  partly  masked  by  the  curves  of  the  oviduct. 

Sfriictnre. — The  ovary  is  divided  into  the  corfe.r  and  the  viediil/a  (Fig.  52), 
the  boundaries  ol' which  are  conventional  and  not  sharply  defineil.  The  cnrfe.r 
includes  the  juM'ipheral  zone,  containing  the  (iraatian  follicles  and  the  ova,  and 
occupies  ap])roximately  the  outer  third  of  the  organ.  The  viednl/a  embraces 
the  remaining  central  portions  of  the  organ,  in  which  the  blood-vessels,  enter- 
ing tlu'ough  the  hilum,  are  ccmspicuous. 

The  bulk  of  the  organ  consists  of  the  orarhni  .sfro^na,  a  peculiar  form  of 
connectivi'  tissue  in  which  lie  imbedded  the  Graatian  follicles,  distinguished  by 
the  great  number  of  its  spindle-cells.  Tliese  cells  are  especially  closely  packed 
in  the  cortex  immediately  beneath  the  surface  covered  by  the  germinal  epi- 


V  "IP 


60 


AMFJilVAX    TEXT-BOOK   OF    OBSTETIilCS. 


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i  I 


If 


m. 


f 


h  ^  :.^ 


,5       i 


tlioliiini,  ill  which  i^itiiation  thov  constitute  a  hiyer  of  greater  density  than  the 
adjacent  stroma,  to  wiiich  the  name  tunica  (ilhuyinca  is  a])|)lie(l ;  this  stratum, 
^jtm-^  however,  is  onlv  a  eondeiisation  of  the  ordi- 


mono;  the  immature  follicles  are  others  in 


Fl(i.  'iJ.— Seel  inn  df  liiiniuii  oviiry.  inrluiliiiK 
oortox  :  ((,  (.'vniiiniil  f]iitlu'lium  nf  I'rci' surfiict' :  b, 
tMiiica  iilbiij.'iiu'ii ;  c,  iicriplu'riil  strnmii  ('(iiitniii- 
iiif;  inimuluiv  (inmllim  tnlliclcs  (i/i;  i.  wcll-iid- 
Viiiici'il  liilliilc  ('nun  wlinsi.'  wiiU  nu'nilininn  ixriinn- 
Icisii  1ms  luirtiiilly  si'iiiiniti.Ml ;,;'.  cnvity  ol'li(|U(ir  lul- 
liciili :  II,  ovum  summniU'd  liy  ci'll-nniss  cuiisti- 
tntinf,'  (liscns  i)riilii;i.'i'ns  (Picrsnl). 


Kic.  ."iii.— Ovary  with  ninturc  (irnnflnn  fdlliclc  nbont 
roiuly  to  burst  (UibcMnont-Di'ssiiiKm's). 


various  stages  of  more  advanced  develoi)ment,  where  the  ova  are  encircled  by 
twt)  or  more  rows  of  pijlygonal  cells  which  by  their  division  give  rise  to  the 
numerous  elements  lining  the  follicle. 

Both  the  ova  and  the  surrounding  cells  are  derivatives  of  the  germinal  epi- 
tlidium  covering  the  free  surface  of  the  ovary,  from  which  they  dip  into  the 
stroma  as  cylindrical  cell-cords.  With  the  increase  in  size  which  accompanies 
their  development  the  (Jniatian  follicles  pass  toward  the  inner  limits  of  the 
cortex  bordering  on  the  mc<lulla,  where  they  undergo  further  enlargement ;  after 
a  time  their  diameter  includes  almost  the  entire  cortex,  and  extends  from  the 
medulla  to  the  surface  of  the  ovary,  the  position  of  the  follicle  becoming  evi- 
dent on  the  free  surface  as  a  distinct  projeetior.  (Fig.  53),  marking  the  point 
at  which  the  final  rupture  of  the  sac  and  the  escape  of  the  ovum  take  place. 

The  mature  (Jraafian  follicles  apjiear  as  clear,  slightly  elongated  vesicles  8  to 
12  millimeters  in  diameter  ;  they  are  defined  from  the  surrounding  tissue  by  a 
condensed  layer  of  the  ovarian  stroma,  the  fhcca  fol/iculi.  Within  the  thcea  fol- 
lows the  iiicuihninfi  f/rdiiKlnsa,  consisting  of  many  layers  of  small  polyhedral 
epithelial  cells.  At  one  j)oint  the  inembrana  granulosa  presents  a  thickening 
which  encloses  the  ovum  and  constitutes  the  discux  pvolif/crus.  The  cells  of 
the  discus  next  the  ovum  lie  vertical  to  its  surface,  forming  a  radial  zone,  the 
cornna  ritfJiatd.  Within  this  layer  lies  the  sexual  cell,  the  ovum,  which  will 
be  considered  more  fully  in  the  section  relating  to  its  developnieut. 

The  formation  of  new  follicles  continues  only  for  a  short  time  after  birth; 


AXATOMV    OF    TITK    (iKXFJiATIVE    OliCAXS. 


61 


(jvisu's  aro  tlicii  mitst  miinerous,  the  fntiro  number  ooiitaincd  witliin  the  two 
ovaries  of  the  child  beiiij;  ewtiniated  at  over  seventy  thousand.  In  view  of 
tiic  unquestionably  iarji'e  number  of  follieles  in  very  yoimj!;  ovaries,  and  the 
relativelv  small  proportion  of  ova  which  reach  maturity,  the  defeneration  of 
nianv  follicles  ai'ter  attaininji;  a  certain  development  seems  certain.  The  atrophic; 
remains  of  such  dciicnerating'  Graafian  follicles  continually  encountered  point 
conclusively  to  the  fate  of  a  lar<>;e  contin<,rent 

The  mcdnlla  contrasts  with  the  corte.\  l>y  .'  Kxjser  structure  and  the 
numl)cr  and  size  of  its  vascular,  and  particidaily  its  venous,  canals.  A  con- 
siderable amount  of  involuntary  muscle  is  intermingled  throughout  the  fibrous 
tissue  soijarating  the  blood-vessels.  Irreguhir  groujjs  of  polyhedral  cells  aiv 
encountered  between  the  fibrous  bundles  of  tlie  medulla  ;  these  elements,  the 
intcvMitial  cclh,  represent  the  remains  of  atrophic  parts  of  the  fetal  WoUHan 

bodies. 

On  the  escape  of  the  ovum,  surrounded  by  the  cells  of  the  discus  pro- 
lii>('rus  the  ruptured  and  partly  collapsed  follicle  becomes  filled  with  blood 
i)oured  out  li'om  the  torn  vessels  of  the  walls  of  the  follicle.  Subse(pieut 
chaii<''<s  lead  to  the  conversion  of  the  follicle  into  a  corpus  Itdcidu.  This 
characteristic  structure  is  formed  by  the  ingrowth  and  rapid  proliferation  of 
the  vascular  tissue  of  the  fi)llicular  wall,  spindle-shaped  connective-tissue  cells 
and  lar«>('  cells  containing  yellow  pigment,  hitch),  being  the  most  active  ele- 
ments in  the  process.  The  history  of  the  corpu-  luteum  is  materially  affected 
bv  the  occurrence  of  pregnancy,  since,  instead  of  being  almost  entirely 
absorbed  within  a  few  weeks,  as  is  the  rule  with  the  ordinary  bodies,  when 
fertilization  takes  place  they  ])ersist  until  after  the  end  of  gestation.  It  is 
usual  therefore,  to  distinguish  the  corpus  hitcvm  of  pref/iuoieif,  or  the  corpus 
vcrniii,  from  the  corpus  hifeum  of  iiictistruation.  The  mode  of  growth  is  iden- 
tical in  both,  the  stinudus  of  impregnation  leading  usually  to  excessive  devel- 
opment. The  primary  blood-dot  occupying  the  ruptured  follicle  becomes 
invaded  bv  the  eidarged  and  thickened  wall,  which  soon  beeouKs  corrugated, 
the  plications  encroaching  upon  tiie  clot  and  increasing  to  such  an  extent  that 
the  folds  crowd  against  one  another  and  eventually  form  an  irregular  broad 
envelope  surrounding  the  remains  of  the  central  clot.  When  jnvgnaucv 
occurs  the  processes  are  continued  beyond  their  usual  length,  resulting  by  the 
enil  of  the  first  mouth  in  the  production  of  a  mass  from  12  to  '20  millimeters 
in  diameter,  characterized  by  a  brilliant  yellow  ])eri])heral  zone  siu'rounding  a 
lighter  centre.  This  condition  is  succee<led  by  the  gradual  reduction  and  cica- 
trization of  the  central  area  and  the  lighter  tint  of  the  now  greatly  corrugated 
broad  outer  belt.  By  the  end  of  gestation  t\w  white  nucleus  constitutes  about 
one-third  of  the  entire  corpus  luteum,  which  has  already  become  somewhat 
smaller  (10  to  13  millimeters)  than  at  the  sixth  month.  After  delivery 
absorption  jmigresses  rapidly,  but  fi>r  some  months  later  the  ]>osition  of  the 
corpus  is  distinguishable.  The  characteristic  yellow  color  of  these  bodies  is 
due  to  the  presence  of  a  peculiar  pigment,  hdchi,  and  not  merely  to  disinte- 
grated blood. 


r 


ni 


it 


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f 
1 

! 

i 
1 


i  ^ 


(i2 


AMKIilCAX    TEXT-nOOK    OF    OllSTKTnWS. 


Tl»c  pf'ctiliaritiis  distiiijinisliiiiji'  the  forpiis  liitciim  of  pregnancy  from  that 
of  mc'iistnuitioii  havi'  Iniijjj  km  regarded  as  of  especial  signilicaiiee  as  stipplv- 
iiijj;'  positive  evidcnec  that  ])r<'i;iiaii('y  has  tak  ii  phiee.  WhiU'  the  presence  of 
the  typical  yellow  liody  iiiiist  he  rejiarded  as  stro  .<>;ly  iii<licativ(!  of  such  condi- 
tion, the  occasional  encounter  in  the  ovaries  of  inidouhted  virgins  of  <'or- 
pora  lutea  possessing  the  characteristics  of  those  of  pregnancy,  as  recorded  by 


'I'lll;-  nil 


VI.— Oviirir.s  (if  t\v 


i|■t.'iIl^,  show  iiit;  Im-p'  cciriKirii  liitiii.  rcscinliliii^'  tlmsf  of  iirctriiiinry  (Hirst). 


•  Ilir.st  (Fig.  54),  should  lead  to  some  reservation  and  to  a  demand  for  cor- 
rohorative  evidence  in  the  acceptance  of  these  bodies  as  infidlible  signs  of 
the  existence  of  pregnancy. 

Tlic  VdYovar'mm.  —  The  jHirontrinin,  the  cjxiujihoron,  or  the  nrf/an  of 
J-ioscimiiif/cr,  consists  of  a  grouj)  of  inconspicuous  tui)ular  structures  within  the 
broad  ligament,  between  the  oviduct  and  the  t)vary,  not  far  from  the  attached 
border  of  the  latter  organ  (Fig.  4(i).  The  parovarium  consists  of  a  series  of 
fi'om  twelve  to  eighteen  short  (iibitlcx  which  lie  irregularly  parallel,  their 
ovarian  en<ls  slightly  converging,  and  which  are  connected  at  their  opposite 
extremities  with  the  longitudinal  licod-fiihc  of  larger  diameter  extending  for 
some  distance  within  the  broad  ligament  toward  the  uterus.  The  tubules  are 
lined  with  low  columnar  epithelial  cells,  the  representatives  of  the  elements 
clothing  the  embryonic  canals. 

The  ])arovarium  represents  the  partially  obliterated  remains  of  portions  of 
the  Woiniaii  body  of  the  fetus;  the  short  canals  correspond  with  the  tubules 
of  the  body,  whil(>  the  head-tube  is  identical  with  the  u|)per  ])art  of  the  Wolff- 
ian duct.  Wlii'U  this  latter  canal  persi.-ts  throughout  the  greater  part  of 
its  original  extent,  it  constitutes  Udrtner'x  duct,  the  homologue  of  the  vas 
deferens;  the  entii'e  parovarium  corresponds  morphologically  with  the  tubules 
constituting  the  globus  major  of  the  epididymi>. 

Additional  fetal  remains  in  the  form  of  rudimentary  tubules  are  sometimes 
encountered  within  the  broad  ligament  in  the  vicinity  of  the  ovary,  although 
situated  rather  nearer  the  uterus  than  the  parovarium.  These  strnctui'cs  con- 
stitute the  jxiraojilinraii,  ;md  represent  the  atrophic  transverse  tubules  of  the 
lower  ])art  of  the  ^\'ol^iau  body,  being  homologous  with  the  paradidymis  of 


ANA"'K)fV   or    Tin-:    aEXEliATlVE    OltdAXS. 


6;', 


tin  tliiit 
siipply- 

«'ll(-'(!   of 

li  fojuli- 

(»f"  (Mtr- 

)1(1('(1  l)V 


ry  (llirsi). 

1  ibr  cor- 
sigus  of 

nrf/(ni   of 
ithin  the 

attached 
series  of 
lei,   their 

opposite 
luliiig  for 
1)11  les  are 

elenieiits 

)rtions  of 
e  tuhules 
le  Woltt- 
part  of 
the  vas 
le  tuhiiles 

)iiietiiues 
although 
iires  eon- 
les  of  the 
(Ivniis  of 


Fi(i.  .^fi.-siHlUcd  liyiliitiil  iit- 
tiichcd  tu  liuiliriiiti'J  cxtrfiiiity  of 
l''iillii]iiini  tiilic  (NfW  Yiirk  llos|iital 

C'llljillL'tl. 


the  male.  The  closed  tnhules  of  the  paroophoron  are  lined  with  low  cohinniar 
epitheliinn  and  are  often  oceludcd  hy  partially  shed  cells.  The  tubules  of  these 
atrophic  organs  possess  a  practical  interest  from 
their  liability  to  become  diseased  and  converted 
into  cysts  which   may  assume  Iarg(!  diameters. 

'fhe  .st<i/l<<'if  lii/(l<iliil  "f  Morgagui  fre(|iiently 
forms  a  conspicuous  a|)peiKlage  to  the  broad  liga- 
iiieiit  near  the  limbriated  extremity  of  the  ovi- 
duct O''-'  •"*'"^)'  '''''■'*  l»'duncidated  vesicle,  which 
varies  urcatlv  in  size,  represents  the  remains  of 
the  nrniMphros,  being  connnon  to  both  sexes.  Lmw 
,,,,|ii,iiii;ir  or  eubuidal  epithelium  forms  the  lining 
,,!'  it-  (lilatcil  sac  and  stalk  so  i'av  as  pervious. 

The  Vessels  and  Nerves  of  the  Internal 
Generative  Organs. — The  vascular  and  nervous  su])plies  of  the  uterus  and  its 
apiHiiilaues  and  of  the  ovaries  are  so  intimately  related  that  they  may  conve- 
iiiciitlv  be  considered  together.  These  organs  receive  their  blood  from  three 
^,, ,,!,.,,.; — the  uterine,  the  ovarian,  and  the  finiicidar  arteries  (IM.  7). 

Tile  iihrinr  artery  is  given  off  from  the  internal  iliac  close  to  the  ])elvic 
wall,  aloiii;'  w  Inch  it  runs  as  far  as  the  broad  ligament,  within  whose  folds  it 
then  p:i-st'>,  in  front  of  the  ureter,  toward  the  cervix  uteri.  After  giving  oif 
twio-s  wliicii  surround  this  part  of  the  uterus  the  artery  ascends  along  the  body 
(if  the  uterus,  sending  oif  branches  which  anastomose  with  those  from  the  oppo- 
site -iile  to  encircle  the  organ.  The  upper  terminations  of  the  uterine  freely 
(■(imiiiuiiicate  with  the  branches  of  the  ovarian  and  the  funicular  arteries. 

The  (iniriiin  arterij,  the  homologue  of  the  spermatic,  is  a  l>ranch  from  the 
alidfimiiial  aorta,  and  gains  entrance  through  the  iufundibulo-pilvic  band  into 
the  liinad  ligament,  within  which  it  divides  into  its  two  principal  branches — 
the  i)il»(l  ;iiid  the  ovarian.  The  tubal  branch  extends  along  the  border  of  the 
oviduct,  .-ending  numerous  twigs  for  the  nutrition  of  the  tube  and  the  tissue  of 
the  limad  ligament.  The  ovarian  proprr  is  of  larger  size,  and  passes  close  to 
the  tree  holder  of  the  ovary,  which  it  particularly  supplies,  tiiially  anastomosing 
with  the  nieriiie  and  funicular  arteries  iicai-  the  upper  angle  of  the  uterus. 

The  /iiiiiri(/ar  artcrif  is  given  off  from  the  vesical,  after  which  it  joins  the 
round  liuanieiit  at  the  internal  abdominal  ring  and  divides  into  ascending  and 
(hseeiiding  iii'anclies,  the  latter  jiassing  into  the  labium  along  with  the  liga- 
ment, tiiere  to  anastomose  with  the  external  jmdic  ;  the  former  ascends  back- 
ward within  the  liLiameiit  as  far  as  the  angle  of  the  uterus,  where  it  Joins  the 
ovarian  and  the  uterine  arteries. 

The  riliis  of  the  uterus  and  of  the  ovaries  are  large  and  numerous  and 
tend  to  tiirni  plexiibrm  netwin'ks.  Those  of  the  ntrriiK,  always  large,  but  of 
enornioii-  size  during  ])rcgnancy,  form  a  plexus  within  the  broad  ligament, 
which  |)h'\iis  subse(|ueutly  gives  place  to  a  trunk  which  accompanies  the 
Miteiy  and  terminates  in  the  internal  iliac  vein.  The  ovariim  reins  are 
pMititiihii'ly  well  developed  in  the  vicinity  of  the  hilum  ;  within   the  broad 


■iili 


6J 


.ij//;A7r.i.v  Ti:.\T-r,(K>K  or  oiisTi/rix'ics. 


m 


lijrniiiciit  tlicy  (in'iii  :iii  iiitriciitc  incsliwork,  the  jxiiiijiinij'onii  jih.niH,  wliicli 
siirroiiiids  tlic  iirlt'iy  and  uii  tin'  ri<f|it  si<l»>  tcniiiiuitcs  in  tlu'  inl"i'ri(»r  cava,  on 
tlic  k'f't  ill  flic  I'ciial  vein.  Tlic  siili|icritoii(  al  tissue  cdiitains  irrcat  nnmhcrs 
oi'  vciKiiis  cliaiincls,  tlic  presence  ni'  wliieli  is  a  iiiatter  oi"  practical  import. 
Tlic  fi/iiijtIiti/irK  (IM.  9,  Fi;rs.  2,  8)  e(Hinccte(l  with  tlic  internal  (irjrans  ol' "fen- 
eration iM'ifin  as  intcfstitial  lyiuph-clel't.sand  radicles  which  these  viscera,  in  coin- 


uterus. 


^    i 


.,u 


Fiii. 'iCi.— Nerves  III' llu>  pelvic  (irfiiiiis  of  tlie  feiimle  (  Kninkriiliiiusein  :  1.  nerves  to  fundiis  of  uterus  ; 
'.'.  ri^'lit  Fiilliiiiiiin  Hibe:  ;l,  ri«lit  nmiiil  liKiinieiit;  I,  nerves  tn  Fiillnpiiiii  Hilie;  .".,  edMiinniiieiUion  between 
oviiriiui  iinil  uterine  nerves;  i\,  civiiriim  plexus  nf  veins:  7,  ovariim  vein;  s,  nerve  (nissinn  tci  join  oviiriiiu 
plexus  ;  'J.  liniliriiited  extremity  (if  Fiillopinii  tulie  ;  in.  relleeteil  peritcmeDUi ;  II,  uterine  nerves;  p.",  supe- 
rior liypnpistric  jilexus  ;  i:!,  briinehes  from  liypofiiistrie  plexus  to  uterus  ;  11,  inferior  liyponiistrie  plexus  ; 
l-'i,  vi'sieiil  nerves  ;  1(1,  eonimunicMtinn  briinehes  to  vesical  plexus;  17,  eervieiil  n'ln^'lion  ;  !.'»,  brunches  of 
hypoi-'iistric  plexus  to  cervical  ^'aim'lion  :  I'.i.  first  siicral  nerve;  jn,  branches  i>assini.'  .obladil.'r ;  'Jl,  brunches 
jiassins:  between  bladilcr  ami  rectum;  'JJ,  commnnicatiiii.'  brniiches  from  second  sacral  to  cervical  ^iin- 
KJion  ;  ■-';!,  branch  from  third  sacral  nerve  to  cervical  pini-dion  ;  'Jl,  second  sacral  nerve  :  '.'."i,  branclu-s  from 
third  sacral  nerve  to  vagina  and  bladder:  'Ji,  branches  jiassinn  from  fourth  sacral  to  cervical  Kan^rlion. 

iiion  with  others,  po.s.se.s,s  in  larj^e  luiinbers.  The  ve.s.sels  thus  orijiinatiii<:;  are 
arranjfed  as  three  principal  groups  :  1.  The  .set  conipo.sedof  tho.-^e  coming  from 
the  body  of"  the  uterii.s,  the  ovary,  and  the  oviduct,  which  end  in  the  prevertohral 
lymph-glands  in  front  of  the  aorta  and  the  interior  cava ;  2.  Those  from  the 


IIS,  wliicli 
r  cava,  on 
t  inimhcrs 


11  import. 

IIS  of  ircll- 

•a,  ill  coin- 


I 


—  1 

—  2 


111 


us  (if  iitcrns; 
lion  lii'twi'cii 
I  join  oviirian 
vos;  IJ,  sM]ii'- 
istric  iilcxii." ; 
Ijraiiclu'S  <if 
;  'Jl,  lininclK'S 
I'lTvical  j.'!in- 
niiiclics  I'm  mi 
1  fjiinnlion. 


[latiiig-  are 

iiii)<>;  from 

evortehral 

from  tlie 


rsmmmmm 


"v^^fp^niF'p.w  ujn' w^i'  ■' 


ti 


EXPLANATION   OF   I'l.ATK  ',». 


Fl(i.  1.— I.yni|iliiili<s  (ifllic  lit. ■ru'i,  which  hiis  hrcii  tiinu'd  lorunril  (Siippcy) :  A,  imrtii ;  ii,  cnnimipn 
iliiu's:  c,  liif'Mriiitiiiu  iiitii  iuU'iiml  lunl  fxtiTiial  iliacs:  n,  vcim  cnvii  liifi'rior;  i:,  cniiMiKin  ilinc  veins; 
K,  iiti'i'iis  topiili'd  I'nruiinl ;  lu  ri'clmii ;  ii,  lijiiiiiu'iit  iiuitiiiK  micmmii  with  lil'tli  liimliMr  viTlrhni ;  1,  lyiiipli- 
iitic  vi'ssi'ls  jmssini;  muli'i'  nyarii's  to  follinv  llu-  cuiirsi'  ol'  oviiriiin  vcj-si'ls;  'j,  lym|iliiitics  from  huily  nl' 
ntcnis,  whicli  ctkI  in  lyin|ih-j;hiii(l.s  iiccoiniiniiyiiiK  thi'  iliac  vessels;  :!,  lympli-Kliinils  iccciviiiK  Hie 
lymiili-vcssels  of  iinieims  menihraiie  uf  cavity  o(  hoily  ;  I,  I,  lyinplialics  from  lower  portion  ol'snrt'ace  of 
litems,  ^'oin^'  to  tlic>  L'lanils  lniiind  intenuil  iliac  vessels,  which  ulaiuls  (:"i)  vary  in  niiiiihi'r  and  volume. 


iiiiiiion  iliacs  ;  c,  eyteniiil 

veins;   ii.nnlers;   i,  reelniu;  K,  iitenis;  i,. 

II,  (I,  ovaries  ;  ij.  i),  romiil  li^tamenl  ;  J,  siiperlicial 

iiverKiiii;  trunks  ol'  same,  emptying  into  lymph  ulanils  {I);  7,  7,  lyniphati<'  plexus 

mrse  of  iilero-ovariaii  veins;  10,  11, 
lining'  ovarian  iilexiis,  with 


l''|i..  J.-   l.yniphiilics  of  the  iielvic  \  iscera  .■iml  the  aliclomeli  (Sappey  i :  ii 
Mini  in;    rnal  iliacs;   o,  vena  cava  inferior:  o,  common  iliiK 
cervix;  M.  M,  section  of  vniiina:  N,  N,  Fallopian  tiihes 
renal  lymphatics;  :',,  eonverKiin;  trunks  of  same,  eiiip  . 
ol  tho  ovarii's;  ><,  ii,  trunks  lei'eiviiit,'  ovarian  plexus  followiiiK'  ( 

«lanils  receiving  the  lymi.liatics  from  ovaries;  r_',  lymphatics  from  fiiinlus,  |omiii^  oviinaii  pie.Mis,  n.yu 
same  lermiiiatioiis  ;  II,  ulanils  receiving  (le)  trunks  from  siirliices  and  hi.rilers  of  liody  of  nteriis;  I'l, 
lymphatics  ori^'inatinu;  in  lower  liart  of  cervix,  mucous  memhrane  of  uterine  cavity  and  va^:inlll  for- 
liices;  1(1,  lymph-ulands  occnrriiD-'aloiiK' the  course  of  these  vessels;  17.  elVerenl  vessels  of  these  ^-lands 
takiMt;  their  course  to  the  glands  lieiieatli  external  ilia(;  vessels ;  Is,  lymphatics  which  proceed  from 
the  posterior  surface  of  the  cervix,  ti'rminatinu'  in  the  lihiiids  accompanyini.;  the  internal  iliac;  I'.',  excep- 
tional lymiih-lrnnk  from  cervix  passinj.'  to  filand  in  front  of  lifih  liimhar  verlehra;  Jn,  another  excep- 
tional lyinph-ulaiid  anil  vessel  situated  alon^r  the  course  of  the  common  iliilc. 

Fiii.  :f.- Lymjihatics  of  the  breast  (Sappey):  a,  celliilo-adipose  cnshioii  siipportinn  mammary  ulaiid  ; 
II,  contour  of  mammary  Klaiid  :  i  ,  superlicial  blood-vessels;  1,  network  of  siiperlicial  lymphatics;  '-',  net- 
work of  lymphatics  orinliiatihi,'  in  and  draiuiii);  the  lobules  of  the  uhiiid  ;  :i,  lartrc  lymphalic  trunks  orii;- 
inaliri),'  in  the  |ieripheral  network  ;  I,  plexn.s  of  lymphatics  haviim  their  origin  in  the  di'eper  parts  of  the 
t;liiiid;  .'i,  large  vessels  orik'inatinj,'  in  the  inner  jiart  of  tills  plexus;  (i,  7,  .s,  larizc  lymphatic  trunks. 


'  t 


h 


(iKNKKATlVK  oltd ANS. 


Pi, Air,  0. 


11,    (MlllllllOIl 

iliiic  veins; 
1  ;  1,  lyiui'li- 
•,,111  l""ly  I'f 
■(■I'iviiiK  llH> 
il'siurmT  111' 

111  vnlllUU'. 

;  r.  (•yli'riiii\ 
K,  uliTUs  ;  I , 
■J,  i.ii|u'rli(iiil 
iliiitic  I'li'xiis 
veins;  m,  H. 
jilcxiis,  Willi 
>f  iitiTUs;  l,"i. 
I  viiniiiiil  I'lT- 
llirsc  ^'Imiils 

|inil'l'l-'il    IVnlll 

lie;  I'.i.  cXKii 

nlluT  I'XCl'p- 


iiiniy  ultunl : 

ilics;  ■-',  ml- 

\v  tniiili!'  iii'iK- 


r  p; 


Its  111'  llic 


Iniiilcs. 


>     - 


1    I  \  iii].liiiiir-  ■i|  Uii'  uliTii^,  u  lilrli  luis  lircM  turin'il  lonMH 


il    Mipi'i'V  .     J.   I  ymi'liiiiii'v  III  till'  |irl 


\  II'  \  1^11  111 


Mini  mIiiIiiIih'Ii  ,-ii|i|M'y  ,     '.\    I  >  iii|iliiil ii  -  ■  I'  llir  lui  n-l    -ii|i|iiy 


^"mmm 


;:  i 


m  I 

l!    f 


I  ! 


I  f 

II  % 

■4 


,,i    ! 


AXATOJfV   or    THE    (i KXERATIVi:    OlidAXS. 


Go 


•ft 


cervix  anil  adiacciit  part  of  the  vagina,  whicli  extend  along  the  base  of  the  broad 
licrament  and  terminate  within  the  internal  iliac  u;lands  of  the  pelvis  near  the 
iltao  arterv  at  its  point  of  divi.-^ion  ;  •■'».  'I'hose  which  accompany  the  ronnd  lig- 
an'ient  and  eni]»ty  into  the  in>;ninal  irlands.  These  latter,  as  in  the  male, 
hichide  two  groups,  those  lying  along  the  conrse  of  Poupart's  ligament,  wliich 
constitute  the  ohiiquc  s(!t  and  receive  the  lymphatics  from  c"ie  genitalia,  and 
.1  :irraii"'C(l  about  the  sai^henous  opening  as  the  vertical  set,  into  which 
emptv  the  suporlicial  lynii)hatics  of  the  lower  limb.  The  great  abundance  of 
the  Ivmiihatirs  of  the  uterus,  the  cervix,  and  the  vagina  is  a  matter  of  nnich  prac- 
tical importance,  since  tluse  channels  furnish  the  paths  by  which  septic  mat- 
ters mav  invade  and  affect  parts  widely  removed  from  the  focus  of  infection. 

The  nerves  (Fig-  5^)  of  tlie  uterus,  the  ovary,  and  the  oviduct  are  derived 
partly  from  the  sacral  nerves,  particularly  the  third  and  the  fourth,  and  partly 
from'the  svm])athctic  sy>tem  as  represented  by  the  hypogastric  and  ovarian 
plexuses.  The  nerves  include,  therefore,  both  medullated  and  pale  fibres,  the 
latter  beiii"-  especially  destined  for  the  blood-vessels  and  the  masses  of  invol- 
untary nniscular  tissue. 

The  Mammae. — The  mammary  glands,  being  really  but  highly  specialized 
and  urcatlv  developed  sebaceous  follicles,  belong  to  the  integument,  and, 
strictlv  reirardcd,  have  no  place  among  the  sexual  organs.  The  closely  asso- 
ciated functional  relation  of  these  organs  in  furnishing  the  nutriment  for  the 
ni'wlv-born  animal,  however,  as  well  as  convenience,  has  made  it  customary  to 
describe  them  in  connection  with  the  organs  of  generation.  The  present  pur- 
pose will  rc(iuire  the  consideration  of  the  glands  as  developed  in  the  female 
alone,  the  rudimentary  organs  of  the  male  being  disregarded. 

The  iiiaimnary  glands  of  the  human  female  (Fig.  57),  as  seen  in  well-devel- 
oped women  prior  to  pregnancy,  protected  by  the  integument  and  the  fascia'  and 
the  associated  masses  of  adipose  tissue,  collectively  form  a  j)air  of  hemispherical 
])rominences,  the  breasts,  surmounted  by  the  conical  mainmi/kt  or  nipples. 

The  breasts  as  a  whole  are  not  (piite  circular  in  outline,  since  their  attached 
bases  present  slight  extensions  inward  over  the  sternum  as  well  as  outward, 
above  and  below,  toward  the  axilla.  Neither  is  the  gland  always  limited  by 
the  deep  fascia,  since  small  aggregations  of  the  glandular  tissue  may  pierce  the 
fascial  septum  and  lie  upon  or  become  ind)edded  within  the  pectoral  muscle — 
a  matter  of  much  practical  moment  in  amputations  of  the  mamma  for  malig- 
nant disease. 

The  size  of  the  breasts  depends  so  evidently  upon  the  functional  condition 
of  thi>  glandidar  tissue  and  the  quantity  and  tonicity  of  the  surrounding  adi- 
pose tissue  and  other  ]n'otectiiig  structures  that  the  dimensions  of  the  organs 
must  iiichidc  a  wide  latitude  of  variation.  The  breasts  may  be  said  ordinarily 
to  extend  from  the  third  to  the  seventh  rib  and  from  the  sternal  bonier  to  the 
anterior  axillary  margin,  with  a  pi'ominciicc  depending  nnich  upon  the  amount 
of  tilt  or  updu  the  condition  of  the  gland.  The  nijiple  is  usually  siiuated  on 
a  line  correspdnding  with  the  level  oi'  llie  fourth  rib,  being  directed  somewhat 
outward  and  iipwanl. 


:!  ^  ^: 


i'  ;; 


l! 


1    ,  '.-'■ 


M 


■I 


m 


AMi:i;i<  AX    TKXT-JIOOK    OF    (UlSTETIilVS. 


Viii'viiii:'  witli  the  uciicriil  ('(implcxidii,  tlic  nipple  is  of  a  roseate  or  a  ])iiil<- 
isii-l)ro\vii  tint,  and  is  siirroiiiided  at  its  base  hy  tlie  (ircola,  an  area  ol"  niodilied 
inte<fiinieiit  al»oiit  an  ineli  in  dianii'ter,  posse>sin<i-  tlie  same  color  as  the  nip|)le. 
The  eliaiiii'es  in  tlie  a|tpearanee  of  this  /one  indiieed  hy  pre«rnaney  are  more  or 
less  permanent,  the  dee|)ly  pitiinented   areola  of  the  dark    hrnnette  nevi'r  re- 


F>rsl  n'fi. 


ifilli  iii/i'xiiiiiiiit.  ■  — 

(ii.tiufNiiir  ti.^sUt-. 

Mass  0/  a,Uf'osi  '/mtt' 


/.iwst'r  /r,  /(';•((/  muscle. 
Intt^rirstal  muscles. 


/nfrr/i'/'it/uf  (/.r'.'/r'A-  ;i\sut\ 

Illili/l  ll'IIS   i/lIlt 

Aifif'uUa .  -. 
CiitHiiltlai  ff'sxur.  . 

r*'y!phi-ial  <u  i»i.~ 
Mitss  <y"  iii/i/'ii.f  ti.ssHi\ 

Fiy'y<^Ui  sr/>ia. 
Intyguiiii'iit 


lln  izoiitiil  axis  of 


Si.xth  yib. 


Extt-rna!  fl'li  iu<  tiiH^Lii'. — i' 

I'll..  .''T.—l/'iitzituiliMiil  xTtinii  III'  iiiMiiiiiiiiiy  t-'liiinl  in  siVk  ,■  friizi'ii  siitiji'ct  iif  twi'iily  yours  iTi'sHit). 

jrainiiiL!.-  its  former  tint  ;  in  lijiht  Itlondes  the  darkeninji;  of  the  areola  uecom- 
panyiim'  |)ret:naii<'y  is  often  very  sliuht.  and  mav  sphsecpiently  almost  entirely 
disappe;'!'. 

The  skin  eoverinu'  the  areola  i-  eharaeterized  by  its  variable  j)i<j;mentation, 
l>y  it>  delicacy.  i)y  the  absence  of  siilxiitancons  adipose  tissue,  and  bv  the 
prest'nee  of  lar<i('  sebaceons  follicles,  and,  in  addition  to  wi'll-develop"d 
sweat-Li'land-,  -m;ill  uroiips  of  ulandiilar  ai'ini.  the  acccssDr;/  nii/k-(/f(ni<Is, 
of  which  I'lMiu  five  ti)  twelve  arc  ii.-iially  present.  The  sebaceous  follicles 
(hiring  pregnancy  become  tjrcatly  increased  In  size  and  Ibrm  prominent  ele- 
vations, the  '//(//((/.v  o/'  J/«y///yn//(('/7/.      In  addition   in  independent   ducts  open- 


.LV.i7-o.i/r  OF  Tin-:  ai:xi:iiATivi-:  <>I!(;axs. 


67 


a  pinU- 
nodiiuHl 
'  nipplt'. 
innlT  ol" 
I'VIT    IV- 


<i,il  iiiiiscle. 
muscles. 


fascia. 


I  a.ris  of 


■   M'  (.11  the  -iirt:i<'i'  <>'   ''"'  :"'«'"'''•  ^'i''  acccssorv  <j;laii(ls  somctiincs  are  connoctcd 
uhh  the  inilk-tiil'c-  travcrsinn-  tlic  ni|.i)lc. 

Iiuth  tlir   iiipplt'  and   the  arcohi  ctmtaiii   luiiiicroiis  hiiiidks  of   mistripcd 
nuisciihir   ti-tie-    arraiiuvd    as    ciividar  _  .jZi*C>-^.rfi 

and   radlatin--  til'n-,  which  ivsp.md  to 
„.,.rhanical   ^  timuhition.      The   contrac- 
tion   of    the    ciivnlarly  disposed    fil.res 
,.iiuses    the     lupple    to    iH'conio    ni(.rc      .^ 
p'ron.iu.'nt     nr    ••erected;"     tlic    radial       : 

til.rcs.  nil  thi i.trary,  tend  to  depress 

,„•  ivtraci    the   iiijiph'.  ^^ 

Thi'  ,v(ry,///(.v  //••>•••<■'"    oi"  the   niannna      >;j|t', 
consists  of  an  aunn'Mation  of  pyramidal 
masses  I  frnm  fifteen  to  twenty  in  nnm- 
1),,,.)   nf  acini    and   Awi^    wliieli   corre- 
spond with  I  hr  l.ihescomposinjj:  the  oru'an 

(Fit:'.  •">''^)-  ''•"■''  '"'"'  I't'P'"'"'*'"^'^  ''  •'^'",-'<' 
hiiihlv  developed  and  spcciali/ed  seha- 
ceims  -ilaiul.  \vho>e  excretory  tnhe  is  tiio 
htcfifcr(iii''<  or  (/(il<icli'})lii>roiis  duel,  and 
whose  secretoi'v  pnrtioii  is  the  associated 
^roiip  i»l'  acini. 

The    individual    component   u'land^,     of  hrciisi,  the  rm  iiHvini:  iiccti  rcuK.viMi  to  >iin\v 

11  •  ill..  »1.,.     ......  .1..,. I         tho  ducts  mill  acini  I. Vslk'V  CiMiiviTi. 

tli(>  lolies.  are  invested  hy  the  .-nrroiind-  ' 

in"-  connective  tissue  wliieh  constitutes  the  <reiieral  supporting  framework  of 


I'lii.    .'iS,— Arrimt'ciiu'iit   nf  uluinliiliir  tissue 


rs(Tcstiit). 

,1a  acciini- 
4  entirely 

^mentation, 

iiid  l)y  tilt' 
-dcvelop"<l 

Ills  follicles 
inincnt  cle- 
iliicts  open- 


I 


•J 

I 


J.:^z:^i^/^ 


Vw. 


-.  iiimi  ..I  iniuiiniiirv  L'liiiiil  'luriiiL'  l:i' miIom  i>liictyi:  •!,  n,  liplmlcs  nl' ^ccrcliiiu  tissue,  cdii- 
slsliiii.' I'l' iicliii  'li.hs  liiiccl  with  nctivc  c|iillicliuiii  ,  i ,  r,  sccliuiis  (if  cxcicluiy  ilui  t^  ;  <l.il.  iMtcrlxhular 
(I'lincclivc  li^siic. 

the  oruan  and  the  >c|)ta.     The  latter  penetrate  within  llic  a<ri;rou;atioiis  of 
acini   ainl   >iihdivide  the   lohes   into   loltiilcs. 


^m 


68 


AMEIilCAX    TEXT-BOOK   OF   OBSTETRICS. 


In 


>    f 


'Ifi 


I   ^^h 


Before  the  occurrence  of  ]>re«::imncy  and  of  the  functional  activity  asi^o- 
ciated  with  lactation  the  secreting  tissue  forms  hut  an  insignificant  portion  of 
the  entire  voluni(>  of  the  nianinia  (Fig.  59),  hut  during  lactation  the  acini 
become  enormously  developed,  tiie  lobules  of  true  glandular  tissue  being 
readily  discovered  as  nodular  masses  within  the  more  yielding  areolar  adijKtse 
envelope.     Under  the  stimulus  of  the  unusual  demands  made  upon  the  organ 

under  such  conditions,  it  is  ])rol)able  that  new 
glandular  tissue  is  formed  as  extensions  of  the 
existing  a(!ini. 

The  (tcini  of  the  fully  developed  but  non- 
functionatiny;  or<>an  are  lined  bv  a  siny-le  laver 
of  >liort  columnar  or  polyhedral  e])ithelial 
cells,  the  protoplasm  of  which  appears  gran- 
ular. Th(!  cells  rest  upon  a  delicate  mem- 
brana  propria  which  envelopes  the  aciiuis  and 
which  is  continued  on  to  the  minute  excretory 
ducts  with  which  the  acini  are  connected. 

These  passages,  lined  with  a  modilication 
of  the  glandular  epithelium,  join  with  others 
to  form  larger  tubes,  whicli  in  turn  tal\(>  part 
in  forming  the  interlobular  canals.  These 
canals  are  superseded  by  the  wider  excretory 
tubes  draining  the  entire  lobe,  which,  directly 
or  after  joining  other  tubes,  become  the  con- 
verging lactiferous  or  galactoj)hor()Us  ducts. 

The  /(K'fifrroHfi  diictt^  (Fig.  (30)  on  reaching 
the  areola  undergo  dilatation  and  form  the 
utnpulhv,  or  vii/k-si)iuses.  These  amptdlic  lie 
beneath  the  areola,  and  during  lactation  attain 
each  a  diameter  of  from  4  to  0  millimeters, 
constituting  important  reservoirs  for  the  milk 
secreted  during  the  periods  intervening  be- 
tween the  evacuations  of  the  gland.  At  the 
base  of  the  nip])le  these  ducts  undergo  a  re- 
duction in  size  and  become  closely  collected, 
the  larger  tubes  occupying  the  centre  of  the 
grouM  ;  siuTo'inded  by  areolar  and  liiusciilar  tissues,  they  ascend  to  the  summit 
of  the  mammilla  as  indc])eudcnt  tubes,  whei'e  they  ternunate  by  distinct  orilices 
which  open  into  minute  <le|)rcssions  occii|)yiug  th(>.  apex  of  the  nipple. 

The  (  pithelium  lining  the  ampullie  and  tli(>  lactiferous  ducts  is  of  the  low 
(•olumnar  or  ciil)oi<lal  vai'icty  ;  within  a  slwtrt  distance  of  the  termination  of 
the  ducts  upon  the  nii)ple,  the  lining  of  the  tubes  changes  its  character  to  cor- 
respond with  that  of  th(^  adjoimug  epidermis,  becoming  stratified  sfpiamous. 

The  changes  taking  place  within  the  lining  cells  ol"  the  a<'ini  on  the  estab- 
lishment of  lactation  arc  verv  marked.      In  the  earliot  stage  of  activitv,  when 


Klc;.  I'lil.- DisMM'liiiii  <•(  !>rciisl,  slmw 
iw  susiiciisMy  li^'iinu'iitx  uiiil  iiulk 
<liicl>-  (A.-^ll-  y  CiiMiPi'r). 


[XATOMY    of    the    CENI'UiATIVK    ORGANS. 


(59 


ty  asHO- 
ii'tion  of 
he  acini 
le  bcinp; 
•  adipose 
ho  orpm 
that  now 
)ns  of  the 

\)iit  non- 
lolo  hiyor 
opitholial 
>arrt  ^ran- 
•ato  nioni- 
loiniis  and 
exoi'ctory 

K'tod. 

ludilication 
kith  others 
take  part 
Is.      These 
r  excretory 
c'h,  directly 
>e  the  con- 
is  (hicts. 
M\  reachinji; 
1   iorni   the 
ii\ipiillic  lie 
ation  attain 
nilliineters, 
or  the  milk 
venin^    1)C- 
hd.      At  the 
Idcrii'o  :»  ''''- 
V   coUeeted, 
tntre  of  the 
the  snnunit 
inet  oriliees 
ph'. 
,,f  tlie  low 
Imination  <it 
;icter  to  cnr- 
Llitaniotis. 
In  the  estab- 
Itivity,  when 


tl     Hi.w  of  milk  first  begins,  many  acini  still  retain  their  primitive  condition 

ft"  ^  UtUtv-    ill  >n''''  ^'•^^'^^  t''*-*  elements  oecnpying  the  central  parts  of  the 
4  1    lo-  iind'i""  li'tt^'  degeneration,  some  becoming  disintegrated,  while  others 

.'i  .     „•  ,,,  iirwses  whicli  constitnte  the  colo.stnim-corhi(.sc(cfi  fonnd  in  the 

%  are  cast  on  .!•'  ""■■  -t 

,„il|.  .lurino-  tlw  lirst  feu-  days. 

Tl  '  iii)ii"i'iii'^'  ui'iundar  protoplasm  of  the  cells  at  rest  becomes  invaded  by 

-  .,   |,.,,p,  v,iirii  (iinctionalaetivity  begins,  and,  as  secretion  progresses,  it  becomes 

,      ,.       una;.!  displaced  by  the  aecnmnlation  of  oil-globnles  within  the  cell. 

i  rpi  ,  ,,,j„,iir  /li-diops  exist  at  first  as  sejiarate  particles,  which  gradnally  increase 

^  .    ^j      ,j|,,ji  (i](.v  become  confluent  and  form  a  single  large  globule  occupying 

r  1      ,,,,.,,. I j,  ;■  n;itt  (if  the  cutirc  ccll.     The  nucleus  in  consequence  is  displaced 

.       '   I  (1,,,  Mcilnherv,  next  the  basement  membrane,  where  it  lies  imbedded 

jj]iji,  ii,  .  diiii  belt  of  protophism  occu])ying  the  outer  zone  of  the  cell. 

^  r|'jii.  .,(1].;  within  a  single  acinus  generally  contain  very  unecpial  amounts  of 

1         oil  •  -^iiiix'  "'  ''"'  <'k'iii*-'"ts  are  so  loaded  that  the  entire  cell  is  occupied  by  the 

■'k        oil-driip.  wliilr.  ou  tiio  other  hand,  tiie  neighboring  cells  may  contain  so  little 

%        oil  that  till'  ]>r(scuce  of  the   fatty  particles    is    masked  by  the  protoplasni. 

1        I'xtwccii  diiM'  extremes  all  gradations  may  be  found. 

,|  ['iKiii  atiiiir-ing  a  certain  tension  the  contained  oil-globules,  escaping  in  the 

%  (lin'ctiiHi  I  i'  liii-t  resistance,  are  discharged  into  the  cavity  of  the  acinus,  where 
tlicv  tonctliii'  with  the  graiudar  debris  of  old  epithelial  cells,  are  collected 
wiiliiii  ail  iiKiiiMiinous  fluid  and  cctnstitute  the  /(icfiferous  secretion,  or  milk. 
Diuini'' scent inii  the  acini  possess  a  comparatively  wide  lumen,  the  epithelial 
lavor  fiirmiiii:  l>iit  a  thin  lining  to  the  irregidar  spherical  or  tubular  spaces. 
At  tlic  cr-sation  of  lactatiou  the  acini  bceome  once  more  reduced  to  narrow 
tiiliiili's,  iiianv  lu'iug  atrophic,  siu'roundcd  by  t\u\  thin  jirejmnderating  areolo- 
ailipii^e  tis-iH'.  \\'ith  each  succeeding  ])rcgnaucy  a  new  period  of  cellular 
aiiiviiv  and  mw  giowth  takes  place  in  the  preparation  of  the  gland  for  its 
active  I'tMc  during  lactation. 

Tlirclo-c  (if  the  jK'riod  of  sexual  activity  is  followed  by  gradual  ]icrmancnt 
ati'dliliv  of  tlic  secreting  structures,  so  that  secretions  of  the  uuuunue  of  aged 
wdiiicii  sIkiw  little  more  than  the  atrophic  remains  of  the  sometime  conspic- 
uiiiis  uland-aciiii  iinl)ed(led  within  the  connective  tissue  which,  with  a  variable 
aiiKiimt  III'  lilt,  now  constitutes  almost  the  entire  bulk  of  the  organ. 

Tlic  hliioil-nKsc/s  of  the  mamma  are  derived  from  two  sources  :  principally 
fnim  the  iiuci'iial  mammary  artery,  through  its  j)erforating  branches  within  the 
<i'C(iii(l,  lliiid,  and  foiu'th  intercostal  spaces,  and  from  the  axillary  artery 
du'diiali  the  thoracic  branches,  the  long  thoracic  or  external  mammary  artery 
(ilicii  sending  otf  robust  twigs  for  the  supply  of  the  gland. 

The  (•(■//(.>-■  retiu'uing  the  blood  from  the  deeper  part  of  the  organ  follow  the 
(•(irrespoiiding  arteries  ;  the  superficial  veins  form  a  subcutaneous  plexus  which 
liecdiiM's  conspicuous  during  lactation. 
a|P  'I'lw  hjiiiiihitlivx  are  very  iniinerous,  as  denionstrated  by  the  brilliant  prepa- 

ratidiis  made  by  Sappey  (IM.  !•,  I'^'ig.  ;j),  and  they  constitute  a  superficial  and  a 
(lee|ier  ,-et.      flic  former  exist  as  an  intricate  subcutaneous  network  in  which 


^r^mm 


'•: 


70 


AMi:iiI('AX    TEXT-nOOK   OF    OliSTETlilCS. 


i  ^l 


I:,,' 


4 


I!  t 


the  larpjer  vessels  are  situated  at  tlie  |)erij)lierv,  and  join  the  lympli-j>ath.s  cun- 
verfijin<r  toward  the  axilla.  The  deeper  lyin])hatie  vessels  aceoinpany  the 
deeper  veins  and  pass  dtl'  in  two  jrroiips :  one  set  enters  the  axiUa  and  termi- 
nates in  the  eostal  uroup  of  axiMary  lympli-i>;hinds  ;  the  other  takes  its  eourse 
into  tlie  thorax  and  eonininnieates  with  the  eliain  of  lynipliatic  no(hdes  sitnated 
behind  the  sternuni.  The  profuse  supply  of  lyniphaties  and  the  intimate  rehi- 
tions  these  hear  to  tlie  lymph-<:>;hinds  situated  deeply  and  at  some  distanee 
greatlv  facilitate  the  conveyance  of  infectious  materials  to  other  jiarts,  there 
to  establish,  as  in  the  case  of  carcinoma  mamnue,  new  foci  of  disease. 

The  itcrrcn  supplying  the  mammary  gland  are  derived  from  the  cervical 
plexus  through  the  superficial  descending  supraclavicular  branches,  and  from 
the  fourth,  fifth,  and  sixth  intercostals ;  mnnerous  sympathetic  filaments 
accompany  the  latter  into  the  substance  of  the  gland. 

Variations  in  the  munber  and  position  of  the  mamma;  have  frerpieiitly 
been  observed.  While  reduction  in  number  or  absence  of  these  organs  is 
extremely  rare,  increase  in  their  munber,  as  well  as  abnormal  location,  is  by 
no  means  of  great  infrequency.  The  nipple  alone  may  be  involved,  being 
either  nudtiple  or  supi)ressed,  or  entire  additional  glands  may  be  present. 

tSajH'ntninci-ari/  inanniKv  have  been  observed  in  many  locations,  among  which 
the  arm,  the  axilla,  various  parts  of  the  anterior  body-wall,  the  back,  the 
buttock,  and  the  thigh  are  the  most  conspicuous.  The  interesting  observations 
of  ().  Sehultze  on  the  presence  of  definite  "milk-ridges"  along  the  antero- 
lateral aspect  of  the  trunk  in  embryos,  extending  from  the  root  of  the  upper 
limb  to  the  inguinal  region,  suggest  the  location  in  which  supernumerary 
manuiue  are  most  freijuently  encountered,  such  superfiuous  organs  resulting 
from  the  j^ersistence  and  develoj)ment  of  areas  which  ordinarily  disappear. 
The  presence  of  such  markedly  aberrant  mamniie  as  those  found  on  the  back, 
the  arm,  or  the  l)uttt)ck  is  less  easily  exjilained,  since  they  arise  probably  in 
consequence  of  the  uniisual  development  of  structures  representing  the  ordi- 
nary sebaceous  glands  of  the  integument  of  the  part. 

Til.  Physiology  of  the  Female  Generative  Organs. 

1.  Ovulation. — The  diifereutiatiou  of  certain  of  the  cells  derived  from  the 
ingrowth  of  the  germinal  (■j)itlielium  coveviug  the  young  ovary  into  the  scwual 
elements  proper,  the  ova,  takes  j)la('e  very  early,  so  that  at  birth  the  formation 
of  the  ova  is  already  nearly  eoiiq)lete(l,  the  production  of  new  cells  aftei- 
l)irth  being  very  limited,  ;uid  probably  entirely  ceasing  after  the  se<'ond  year 
(I)isehotf,  Waldeyer).  The  ovaries  of  the  child  of  two  years,  therefore,  eon- 
tain  the  full  <jUota  of  ova,  although  the  vast  majority  of  these  cells  always 
remain  iiiiiuatui'e  and  undeveloped.  i  he  entire  nundjer  of  these  primitive 
sexual  elements  >tored  up  within  tiie  ovaries  of  the  young  child  has  been  esti- 
mated at  about  seventy  tliousand.  While  it  is  probable  that  a  variable  number 
of  the  inunature  ova  umlergo  partial  development  befi)i'e  puberty,  yet  the 
advent  ol'  sexual   matiu'ity  at  that  ju'riod  marks  the  establishment  of  the  full 


A.\.\TuMy  or  Tin:  (iexhuativi-:  <jr<!A.\s. 


71 


hs  con- 
iiiy  the 
1  ternii- 
i?  course 
situated 
lite  rela- 
(listance 
•ts,  there 
se. 

ccTvieal 
111(1  from 
tihmieuts 

refiuently 
or}i;ans  is 
ictii,  is  by 
•eil,  being 
sent. 

Diig  which 
back,  tlie 
iservations 
he  antero- 
the  ujiper 
niunierary 
vesultiiifr 
isappear. 
the  back, 
)bably  in 
the  (inH- 


from  tlie 
tli(>  sexual 
urination 
,rlls   alter 
coiid  year 
cibre,  eon- 
■lls  always 
jirimitive 
.;  lu'di  esti- 
)\v  number 
V,   yet   tlie 
of  the  full 


1  r(MPiil;U'  (li'V('loj)Mieut  of  the  (Jraafiau   follicles  and   tiieir  contained  ova, 

niiKUiit'd  l)v  thi'  usual  attendant   phenomena  of  menstruation. 

TliroU'dinut  the  entire  childbearing  peri(jd,  or  from  about  the  fifteenth  to 

I    lit  tiic  loriv-lifth  year,  the  development  of  the  (Jraafian  follicles,  terminat- 

■   If  III  till'  nipiiiic  of  tlie  follicles  and  the  discharge  of  the  ova,  is  eontinualiy 

~......;i..,       riie  liberation  of  the  ova  usuaiiv  takes  i)lace  at  dcHnite   times, 

oeclll  I  Miii.       1  11^  .1  J 

liieji  ill  >'i'iieral  coincide  with  the  menstrual  epoclis,  one  or  mon^  ovu  being 
^  .f  free  ;il  eiieli  period.     This  agreement,  however,  is  by  no  means  necessary 

jiiviiinlile.  -iitee  nrithttio)!,  as  tiie  ripening  and  discharge  of  the  sexual  cle- 
Piits  i-  lei'iiiid,  undoubtedly  proceeds  independently  of  menstruation. 

The  rioe  Inuiuni  ovnin  is  a  typical  spjierical  cell,  about  O.'i  millimeter  in 
ji'iineter.  euii-isting  of  granular  protoplasm  or  the  rlf(//i(s,  in  which  lies  a 
luicleii- iir '/(/v;i//irf/  nWc/r,  about  0.040  millimeter  in  diameter,  containing  a 
\vell-iii:iri<t'd  iiiieleolus,  the  ffcrw hud  t^pof.  The  proper  cell-wall  is  the  fitc/lliie 
jiiciiihri'iii.  M  -tnictiire  of  great  delicacy,  and  often  overlooked,  outside  of  which 
the  ovum  is  invested  by  the  conspicuous  zona  piUnvithi  (about  0.01  millimeter 
thick),  wlii'h  '""^'^  ''^'  regarded  as  a  secondary  envelope  contributed  by  the 
oclls  lit'  die  -mroniidiug  discus  proligerus. 

Tlie  I'lillv-ileveloped  (iraatian  follicle  is  ovoid,  and  consists  of  an  external 
inve-tiiu'iit 'i'  v;i~eiilar  connective  tissue,  t\w  (iniica  fihroKa,  which  is  lined  by 
!i  thick  liiver  of  granular  polyhedral  epithelial  cells,  the  )iiciiiljr<ni((  f/)-(uiulosn. 

^^,  point  tluse  cells  are  continued  as  a  mass  which  immediately  invests  the 

(iviiiu  ;iiiil  wliicli  is  known  as  the  (fiNcm  proli(/('nt.s.     The  interior  of  the  well- 


^s^;:,:-^^^ 


■i^:m 


I'M.  r.l.-Si'ctinii  nf  \vrn-(k'Vi.'l(i)ioil  (iniiiliau  t'nIIicU'  from  IniniMii  rmliryu  i  Vnii  llcrlVt :  tlio  oiiuIosimI 

iivmii  I'lPiitiiiii.-  two  iiurlri. 

(|evrlo|ieil  liijliele  (Fig.  Gl)  contains  a  Huid,  the  /itpior  j'oUlcii/!,  separating  the 
(iviim  ami  il-  -iirroiinding  discus  from  tli(>  opposite  wall  of  the  sac.  The  most 
|iruiiiiiieiit  part  of  the  ripe  follicle  is  less  vascular  than  those  jiarts  subjected  to 
l('s>  pi-es>iire,  one  spot,  the  lii/nin  fal/lcii/i,  being  free  from  blood-vessels,  and 
eorrc-poiKJiiig  with  the  point  at  which  the  distended  matured  sac,  from  2 
ti)  ]  iiiilliiiieters  ill  diameter,  liiially  ruptures. 


i 


/ir^m 


72 


A  mi:  HI  CAN    TKXT-IiOOK    OF    OnSTETRICS. 


I 


I  - 


-I    I !  I 


2.  Menstruation. — At  iv<riilar  intervals  throiiglioiu  the  childhrariii};  period 
tlie  liniiiji;  ol'  the  uterus  uiuh'rffoes  changes  primarily  designed  to  prepare  a 
lavoraitle  resting-phiee  for  the  prothiet  of  eoneeption.  In  tiie  ease  of  the 
non-oreurrenee  of  pregnaney  these  rhaiiges  terminate  in  the  disintegration  of 
the  uterine  nnieous  membrane  and  in  the  discharge  of  blood,  mneus,  and  tissne- 
del)ris  that  constitutes  tiie  ])iienomena  of  menstruation.  Siionld  |)regnaney 
occur,  menstruation  is,  as  a  ruK',  suspended  (hiring  the  entire  time  that  the  em- 
bryo is  within  the  uterus,  reappearing  usually  from  six  to  eight  weeks  aftci'  the 
birth  of  the  child.  Kxceptions  to  the  customary  ])rompt  cessation  of  men- 
struation are  by  no  means  infretpient,  the  catameiiial  phenomena  often  recurring 
with  regularity  during  the  early  mouths  of  gestation.  The  anatomical  explan- 
ation of  this  variation  is  found  in  the  tiiet  that  the  uterine  cavity  is  not  obliter- 
ated by  the  apposition  of  the  decidua  reHexa  against  the  mucous  nuMnbrane  of 
the  uterus  or  the  decidua  vera  until  the  end  of  the  lifth  month.  The  very  rare 
occurrence  of  the  menses  throughout  gestation  is  jirobably  associated  with  an 
abnormal  and  imperfect  fusion  of  the  deciduse.  The  reputed  instances  of 
women  menstruating  only  during  })regnaucy  must  be  viewed  with  sus])ieion, 
since  the  discharge  in  such  cases  probably  always  results  from  pathological 
conditions  of  the  cervical  canal. 

The  complete  menstrual  cycle,  which  typically  oeeujues  twenty-eight  days, 
may  be  divided  into  fotu'  stages  (Marshall),  following  one  another  in  regular 
sequeiuie  and  lasting  a  definite  proportion  of  the  entire  jieriod  : 

(1)  The  first  or  crmstructiir  st(i(/e  is  one  of  ])reparation  for  the  reception  of 
an  ovum,  and  is  characterized  by  the  fi)rmation  of  a  menstrual  decidua  in  the 
j)reparation  of  which  swelling  of  the  mucous  membrane,  enlargement  of  the 
uterine  glands,  and  inereasc  of  the  connective  tissue  all  take  place.  This  stage 
probably  lasts  about  one  we(>k,  and  is  followed,  when  pregnancy  has  not 
occurred,  by  dcgeuerative  changes. 

(2)  The  second  or  (Icfifriirfirc  xUir/c  is  marked  by  the  destructive  ])roeesscs 
which  give  rise  to  the  usual  phenomena  of  the  menstrual  ])eriod,  including 
the  discharge  of  mucus,  blood,  and  disintegrated  uterine  mucous  membrane. 
Five  days  constitute  the  average  duration  of  the  menstrual  flow,  although  its 
continuance  may  be  extended  or  curtailed,  owing  to  individual  peculiarities. 

(3)  The  third  or  veparatiir  sUu/c  is  one  of  re])air,  during  which  the  dee])cr 
and  unaffected  parts  of  the  uterine  mucous  membrane  institute  constructive 
processes  which  within  the  short  period  of  from  three  to  four  days  result  iu 
the  formation  of  a  new  nuicosa. 

(4)  The  fourth  or  qi)lcsce)d  star/c  includes  the  remaining  twelve  or  four- 
teen days  of  the  menstrual  cycle,  and  represents  the  (|uiescciit  period  j)rcceding 
the  initiative  changes  marking  the  beginning  of  the  next  ju'riod. 

The  relations  b<>tweeu  ovulation  and  menstruation  are  of  great  interest,  fi)r, 
although  the  discharge  of  the  ripened  ovum  and  of  the  degenerated  uterine 
decidua  takes  ))lace  usually  simultaneously,  it  is  well  established  that  it  is  neither 
invariably  nor  necessarily  so,  since  authenticated  observations  have  shown  that 
menstruation  mav  be  unattended  bv  the  liberation  of  an  ovum.     While  these 


A.y.iyoMy   of    the    nEXEIlATIVK    (JliUAXS. 


7;j 


•iiijT  period 
jjrcpare  a 
ii.so  of  tlic 
'•jratioii  of" 
aiul  tissiic- 
juvfriiancy 
lat  the  ern- 
es al"t(  r  the 
n  oi'  ini'ii- 
II  reeiirriiifjj 
ral  ex])laii- 
lot  oblitcr- 
■inbraiic  of 
e  very  rare 
lhI  with  an 
istaiices  of 
suf<j)icion, 
athological 


two  processes,  as  a  rule,  may  he  rej^arded  as  associated,  tlie  deteriiiination  of 
the  exact  r(>Iatinn  hetween  the  diseiiarged  ovum  and  the  uterine  chan-'es  coin- 
,.id,.ntly  takiii-  place  i.s  not  yet  positively  estahli.shed.     It  may  be  assumed 
that  the  til-!  nr  constructive  staj^e  in  the  eycle  of  uterine  ehanj,^es  is  particularly 
favorable  Im  tli<>  reception  of  the  ovum  :  this  being  the  case,  it  is  evident  that 
the  prepaiMlinn  of  the  uterine  mucous  mendn-ane  cunnot  be  directed  toward 
the  n..rptl..n  nf  the  ovum,  whose  discharge  takes  place  with  the  coincident 
meii^tiiKil  i.h.'ih.ii.ena,  since  it  is  probable  that  at  least  a  week  is  occupied  in 
the  tran^it  of  the  <'.i:g  from  the  „vary  to  the  uterus.     Marshall's  eonclu.ions 
that  "the  ^l.ri.!iia  o(  a  particular  menstrual   period  is  related,  not  to  the  ovum' 
discharo..!  ar  lli;i(  period,  but  to  the  ovum  discharge.l  at  the  preceding  period  " 
:uv  lullyunnntcd  by  the  more  exact  data  furm'shed  l)v  ean-ful  observ  ition 
The  well-k.H.vn  coincidence  of  ovulation  and   menstruation  finds  its  partial 
explauatinn,  nt  least,  in  the  marked  congestion  of  tlu,  ovaries  and  the  eonse 
qiient  -.inniilatiu,,  and  vascular  engorgement  which  the  nterus  experiences  by 
reason  ot  th.'  .lose  arterial  anastomoses  between  the  vessels  of  these  oro-ans 
the  iv^iiltin^  inrgescence  probably  being  an  important  factor  in  establis^iin'i; 
die  inciistnial  Mow.  " 


eight  days, 
in  regular 

?ception  of 
idiia  in  the 
iient  of  the 
This  stage 
cv  has  not 


c  processes 
,  including 
meiubraiie. 
Ithough  its 
iliarities. 
the  deejier 
'onstriictive 
)s  result  in 


ve  or  fonr- 
l1  })reeeding 


nterest,  for, 
ited  uterine 
it  is  neither 
shown  that 
While  these 


IMAGE  EVALUATION 
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WnSTER.Nr.  usto 

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II.  PHEGNAISl  Y. 

I.  PHYS10J.0GY   OF  PlIEGXANCY. 

1.  Development  of  the  Embryo  and  the  Fetus. 

1 .  Maturation  and  Fertilization. — Cuincidi'nt  witli  tliogrowth  of'thcGraaf- 
iaii  I'olliclc,  wliidi  ciilininutcs  in  the  rupture  of  the  i^ac  and  tlie  disdiarge  of"  the 
liiju*)!'  i'ollieuli  and  the  egg  surroundeil  by  the  di.seus  ])roligenis,  the  ovum  |)a.s.ses 
through  a  series  ot'ehanges  eolleetively  termed  VKitnratiou,  hy  whieh  the  female 
sexual  cell  i.s  prepared  lor  the  reeeption  of  the  male  element,  without  the  com- 
pletion of  "ivhieh  preparation  fertiii/ation  of  the  ovum  is  impossible. 

The  iuaturation  of  the  ovum  consists  essentially  in  the  very  nne<jHal  and 
repeated  dicisiun  of  the  egg,  by  whieh  two  minute  portions  of  its  substance. 


■<■•■'. 


Fic.  t'.2.— Portions  of  ovn  of  Aftrrias  rjtnrialii',  showing  clmncos  iillcctiiiK  the  f^erminiil  vesicle  nt  the 
bfniiiiiiii);  of  iimturiitioii  iHortwiK):  ".  uiTiiiliml  vesicle:  h,  neriiiiiml  .simt,  eomi>osed  of  nuoleiu  iiiul 
puraiiueleiu  (c) ;  il,  iiueleiir  s|iiiiille  in  pmeess  of  I'nrniutinn. 

tiw  j)of(ir  bodiex,  ore  extruded  ;  the  remainder  of  the  cell  after  the  completion 
of  this  cycle  returns  to  a  «|uicscent  condition  to  await  the  advent  of  the  male 
sexual  element,     ^[aturation  takes  place  entirely  independently  of  the  inHu- 


Kiii.  f)H.— Forinit 


^t^•■:^ 


\itln-iiis  <iliiriiili»  (llertwiu'i ;  /i.",  poliir  spiniile  ;  jih',  first  polur 


H,  niieleiis  retiirninn  to  conilitlou  of  rest. 


encc  of  the  malt!  or  of  the  i)robabilitv  of  fertilization,  everv 


th 


1 

hef 


healtl 


IV  ovum 


uiKlcrgomg  tnese  clianges  Detore  it  Deeomes  sexually  ripe 


t  bet 


The  process,  in  brief,  consists  of  the  following  phases  :  (a)  The  migration 
of  the  germinal  vesicle  or  nucltnis  toward  the  periphery  of  the  cell  (Fig.  ()2) ; 
(6)  the  rupture  and  the  disap[)earance  (»f  the  nucleus,  and  the  formation  of  the 


rilYSIOLOGY  OF  PREaXAXCY, 


75 


thcGraaf- 
rge  of  tl>e 
11  111  i)asscs 
he  liMuale 
t  the  coiu- 

etjxml  and 
substance, 


vesicle  nt  the 
f  iiui'leiu  anil 


completion 
the  male 
the  intlu- 


l)U',  first  polur 

Itliy  ovum 

migration 
(Fig.  02); 
tion  of  the 


* 

4' 


unclear  Hi)iii(llc  anil  other  elements  of  the  coniplicat«I  (Tcle  of  iiulireet  eell- 
divisioii  •  ((•)  tlif  extrusion  of  a  minute  portion  of  the  ovum  as  the  jirHt  polar 
Imlii  (Fig-  <»'^'/  ('0  '^'""'t  quiescence  followed  by  a  rejietition  of  division, 
n-siiltiii"'-  ill  giving  ott'  the  second  polar  boily  ;  (  )  the  establishment  of  e(|iii- 
libriinu  tlic  iiupiaraiice  of  a  new  and  smaller  nucleus,  the  female  pvonuclem 
A         «  » 


I:  ■-■  ■  •  ^  ■■•■■  v,-'"iV#'**'^.'-*'* •■i'l 
V-..---- .  ■••v^'i  •■.,'^ 


Ki(i.  (U.-A.niatnrc  nviim  (if  ochiiuis :  v,  feniole  pronucleus;  it.  imnmturc  ovarian  ovum  of  cclilnus 

(llertwiK). 

(Fig.  ()1).  ami  the  return  to  a  condition  of  rest.  Maturation  usually  takes 
i)lace  just  lu'fore  the  rupture  of  the  folli(!le  and  the  escape  of  the  ovum. 

On  tlie  (diiipletion  of  the  phenomena  of  maturation,  the  ovum  is  prepared 
for  the  reception  of  the  male  element,  the  met^ting  of  the  sexual  cells  in  mam- 
mals iisiiallv  taking  jilace  within  the  iipj)er  portion  of  the  oviduct. 

Tiie  iimiiher  of  the  more  vigorous  seminal  elements  deposited  within  the 
vaiiiiia  that  work  their  way  through  the  uterine  cavity  and  into  the  oviducts 
must  l)e  l»iif  an  insigniticant  part  of  the  entire  number  lodged  about  the  exter- 
nal OS.    Of  thdse,  moreover,  fortunate  enough  to  overcome  the  obstacles  pre- 


"•ViV-''".'-''i^')i-V-'f'^ 


I'll..  I'm.— I'lirl inns  nCtlii'  iivii  i>{  AnliiiiiK  filttriali/',  sliowintillu'miiiniHcli  iiiiil  fiisiim  nf  tlic  s|icrnialozip(in 
Willi  till'  iivuiii  I  lli'ilw  iiii ;  (1.  t'lTtillziiii;  niiili'  clcniint ;  'i.  cli'vatinn  "f  iiriilu|ilii.sni  iif  I'trn  ;  '>',  li",  stiij-'i's 

(pI  lllvinli  III'  Ilir  liiail  III'  lln'  siHTniato/rinll  witll  till'  iiviini. 

seiiteil  ti)  tiieir  progress  within  the  uterus  and  tubes,  but  a  single  spermatozoon 
actually  takes  part  in  the  fertilization  of  the  ovum. 

.\fter  reaeliing  the  surface  of  th(>  egu  and  penetrating  the  Z(»iia  pelliicida 
tlie  siiceessfiil  spermatozoon  is  met  by  a  slight  jirojectioii  of  the  protoplasm  of 
the  ovum,  with  which  the  head  of  the  male  element  soon  becomes  blended 
(Fig.  <i.')).  The  tail  is  lost,  and  the  head  later  sinks  within  the  substance  of 
tilt'  egg.    Siil)sef|uently  the  jiosition  <»f  the  impregnating  element  is  indicated 


ill 


« ^1^ 


(6 


AMHlilCAN    TEXT-nOOK   OF   OnSTElJtJCS. 


l»y  the  ajjjwarance  of  a  small  round  or  ovoid  bmly,  tho  iiuik'  itnmuclvuM  (Fig. 
G6,  A,  IJ),  whose  vicinity  is  rendered  eonspieuons  by  the  radial  striation  marking 
the  surrounding  protoplasm.  The  male  and  female  pronuclei  now  ap|)roach, 
and  sooner  or  later  meet  and  become  blendinl,  their  union  prtKlucing  the  «//- 
vwutdthm-niwUxiH  (Fig.  6(),  C)  from  which  are  formed  the  new  generations  of 
elements,  to  the  constitution  of  which  both  parent-cells  have  contribut(Hl. 

Jt  is  of  interest  to  note  that,  since  the  parts  of  the  sexual  cells  most  eon- 
cerued  in  th(!  priKluction  of  the  segmentation-nucleus  an;  rich  in  chromatin,  a 
fusion  of  the  nnclein  seems  to  Ihi  the  essential  feature  ol"  the  process  of  fer- 
tili;{ation.  The  blending  of  both  parent-cells  within  the  segmentation-nucleus 
furnishes  the  ex])lanati(m  as  to  the  fundamental  manner  of  transmission  to  the 
ottspriug  of  the  individual  j)eculiarities  of  both  father  and  mother,  since  the 
new  being  depends  for  its  origin  upon  a  nucleus  to  which  both  parents  have 
contributed  and  by  which  the  characteristics  of  b(»th  are  perpetuated. 

Should  the  mature<l  lemale  element  fail  to  meet  the  spermatozoon,  the 
ovum  after  a  few  days  loses  its  vitality  and  perishes.  The  period  during 
which  the  human  egg  retains  the  possibility  of  fertilization  has  been  variously 
estimated,  about  eight  days  being  the  pntbable  limit  of  the  retention  of  this 
power,  since  the  death  of  the  unfeeundated  ovmn  usually  occurs  belbre  the  egg 
reaches  the  uterus. 

2.  Segmentation. — The  meeting  and  fusion  of  the  male  and  female  pro- 
lUK'lei,  already  describetl,  result  in  the  fornuition  of  the  new  segmentation- 
nucleus  (Fig.  6(J,  (-'),  whose  appearance  institutes  the  process  of  cell-division  by 


Fk;.  I'lCi.— a,  fiilili/.fd  iivn  uf  cphlniis  U'lrtwiui:  tlii'  iiml>'  (ti)  iiml  tlio  tViiiiilc  proniicU'iiK  iU)  arc 
npiiroiicliiin::  iji  It  llicy  liiivi'  iiliiiDSt  fusoil ;  c,  iivum  nf  ofhlnus  nftor  coinpU'tiKii  uf  fi'rtili/iitinn  (Uort- 
witri:  f.ii.,  si');iin'iitiiti(iri  luii'lcus. 

which  the  original  egg-cell  gives  rise  to  an  extendinl  series  of  generations, 
leading  to  the  ])ro(luction  of  the  blastoderm. 

Since  the  youngest  human  embryo  carefully  examiiunl  and  recordinl — that 
of  Iteichert — was  already  j)robabIy  twelve  days  old,  the  early  phenomena  of 
impregnation  and  segmentation  have  never  been  observed  in  man.  Direct 
observations  upcm  higher  mammals,  as  the  dog  and  the  rabbit,  have  supplied 
our  hnowledgi!  of  the  details  of  these  early  stages  of  «levelopnu'nt,  which,  in 
the  main,  probably  closely  correspond  with  the  changes  taking  place  within 
the  luunan  ovum.     Nagel's  examination  of  a  ripe  human  ovum  and  the  dis- 


SKci.MKNTAl'lo.N    oK    IIIK   oVIM. 


I'l.AlK    10. 


-IM  (Fig. 
nuuking 

;  tlu'  «<'.V 
iitioiis  of 
iUhI. 

ii«)st  <:on- 
oinatiii,  a 
ss  of  li-r- 
•n-mu'leus 
lion  to  the 
,  siiHV  the 
rcMtt*  have 

1. 

tozoon,  the 

ioil  tlir/mg 
1  variously 
:ion  of  this 
"ore  the  egg 

female  pro- 
if  mentation- 
-division  by 


fi'V-.^... 


Oiil,''  ..// 


i->!,l.-<  ,rlh 


ihiUi  ••■li' 


,  ,/A 


hin>-y  '/•// 


r  i«^.  >•  (■(•//.i. 


iM 


Itlllziitlou  illort- 


jreneratiot>s, 

lorded— that 
Lnoniena  of 

(lan.  l>irc<'< 
Live  sujudi*''! 
It,  \vhi<'h,  in 
Iplaee  within 
land  thedis- 


I 

i 


St..Mi\iMiciN,-  I  ■:.   I'liiirriiin'.  illii^lr.iliii'j  llic  ■icuiii'iil.'ilinii  irrilii'  iiiiniiiii.'iliiiii  nvmii  >  \ll"ii  ni.iiii|iM,ii,anfr 
!■;  \.  llc'Ui'iliMi.    I.  Iiiiiui'iiiii  i<|.ii  -iiiliiiu  llir  icliiliiiii  i.r  ihi'  |iiliiiiii\  liiyii>  III  iln-  liliislmlcnii  '  Hniiiu'tl, 


friT!^ 


PJIYSIOLOdY   OF  PltEdNANCY. 


77 


•ovcrv  of  the  nroscnco  of  two  polar  ImmHos,  as  in  other  manimal.s,  still  further 
jiistiHcs  the  assumption  of  this  similarity. 

The  minute  amount  of  food-yolk  possessctl  by  the  nianinialian  egg  is  uni- 
fornilv  (listril)'''tetl  throughout  ita  protoplasm,  and  is  not  colla;ted  as  a  distinet 
hodv  •  siieh  ova  are  therefore  known  as  akcithul.  As  inttuenewl  by  the 
amount  and  arrangement  of  the  yolk,  these  ova  experience  entire  cleavage 
diniu"'  their  division,  and  are  said  to  undergo  total  segmentation,  being  thcrc- 
fori'  liohhl""!!''-  •'^'"^'*^  t''*'  resulting  cells  may  be  regarded  as  practically  e(pial 
in  >^i/.t'  tli'i''  '^I"'  "^'^  segmentation  may  further  l)e  designatcnl  as  aptttl.  The 
huniaii  ov'iiii.  therefore,  is  technically  described  as  an  alecithal,  holoblastic 
ocr<r  imil(i'j:(iiii,i:  e<iual  segmentation. 

Mil, .1-1  ilin'ftlv  after  the  apj)earance  of  the  nucleus  of  segmentation,  the 
i)li,  iininiiKi  "f  t't'll-division  apjjcar  within  the  parent-cell,  the  cycle  resulting 
ill  till'  lurniatiDii  of  the  first  pair  of  daughter-cells  (1*1.  10,  Figs.  1-3).  These 
(•(•11>  ill  tiiiii  "hccome  the  seat  of  similar  activity  by  which  four  cells  are  pro- 
(liKcil,  the  i)n'i'ess  of  cell-division  continuing  until  the  original  element  is  rep- 
resoiitcil  l)v  niMiiv  generations  of  direct  offspring.  "While,  for  convenience,  the 
s(M.|ii(iitatioit  of  the  mammalian  egg  may  be  regarded  as  etpial,  yet,  when 
cIiM'lv  oxaiiiiiit'd  after  the  third  or  fourth  cleavage,  a  slight  difference  may  be 
noted  in  the  >iz<'  "f  the  resulting  elements,  or  hldatomeira.  This  discrepancy, 
iiisiiniiticaiit  in  its  individual  variaticm.  Incomes  gradually  manifested  by  the 
separation  ol'tlie  blastoineres  into  an  inner  and  an  outer  ccU-grnup,  the  cells  of 
the  (iiitpr  irrniip  undergoing  n>ore  rapid  increase  than  those  of  the  inner  group, 
which  latter  "clls,  in  conseiiuence  of  this  inequality  in  growth,  gra(lually  are 
invested  hv  an  enveloping  layer  composed  of  the  outer  cells  (PI.  10).  This 
iiroeess  of  eovering-in  progresses  until  the  outer  cells  constitute  a  complete 
envelopo,  the  entire  segmcntetl  ovum  now  corresponding  with  the  nndberry 
mass,  or  morula,  of  the  older  anatomists. 

Examined  in  section,  the  ovum  at  this  stage  consists  of  the  single  layer  of 
outer  cells,  to  the  inner  surface  of  which  at  one  point  adheres  the  less- 
expaiidcKl  gnmp  composeil  of  the  inner  cells,  the  space  between  the  two,  the 
xrt/iiiniMioii-i-drll;/,  being  ocn'tipiinl  by  a  clear  albuminous  fluid.  This  stage 
of  tlio  liolldw  sphere  of  the  mammalian  ovum  is  known  as  the  bhistula  or 
bktslddirniii-  vesicle  (PI.  10,  Fig.  4). 

The  flirt lier  changes  within  the  blastida  are  marked  by  the  rapid  and 
enormous  increase  in  the  size  of  the  oviun,  in  consequence  of  which  increase 
the  outer  cell-layer  undergoes  great  extension,  with  corresponding  attenuation 
di'  its  elements,  which  are  change<l  into  thin,  scale-like  ])latcs. 

Coiiieideiitly  with  these  changes  aflecting  the  layer  of  outer  elements,  the 
group  of  inner  cells  has  undergone  an  important  although  inconspicuous 
modifieation,  in  consequence  of  which  a  differentiation  of  these  cells  into  a 
rapidly  proliferating  peripheral  layer,  next  the  thimied-out  stratum  of  invest- 
inif  outer  cells,  and  a  more  slowly  dividing  central  mass  has  taken  jdace 
(I'l.  10,  Fiiis.  1-.'}).  This  peripheral  layer  is  the  primitive  ectoderm  proper ; 
the  iuiuT  mass  is  the  primitive  entoilerin. 


"s 


AMi:itirAx  TKxr-naoK  of  oustetkics. 


Ile.ul- 
S.ul,-  of 

IllllSfll. 
lllMlll. 


/'riiiiit/T'i 


I'll..  I'lT.— Kinliryoiiic  nrt-n  of  riiMiit  cmliryo 
iK.  V.  lU'iit'iU'iii:  iirlinitivc  stroiik  lic),'imiiiiK 
in  <rll-|>ri>liftTutiiiii,  known  as  the  "nmU'  of 
llcnsi'n." 


With  (lie  f^rowtli  of  tln'  ft-tcMlcrmic  hiyor  the  primarv  oiit'T  cells  l)eeoine 
more  atteiiiiiite*!,  and  alter  a  time  hleml  with  the  (levi'lopiiijj  eeto<lermic  tissue, 

the  two  toojether  eoiistitiitin^  the  early 
true  ectoderm.  When  this  strnetnre  is 
examined  its  surface  is  loimd  covered 
with  Hat  elements,  liisilorm  in  profile, 
known  as  liuulnr^  celif  (1*1.  10,  V'l^.  4), 
which  later  disappear  and  seemingly  take 
little  or  no  role  in  the  formation  of  the 
permanent  ectcxlermic  structures.  The 
cells  of  Uanl)or  are  j)robably  the  remains 
of  the  attenuated  layer  of  the  jmntary 
outer  et^Ils.  The  ectoderm  expands  on  all 
sides  imtil  the  ento<lerin  as  well  as  the 
entire  yulk-eavity  of  the  ovum  is  com- 
pletely encl(»sed. 

If  a  mammalian  ovum  at  about  this 
stage  be  exainine<l  from  the  surface,  the 
l)last«Klermic  vesicle  on  one  side  presents 
an  c»val  or  j)yriform  field  of  greater  den- 
sity :  this  is  the  nnbrifonal  r(/r<7,  and  corresponds  to  that  portion  of  the  blastula 
especially  concerned  in  the  <levelopment  of  the  embryo.  Very  early  a  linear 
opacity  known  as  the  primitiir  titredk'  (Fig.  67)  makes  its  appearance  at  the 
smaller  or  posterior  pole  of  the  embryonal  area,  and  seemingly  grows  for- 
ward toward  the  centre  of  this  field. 

On  se<'tion  the  primitive  streak  is  seen  to  deiwiid  upon  a  line  of  proliferat- 
ing tissue  which  marks  the  j)osition  of  fusion  and  intimate  luiion  of  all  the 
embryonal  blastodermic  layers  (Figs.  68,09).  Very  soon  the  primitive  streak 
becomes  occupijnl  by  a  meilinn  longitudinal  furrow,  the  prim  Hire  f/roove.  The 
significance  of  this  pre-end)ryonic  structure  is  still  a  subject  of  nuich  discussion. 
Without  entering  into  the  details  of  the  somewhat  theoretical  and  ctmiplicated 
considerations  of  the  subject,  it  may  bo  mentioned  that  there  are  amj)le  grounds 
for  accepting  the  views  of  His,  Miuot,  and  others  that  the  primitive  streak  of 
the  higher  types  represents  morphologically  the  fusion  of  the  lips  of  the  hltts- 
inporr — the  opening  formed  among  the  lower  types  by  the  invagination  of  the 
l»lastodermie  vesicle  at  one  point  in  the  j>roduetion  of  the  f/aatrnfa  nfdffc. 

In  contrast  with  the  usual  appearance  of  mammalian  ova,  the  early  human 
ovum  is  characterizcil  by  the  precocious  development  of  villous  projections, 
so  that  as  early  as  the  twelfth  day,  as  represented  by  Reicliert's  ovum  (see 
Fig.  8-1),  its  exterior  presents  well-marked  elevations.  These  villi,  however, 
are  not  luiiformly  distributed  over  the  ovum,  but  are  limited  to  the  marginal 
zone  of  the  compressed  spherical  oi:\r^  the  two  flattened  sides  being  smooth 
aiul  devoid  of  villi.  The  embryonic  area  corresponds  in  position  with  one  of 
the  poles  of  the  shorter  axis  of  the  ovum  that  connects  the  smooth  sides, 
although  at  this  stage  little  if  any  trace  of  the  embryo  is  to  be  seen. 


I'llYSlOLOGV   OF  rJlKdXAXVY. 


79 


s  l)ecoinc 
lie  tissue, 
tlu>  early 
lucturt'  i« 
I  covorod 
n    profile, 

[),  Fij?-  -*)' 
ingly  take 
ion  of  the 
ires.  The 
lie  remains 
le  primary 
umis  on  all 
veil  as  the 
ua  is  com- 

abont  this 
surl'aee,  the 
klo  presents 
greater  »len- 
thc  blastula 
irly  a  linear 
irance  at  the 

grows  for- 

X  prolilerat- 

>n  of  all  the 

Initive  streak 

u'oovc.     The 

li  discussion. 

fomplieatetl 
iiple  f^rounds 
ve  streak  of 

of  the  hlm- 

liition  of  the 

utagc. 

early  human 
projections, 

s  ovum  (see 
|iUi,  however, 

he  marpual 

|)oin(T  smooth 
with  one  of 

;niooth  sides, 

)('  seen. 


Coineidently  with  the  fiirtiier  growth  and  differentiation  of  the  two- 
iavercil  blastula,  a  third  layer,  the  mmidcnn,  makes  its  appearance  (Fig.  08). 
riio  ori""in  of  tills  laiM-na  is  still  a  subject  of"  nuieh  discussion,  but  it  .uay  be 
•iccrpted  as  denionstratetl  that  the  mamnialiasi  mesmlcrm  arises  from  two 
^^^,„.^.^,^ principally  by  a  splitting  ofl'  or  dclamination  from  the  cntoilerm, 


ii.r.  re  It 


tnt  ,,, 

HI  'II 

i.'i,    r.-  -  -.,  I  tioi  .11  nis*  llic  jirlniitlvo  stroiik  of  raliMt  embryo  (Kiillikor) :  rr,  prtodcrm  ;  nx.  rr.  i\xinl  rrto- 
.liiiii  uii'l'  I  i.'  '"'•-  prolifLTiitlon,  iw  shown  by  kiiryokini-tic  ligur(.'S  (k) ;  enl,  vuUhK'Tui  ;  m,  mcMoileriu. 

^iipulinirni"!  by  a  jtroliferfition  involving  the  e<'toderm  along  the  anterittr 
iiiirt  111'  ill''  I'liniitive  streak.  This  latter  structure  therefore  marks  the  axis 
jiluiiL'  wlilili  coiuplete  fusion  of  the  three  blastodermic  layers  takes  pla(»i 
Ixlure  til"'  rciiiialion  of  the  true  embryo  has  started.  The  primitive  streak 
is  a  transient  structure,  and  gives  rise  to  no  part  of  the  embryo;  later  it 
ciitiivly  (lis:i|>p('ars. 

Tlic  jrrowtli  of  the  mesoderm  is  rapid,  and  s(»on  protluces  a  layer  partic- 
iilarlv  (Icvcliipt'd  toward  the  caudal  pole  of  the  embryo,  expanding  in  broad 
Intcnil  tit'kls  on  cither  side.  Viewed  as  a  whole,  the  mestKlermic  sheet  ap|X}ars 
i>vrit'oriii,  with  its  smaller  end  directed  anteriorly  or  opposed  to  the  corre- 
snoiitling  part   of  the   embryonal    area.     At   first   a  continuous    layer,    the 


/  'rimitivf  s''i>"ve. 


Ufginning 
amnion  foiti. 


ixtMl  I  I" 


l\ir:,/,l/ 


I'liii-iiil  liiyer 

,'/  mrsi'ilerm.  Entothrm. 

Y\u.  I'.'.i.-TninsviTsc  siTdon  of  the  ombrymilt"  nroa  of  a  fourteen  and  a  half  day  ovum  of  shcop  (Bonnet). 

mesoderm  later  l)ecomes  displacxxl  along  the  immediate  axis  of  the  embryo, 
this  division  resulting  in  the  formation  of  two  closely  approxinmted  but 
Bepanitod  halves  :  in  each  of  these  a  paraxidl  and  a  lateral  (rod  are  further  to 
be  vei'(t<rniz<'<l.  The  latter  •ndergocs  cleavage  by  the  formation  of  the  intra- 
me-dderiuie  bod if-ca nl if  or  the  cclnm  (Fig.  6!() ;  the  resulting  upper  and  lower 
jlaiiiellie  eoiislitute  respectively  the  parietal  and  visceral  layers  of  the  meso- 
[dorni.    Tile  parietal  or  somatic  layer  joins  the  ectoderm  to  form  the  soma^o- 


«  ■  T.'-r' 


T 


I  f 


1 1 


ii 


80 


AMHIiFCAX    TKXT-HOOK    OF   OBSTKriUCS. 


jtleurc ;  the  viscj'iiil  or  Hplaiiclinic  layer  uiiIIoh  with  the  eiilodorm  to  form 
the  «y>Aoic/(/i»>y>/«M/'t"  (Fijr.  70).  Tlio.«e  Htriictures  hiter  prinhice  the  iMKly-walla 
and  the  wall;-*  of  the  primitive  <lij?e.stive  tiiln'. 

About  tli(!  emi   of  the  second  week  the   Iniman   ovnm  enters   npon   tiio 
uarlie:jt  initial  stages  of  the  formation  of  the  embryo  proiHT.     In  addition  tu 


Axiiil  time.         ,  \iuiai  laiuil 


Soiiiitf. 


Latrtiit  Ziine 


I'll?'//)'  wilhiu  tomilt. 


Lateral  f>liitts/or 
boiiy-ivtitii. 


iMileral  pUitis/or 
giil-tr4tit. 


—    I'ariital  mtiodtrm. 


ritu  rot>er)lonfiit 
Liivily. 


M,;iulU>y 

fihlltS. 


_  Mttiulliiry 
Jurrmv. 


Viteitine  ?'(•/«. 
FKi.  70.— Tninsvorso  sci'ticni  nf  ii  scvcntcrii  ami  a  half  day  slu'i'|i  ombryo  (lionnot). 

the  primitive  streak,  which,  as  above  stated,  is  a  transient  strnctnre  havini: 
nothing  directly  to  do  with  the  embryo,  the  fundamental  developmentiil 
pnx-esses   include  the  formation  of  the  neural  fnldn  and  the  neural  camil, 

the  chorda  dorsalis  or  noto- 
i'hoyil,  and  the  somites  or 
provcrlcbra: 

Neural  Canal.— T\\c  de- 
velopment of  this  strneturc 
consists  first  in  the  aj)|x>ar- 
ance  of  the  neural  or  medul- 
lary folds,  which  together 
constitute  a  A-shaped  dupli- 
eature  embracing  the  anterior 
extremity  of  the  primitive 
streak ;  by  the  thickeniiit: 
and  the  approximation  of  tlio 
summits  of  these  folds  tlio 
neural  or  medullary  (jroove  is 
j)rotluced  (Fig.  71).  This 
furrow  is  later  convertctl  into 
the  neural  canal,  the  early 
reprer>entative  of  the  nervous 
system,  by  the  further  growth 
and  union  of  the  folds  along  the  dorsal  line  of  contact,  the  closure  Iwing  lir«t 
eftected  near — not,  however,  at — the  cephalic  extremity  of  the  embryo,  imt 
some  little  distance  farther  caudally,  at  a  position  which  later  corresponds  with 


Kiu.  71.— Siirliice  vii'W  of  ana  )pi'lluciila  (if  an  eighti'ou  hour 
c'hii'k  I'lnbrvu  (llalfniin. 


i 


rj/ys/ftLoffV  or  rJiKaxAycv. 


81 


to    form 


upon 


the 


addition  to 


,1/  nitioii"')'!. 


imnet). 

u'turc  liavinu 

flcvolopini'"*"' 

ncuv<tl  canal. 

miUs  or  nolo- 

le    somUvs    <>v 

„,,i.__Tlio  d.- 
this  strnctun' 
in  the  apiwar- 
ural  or  vmM- 
•hich     together 
-shapetl  dueli- 
ng the  aiitcrinr 
the   primitive 
he    thickcninir 
ximation  of  tlio 
l,esc    fohls  tlio 
Hilary  yroove  is 
|ig.    71).     This 
oonverteil  into 
anal,   the   early 
of  the  nervtms 
further  growtli 
>sure  being  lir^t 
ihe  embryo,  imt 
irresponds  witli 


^ 
,< 

I 


tlic  ctTvical  region  of  the  spinal  eord.  The  extrt-nie  e<'phalieend  of  the  neural 
( ■  nil  nndergoefi  expansion  into  three  primitive  hrain-vesieles.  The  neural 
Inl.js  of  tlie  caudal  portion  for  a  long  time  remain  widely  separated. 

( 'hordii  Dorsiilix. — Tiie  appearance  of  the  chorda  ^loraalin,  or  tlie  notochorfl, 
-I'  lili-lie-;  tiic  earliest  representative  of  the  IttwjiUuUual  axis  which  constitutes 
the  fiuulaiiuiital  characteristic  of  all  vertebrates.  While  the  earliest  develoj)- 
t  of  this  striK'tnre  has  not  been  observed  in  man,  it  is  fair  to  assiune  a 
■In-e  (i.irespoiideiuie  with  the  prcK-ess  as  studiwl  in  other  niannnals.  In  these 
the  mesial  p(>rti"ii  of  the  entoderm  gives  rise  to  a  eell-group  (Fig.  72)  which 
rpidiiiilK-  iMcoiiies  separated  from  the  inner  layer  and  displaced,  so  that  the 


/•  .:•,/•■"» 


C/i'Slllf.' 


Amnion. 


rarifial 

mesoderm. 


Celhma^s/or 
U'o/Jjian  iody. 

-  Celom. 

-  Afesotlielium. 

Vtisnitive 
iiii/olluliuiM. 

y/siirni 
mesoderm. 


Xofcc/iord. 
I-  ii.  :.'.-  rriiiisVLisi'  M'ltiipii  of  II  llrti'on  and  a  half  day  shepp  embryo  posscsHing  seven  somiteH  (Bonnet). 

rc^ullini:  (cll-iiiass  forms  a  slender  cylinder  which  stretches  from  the  anterior 
extreiiiitv  nt'the  end)ryo  to  its  caudal  pole.  On  section  the  notochord  appears 
as  an  oval  irnnip  of  wlls  situatinl  immediately  beneath  the  neural  groove  or 
e;iii;il  and  ahove  the  entotlermic  layer  (Fig.  74).  The  notochord,  for  a  time 
represpiitiii^f  the  longitudinal  axis  of  the  embryo,  is  usually  replaced  Sy  the 
pcnnaiu'iit  vertei»ral  axis,  at  first  cartilage  and  later  bone.  The  remains 
of  this  eiuliiyonal  structure  in  man  are  seen  in  the  central  areas  of  spongy 
iiiiiterial  oeeiipying  the  intervertebral  disks. 

Si,mit(''<- — flie  formation  of  the  somlfm  or  provcrfvbrw  marks  the  estab- 
lisliiiient  of  the  segmentation  which  later  is  permanently  efik'ttnl  by  the  devel- 
o|)ment  (»f  the  vertebra  and  the  associated  parts  of  the  trunk.  The  production 
of  the  somites  is  so  closely  related  to  that  of  the  mesoderm  that  the  primary 
arr:ii)i:(iiieiit  of  this  important  sheet  must  be  rwalletl.  After  its  origin  from 
the  (loiihie  source  of  entoderm  and  ectoderm,  the  mesoderm  rapidly  expands 
laterally,  the  growth  being  particularly  active  toward  the  caudal  pole  of  the 
enihrvo,  in  eonsecpiencc  of  which  the  layer  becomes  pyriform  in  outline  when 
stH'ii  from  its  upper  surface.  At  first  a  contimtous  sheet,  the  further  develop- 
ment iif  the  neural  groove  from  above  downward  and  of  the  notochord  from 


If 


«2 


AMt:iil<'A\    TIIXT-JUHJK    OF   OliSTKTJtlCS. 


Iff 


t 


Im'Iow  n|>\vHr(l  s<H)ii  divitlcs  tlu>  iiicscHlci'inic  tnti-t  aloii^  the  cinhrvonic  axiis  into 
two  j;rt".it  wiiifTs  (  Fij;.  ".'>). 

Facli  of  tlicso  wiiijjfs  iiii*l(>i'^<N's  ('iirtlu>i'  ditUM'ciitiatioii  into  a  paraxial  Itantl 
no.xt  till*  uiitUlino,  an*l  a  lateral   |)latt>  which   hliMids  away  laterally  into  the 

l»ini,n. 


Msoiit'im 


l\i>i,i,t/ 
ff/i  i,'t/i-rfH 


/Vr«»<i/>'>  (I  II)  ■         I'l'  iiiinlhil 
liiiil  i.ii-,ily.  f'liiiii. 

Yv,.  7;l.— Tnilisversf  scctinii  of  n  sixteen  iiiid  ii  liiilf  iliiy  sliee|(emliry(i  (f<<iimet). 


Exlfinion 
i'f  .  floni 


widely  extending  niesoderniie  area  (Fijr.  74).  The  lat«ral  mesoderm ie  jdate 
nndergoes  cleavage  intct  an  upper  and  a  lower  huiuna  which  respectively 
adhere  to  the  ectoderm  an<l  the  entoderm.  The  upper  and  ont<'r  of  the  result- 
ing two-luyertnl  lamelhe  constitutes  the  soninfojihiiir ;  the  inider  and  iimer  one, 


Mlilultil  ry 
Juriow. 


I  'lule/l 
Eittiiii-tiii .         vii'svtit'i  tit.         Aiiniit'ti 


rarii'tal 
iiii-stHii't  m . 


Cfliwi. 


I'hi  mi/ 
tiitsi'i/t'rm. 


Noiochoril.  Soiiiitf.     Cut  entoiterm. 

Kli;.  71— Transverse  section  nf  a  sixteen  anil  a  Inilf  iltiy  slieep  emiiryo  jxiKscssiud  six  somites  (Honnet) 

the  ni>l(im-hnnpleure.  The  sj)ace  included  l>otwcen  the  two  leaves  of  the  cleft 
lateral  iiiestMlerm  is  the  primitiir  body-nmty  or  celom,  which  afterward  Ixxjomcs 
the  pleuro-peritoncal  cavity. 


DKVKI.orMKNT  OF  THK   FKTAI-   MKMnUANKS.  Pixtk  II. 


iixirt  inti» 
into  llif 


Jixtf'i^"'" 


IH't). 


1  rospoctivi'ly 
"tho  rt'sult- 
11(1  iiHH  r  oiH  . 


//..«</ 

/,./,/^ 


Amiiiim 


Yolk  sac. 


Ciioi.il 


rari.t.il 

Vtt'SOiii'*  f"- 


0-!o>" 


|s..inilos(Bonm'ti 

fes  of  the  ch'tt 
rwaril  becc>">»'" 


hnniot/i  sif. 


r.iiiltrvo. 


lu'iioH      \ 


M).  Iiiiigniiiis  illiutriiting  thu  furiimtion  of  the  maiiimitliiin  fetal  nivnibniiu's  (inndilU'd  fnnu  Koulc). 


WftW^ 


Mil 


^ 


n: 


■i 


*  i 


i  ( 


DKVELOl'MKNT  OF  TIIK   FKTAL   MEMHKANKS.  1'latk  12. 


AliautoU   Site. 


Amnion 


I 

/  'itvllim-  Vfskif. 


Vasiula*    villi  of 
piaicntai  chorion. 


Ewhrvo. 


Non-p/tuental 
thorion. 


f  I'illi  o/chori.m 
\     jroniioutw. 


Mlantoit.  btOod-Z't'sst'U, 


I,  'J.  DiH^nniis  fUustratin^  tlu*  Inter  sitiuts  nf  (lie  rnnnalioii  of  tlio   iiuitiiinMliaii  iVtiil  inoniltrant's 

llMDililir*!  tVollI  iv(Mllr). 


^ 


'! 


i 

!  ; 


I 


II 


!     ,    i 


I' 


I     1 


PHYSIOLOGY   OF  PREGNANCY, 


83 


S 
t 


The  paraxial  band  of  inosoderm  does  not  undergo  doavajre  as  do  the 
neighboring  hiteral  niesoderiuic  areas,  but  instead  it  suffers  a  transverse  divis- 
ion into  a  series  of  small  quadrilateral  luvi-.s,  the  .soriutcn  or  pimrrtehrtv. 
These  areas  first  appear  immediately  behind  the  cephalic  expansion  of  the 
neural  canal  and  progress  toward  the  caudal  pole,  at  particular  stages  of  tho 
luuuan  embryo,  as  from  the  twenty-first  to  the  thirty-fifth  day,  forming  ;; 
series  of  eonspicnous  markings  on  each  side  of  the  dorsal  mid-line  as  far  as 
the  extreme  caudal  extremity  (Fig.  V2d). 

The  somites  are  transient  and  are  not  represented  by  adult  structures,  since 
tlie  segmentation  of  the  permanent  vertebrse  which  later  appears  does  not  cor- 
respond with  that  of  the  somites,  the  areas  producing  the  vertebra-  falling  in  such 
manner  that  portions  of  the  somites  are  embraced  by  a  single  vertebra.  While 
not  directly  related  to  the  formation  of  the  vertebral  colunui,  the  somites  con- 
tribute to  the  production  of  the  important  muscular  tissues,  since  the  outer 
portions  of  their  masses  become  converted  into  peculiar  flattened  bands,  the 
,niis<>h'-pkdes,  from  which  proceeds  the  development  of  the  great  tracts  of  vol- 
untary muscle,  at  first  of  the  trunk,  later  of  the  limb  appendages. 

3.  Petal  Membranes. — Coincidently  with  the  ])rogress  of  the  fundamental 
))r()cesses  just  described,  the  formation  of  envelopes  for  the  j^rotcction  and 
establishment  of  means  for  the  further  nutrition  of  the  embryo  takes  place : 
tliese  envelopes  are  known  as  the  fetal  mcinhrancii  (Pis.  11,  12),  which,  in  con- 
nection with  the  structures  derived  from  the  thickened  uterine  lining,  con- 
stitute the  membranes  thrown  off  at  birth. 

The  amnion  (Pi.  11,  Figs.  4,  5),  the  earliest  of  the  envelopes,  ai)pears  soon 
at't(>r  the  formation  of  the  neural  folds  and  groove  as  duplicatures  of  the  soma- 
toplenre  which  start  in  front,  behind,  and  at  the  sides  of  the  embryo.  The 
anterior  amniotic  fold  in  luan  grows  with  unusual  rai)idity,  and,  aided  by  the 
lateral  folds,  soon  covers  in  the  embryo  from  before  backward,  the  caudal 
extremity  being  the  last  to  be  enveloped.  The  line  of  union  of  the  several 
(lii|)licatures  has  received  the  name  amniotic  fiuture.  Examined  in  section,  the 
amnion  is  seen  to  comprise  not  only  the  ectodcrmic  tissue,  but  also  the  exten- 
sion of  the  parietal  or  somalopleuric  layer  of  the  mesoderm.  On  reference  to 
the  Figures  of  Plate  1 1  this  relation  will  be  seen  illustrated,  as  well  as  the  mode 
by  which  the  fi)lds  meet  over  the  dorsal  siu'face  of  the  embryo  to  form  the  anmi- 
otic  sac,  which,  when  entirely  closed,  contains  the  anuiiotic  fluid  separating  the 
envelope  from  the  developing  animal.  While  union  and  fusion  of  the  innermost 
layers  of  the  ecto-mesodcrmic  folds  of  the  somato])]eure  produce  the  true  am- 
nion with  its  contai.t.etl  sac  lined  with  ectoderm,  the  separation  of  the  fused 
outer  lamina;  of  the  duplicatures  from  the  amniotic  portion  gives  rise  to  a  sec- 
ond externally-lying  envelope,  the  falxc  amnion,  or  xcronx  membrane,  in  which 
tile  disposition  of  the  component  layers  is  reversed,  since  the  ectoderm  lies  with- 
out, and  the  mesodcrmic  tissue  next  the  included  space.  The  latter  is  directly 
eiintinnons  with  the  interval  between  the  parietal  and  visceral  lamina?  of  the 
cleft  mesoderm,  and  is  the  cxtra-cndnyonal  portion  of  the  primitive  body- 
eavity,  which  thus  extends  widely  beyond  the  limits  of  the  embryo  proper. 


1!1»/ 


/TTT 


84 


AJ/EItlCJX    TEXT-BOOK   OF    OIiST£TIlICS. 


;  t 


h 


With  the  acciimiihitioii  ot'  the  liquor  aninii  the  iUuiiiDii  becomes  separated 
iVoiii   the  embryo  aiitl  is  pushed  a};ainst  tlie  surroiuidiiijif  eiivelofies. 

77ui  amnlotk'jiukl,  or  liquor  (iiiniii,  is  a  serous  fluid  prochioetl  probably  bv  the 
amnion  itself,  having  a  spceitic  gravity  varying  from  1.007  to  1.008;  it  contains 
from  1.07  to  1.06  per  cent,  of  dry  solids  (ProehownicU).  The  amount  of  the 
amniotic  lluid  is  subject  to  great  variation,  the  average  quantity  at  full  term 
being  between  700  and  800  cul)ic  centimeters,  or  less  than  one  liter.  Not- 
withstanding numerous  investigations,  there  appears  to  exist  no  constant  rela- 
tion between  the  quantity  of  the  amniotic  fluid  and  the  weight  of  the  chiUl  or  of 
the  after-birth.  In  addition  to  the  evident  use  of  the  fluid  for  the  mechanical 
protectiftn  of  the  end)ryo,  it  is  probable  that  it  affords  a  source  of  water  to  the 
developing  animal,  since  there  is  stung  evidence  to  show  that  the  fluid  is  con- 
tiimally  swallowed  during  the  greater  part  of  intra-uierine  existence.  Toward 
the  later  months  of  gestation  the  pressure  induced  by  the  growing  fetus  and 
the  large  amount  of  the  amniotic  fluid  pushes  the  amnion  into  close  contact 
with  the  surrounding  false  amniim,  the  two  becoming  closely,  although  not 
inseparably,  unitetl  by  the  end  of  gestation. 

As  the  embryo  gratlually  assumes  a  more  definite  general  form,  the  roots  of 
the  true  amniotic  folds  sink  more  and  more  ventrally  until  they  meet,  thus 
closing  in  the  body-cavity  and  forming  its  anterior  wall.  In  the  early  stages, 
when  the  yolk-sac  or  umbilical  vesicle  communicates  with  the  widely  open 
gut-tract  by  means  of  its  broad  stalk,  approximation  of  the  somatic  plates  is 
prevented.  With  the  decrease  of  the  umbilical  vesicle  and  the  corresponding 
diminution  in  its  stalk  the  ventral  plates  grow  together  and  rapidly  close  the 
])I('uro-peritoneal  cavity  excej>t  at  one  point,  the  umbilical  opening,  through 
which  ])ass  those  structures  that  conntvt  the  embryo  with  organs  lying  with- 
out its  IkkIv,  as  the  umbilical  and  allantoic  blood-vessels  and  stalks  with  their 
acconqtanying  liunina. 

Tlic  Alhudoix. — The  allantnis  appears  as  an  outgrowth  from  the  hind-gut 
(PI.  11,  Figs.  5,  6)  after  the  primitive  digestive  tube  has  become  well  defined 
and  j>artially  closed.  When  typically  developed  the  allantois  grows  out  as  a 
free  sac  into  the  space  between  the  true  and  the  false  amnion,  raj)idly  increasing 
in  size.  In  man,  however,  the  allantois  at  no  time  exists  as  a  free  vesicle, 
since  it  almost  at  once  forms  attachments  with  the  structures  extending  from 
the  cautlal  extremity  of  the  human  embryo  as  the  abdominal  .stalk  (Fig.  7o), 
in  which  is  included  the  lumen  of  the  imprisoned  allantoic  sac. 

The  primary  function  of  the  allantois  is  to  act  as  a  receptacle  for  the  excre- 
tory allantoic  fluids  thrown  ofl'  by  the  Wolffian  bodies,  by  which  primitive 
orjrans  the  effete  matters  are  removed  as  bv  tiie  kidnevs  at  later  stages.  Sub- 
.sequently  the  allantois  takes  an  imj)ortant  part  in  building  up  the  chorit)n, 
from  which  the  fetal  contribution  to  the  nutritive  apparatus  of  the  placenta  is 
directly  derived. 

The  abdominal  stalk  is  peculiar  to  the  human  embryo,  in  which  it  very 
early  appears  as  a  pedtmcidated  extension  of  its  caudal  portions  to  the  sur- 
rounding false  amnion,  over  wliich  it  expands  and  with  which  it  fuses,  tlie 


PHYSIOLOGY   OF  FREGNANVY. 


85 


I  separated 

>es. 

iibly  by  the 

itcontuin:s 
niut  of  the 
t  full  term 
liter.  Xot- 
nstant  rela- 
ichiUlor  of 

nieehanieal 
water  to  the 
HiiUl  is  eoii- 
;e.  Toward 
ig  fetus  and 
•lose  eoutact 
dthough  uot 

,  the  roots  of 

'V  meet,  thus 

early  stages, 

widely  t)peu 
latic  plates  is 
•orresponding 
idly  elose  the 
ling,  through 
lying  with- 

is  with  their 

the  hind-gut 
well  defined 
ows  out  as  a 
ly  inereasing 
free  vesiele, 
tending  from 
%,dk  (Fig.  75), 

for  the  exere- 
lieh  primitive 
stages,  ^^nb- 
the  ehorion, 
le  plaecnta  is 

which  it  very 
ns  to  the  sur- 
li  it  fuses,  the 


allantoic  tissue  taking  part  in  the  formation  of  the  ehorion  (Pi.  12,  Fig.  1). 
The  allantois  in  man,  therefore,  is  never  free,  and  finds  its  expres-sion  in  the 
entodermie  diverticulum,  which  passes  from  the  hind-gut  through  the  abtlom- 
iiial  stalk  toward  the  diorion.* 

Wliatever  its  initial  mo<le  of  formation,  the  allantoic  tissue  grows  with 
rapidity  and  extends  over  the  inner  surface  of  the  false  amnion,  with  whieh  it 
soon  becomes  intimately  united,  the  two  mend)ranes  together  constituting  the 
chorion  a  structure  of  much  imiK)rtance  in  providing  for  the  nutrition  of  the 
cmbrvo  durinir  the  last  two-thirds  of  its  intra-uterine  sojourn,  by  reason  of  its 
active  participatinn  in  tlie  formation  of  the  placenta. 

Tiie  allantois  being  a  direct  outgrowth  or  evagination  of  the  in-imitive  gut, 
its  wall  consists  of  an  inner  entodermie  and  an  outer  mesodermie  layer — ex- 
tensions of  the  splanchn()])leuric  tissues  forming  the  digestive  tid)e.  (oinci- 
dentlv  witli  the  later  development  of  the  allantois,  blood-vessels  extend  from 
the  arterial  trunks  of  the  end)ryo  within  the  mesodermie  layer  of  the  sac  and 
invade  this  tissue,  which  has  become  closely  united  with  tiie  false  amnion  in 
their  joint  j)roduction  of  the  ehorion. 


Fk. 


.Ji-l]  ■111.1,,, ImSw" 

niiitiriiiiiiimlic  Pi'ctiiiiiP  rcprrscntiiiK  uniwth  nnd  nrrniiBPmont  of  the  nninion  in  the  tiirlitst 
sta«i'S  (if  Uic  li\imim  eiubryd  (Hist. 


The  cJiorioii,  covered  with  simple  and  compound  villi,  is  at  first  devoi<l  of 
blood-vessels,  and  is  composed  of  the  ectodermic  and  entodermie  layers  on  its 
outer  and  inner  surfaces,  between  which  lies  the  thicker  lamella  formed  by  the 
fuse<l  amniotic  and  allantoic  mesodermie  strata.  Shortly  after  the  establish- 
ment of  the  chorion,  the  arteries  conveyed  by  the  allantois  spread  out  within 
the  mesodernnc  layer  of  the  chorion  and  invade  the  villi,  which  then  display 
vascular  loojis  within  th(>ir  characteristic  leaf-like,  club-shaped  processes. 
These  processes  often  consist  of  a  main  i>rimarv  stalk  from  which  second- 
ary twigs  branch,  from  which  diverge  the  ultimate  leaves. 

*  Tlip  term  ''chorion''  is  hero  nscil  in  a  restricted  sense  as  indicntintr  the  nieiiihranc 
resiiitiiiK  from  the  fusion  of  tlie  false  amnion  and  the  aUantoie  tissue  :  l)y  some  authors 
(Minot)  (lie  "chorion"  represents  tlie  entire  extra-embryonic  somatopleure,  which  gives  rise 
alike  to  the  true  and  the  false  amnion. 


I  i 


«G 


AMKRICAX    TKXT-JiOOK    OF    OBSTETIilCS. 


Tlic  form  and  arraiim'iiu'iit  of  tlio  villi  varv  soinowliat  with  tlio  duration 
of  prcjiiiancv :  at  the  tiiinl  month,  or  when  the  phu'onta  is  formed,  the  villi  are 
>short,  thiek-.set,  and  of  irregular  shape;  later  they  become  less  irrej^ular,  and 
the  sceondarv  branches  leave  the  parent  stems  less  aeutelv  ;  finallv,  at  full 
terni,  the  villi  are  more  regularly  dispostnl  and  their  branches  have  bec<»me 
long  and  slender  and  less  closely  set.  The  recognition  of  the  villi  of  the  cho- 
rion is  often  a  matter  of  much  practical  importance,  since  their  ])resence,  as 
determined  by  microscopical  examination  of  suspicious  matters  discharged  ^tcr 
raffiiKiiii,  is  positive  evidence  of  the  existence  of  pregnancy.  Their  j)eculiar 
arrangement,  and  their  flattened,  petal-like  fornj,  together  with  their  vascular 
connective-tissue  stroma  and  epithelial  covering,  usually  suffice  to  establish  the 
diagnosis. 

T/if  Plactida  (ind  Ihrifluw. — The  primary  uses  of  mechanical  protection 
atforded  by  the  membranes  in  mammalian  end)ryos  are  supplemented  by  the 
important  rofe  of  assisting  in  establishing  an  efficient  nutritive  organ  through 
which  the  maternal  tissues  may  extend  the  necessary  aid  to  the  maintenance  of 
the  developing  animal  during  the  latter  two-thirds  of  its  intra-uterine  life. 
Such  organ  is  the  placenta,  in  whose  ])rodiiction  both  fetal  and  maternal  struct- 
ures take  an  active  part. 

The  early  villi  of  the  chorion  are  practically  identical  in  all  parts  where 
developed.  Very  soon,  however,  the  villi  occupying  the  area  which  later  will 
correspond  with  that  of  the  placenta  exhibit  unusual  growth,  and  outstrip  in 
size  and  vigor  those  of  the  remaining  parts  of  the  envelope.  This  ditlerence 
in  the  dcveIo])nicnt  of  the  villi  marks  the  division  of  the  mend)rane  into  the 
cliorioti  frnn(l(>.-<i(m  and  the  chorion  hire,  the  former  being  that  jiart  of  the 
<'linrion  wiiich  contril)Utes  the  fetal  portion  of  the  placenta  (Fig.  7G).  The 
villi  of  tiie  chorion  la-ve  undergo  gradual  atrophy  and  finally  disappear. 

The  fertilized  ovum  on  reaching  the  uterus,  after  descending  the  oviduct, 
becomes  entangletl  and  retained  within  the  folds  of  the  soft,  thickened  mucous 
mend)rane  prepared  for  its  reception.  Immediately  after  its  lodgement,  which 
is  usually  in  the  vicinity  of  the  fundus,  the  uterine  mucosa  takes  steps  to 
secure  the  imprisonment  of  the  ovum  by  means  of  a  circular  fold  which 
gradually  rises  around  the  egg  until  it  is  completely  enclosed  within  the  new 
envelope  formed  by  the  reflected  uterine  tissue. 

In  view  of  the  fact  that  the  mucosa  of  the  uterus  is  discarded  at  the  close 
of  labor,  the  thickened  uterine  lining  is  appro])riately  termed  the  ihcldua  ;  of 
this  mend)rane  three  regions  are  recognized  :  the  (hci(fi((i  rcfc.va,  or  that  por- 
tion which  encloses  the  ovum  by  the  reflected  folds;  the  (hvUJud  rcf(t,  or  that 
jmrtion  which  constitutes  the  greater  part  of  the  general  lining  of  the  uterine 
cavity  ;  and  the  (hvlihtu  .scrotum,  or  that  portion  of  the  uterine  lining  includcil 
within  the  embryonic  sac  completed  by  the  reflexa  (Fig.  7G  ;  PI.  l.*?).  Tlic 
decidua  serotina  derives  especial  signiflcance  from  the  fact  that  it  contributes 
the  maternal  jiart  in  the  formation  o^'  the  jylacenta. 

The  changes  afl'ecting  the  maternal  tissues  consist  prinnu'ily  in  proliferation 
of  the  epithelium  and  the  glands,  the  latter  becoming  greatly  enlarged  both  in 


'*^i 


% 


;  ihiratioii 
0  villi  iiH' 
j;nlar,  iiiul 
ly,  at  inll 
ve  become 
»f  tlic  cliu- 


is 


irosen<'e,  n 
harmed  per 

>ir  vai 


■C'U 


liar 
ifular 
;tal)lish  the 


pr 


DtOOtlOIl 


lUed  by  tlio 
ran  tbroniiii 


nti'iiance  o 


utonno 


life 


prn 


[il  striK't- 


parts  where 
t'h  later  will 
(I  outstrip  in 
litVereiu'c 
iito  the 


us  ( 


ane  J 
iiav 


t  oi'  the 
g!  7G).     The 


>near. 


fil>pe 
tl 


le  ovit 


liict, 


:('ne(l  imieons 
ut,  whieh 
step; 


eiiu 
vkes 


to 


fold  whieh 
thin  the  mw 

■d  at  the  close 
(hridua  ;  nf 
[,  or  that  por- 
;  rcva,  or  that 
if  the  nteriiie 
lude.1 
The 


nin<>;  me 
it  contribults 


II  pv 


)liferatinii 


lartred  both  in 


i;r.l.ATH>NS  ol-  rKTlS  ANI>  iniciwr.K 


I'l.Aii:  i:t. 


^■5 


^ 


> 


I 


tD 


_J 


rilYSIOLOGY    OF   PREGXANVY 


87 


size  aiul  in  the  nnml)or  of  the  tubules,  the  increase  particiihirly  involving 
tiicir  deeper  parts.  Subsecpiently  the  j)ressnre  exerted  upon  this  hypertro- 
i)iiied  tissue  by  the  rapidly  growing  embryo  and  its  surroiuiding  structures 
induces  atrophy  and  degeneration,  so  that  i\w  outermost  part  of  the  thickened 
uterine  nuicosa  becomes  the  ntnitum  compada,  and  the  middle  part  the  stratum 
snoin/ioauia  (Fig.  77).  The  limited  zone  embracing  the  fundi  of  the  tubular 
uterine  glands  remains  unaftected,  and,  after  the  expulsion  of  the  structures 


Mucous  /fhii;  -vitliin 
it-fi'iitt/  itttia/. 


Fi(i.  7(i.— Uittgram  illustratiiis  ri'lations  of  structures  of  the  humnn  ntorus  nt  the  end  of  the  seventh 
week  of  pretinaney  inioditied  from  Allen  Thompson). 


constituting  the  after-birth,  institutes  the  processes  of  repair  by  which  the  new 
mucous  membrane  of  the  uterus  is  produced.  As  the  result  of  the  secondary 
degeneration  of  the  epithelial  jwrtions  of  the  titerine  mucosa  the  vascular  cho- 
rionic villi  are  brought  into  close  relations  with  the  vascular  connective  tissue 
of  the  uterus,  by  which  the  interchanges  between  the  fetal  and  Uiaternal  cir- 
culations are  facilitated. 

The  relations  between  the  fetal  and  the  maternal  parts  of  the  placenta,  in 


m 


88  AMKlilCAX   TEXT- HOOK   OF   OliSTKTIilCS. 

the  simplest  type  such  as  posspssoil  hy  the  hog,  consist  ossontially  in  the  rccoj)- 


Kiii.  77.— Scrtion  tliriiiii;li  iiterint'  wnll  nnrt  nttnclii'd  )ilii(>i'iitii  (WnnmT):  »,  iilciiiic  wall  rciKlcri'iI 
spotii.'y  liy  urciilly-iU'Vi'luiicd  iili'iilU'  siinisis  (h.<i  :  mi,  Ipniiiclii's  (if  uteri lU'  tirti'iy  :  (/.<.  rU  riilim  >frnliiiii ;  f, 
line  of  si'|iiinitii>ii  ;./';<.  rcliil  imrlinii  nf  iilnci'iiin,  tmisisliiiu' nf  a  miiss  of  viis<'iiliir  fcliil  villi  ir.r.i.i,  sur- 
roiindiil  liy  tlic  iinitiTiiiil  liluoil  .'•iniisi's :  mn,  iiiiinioii  coviiiiit;  fri'i'  iuliriml  Mirliicc  of  pltici'iita. 

tion  of  tlic   simple  chorionic  villi   within   ccdTcspondinj;  »lc|)rcs^ions  in   the 


Fi'i.  (>.— I'lari'iitii  vifWLMl  from  iiliriiic  surfaci'  of  aitacliiiu-iit,  slmw  iii'_'  ilivi>ions  iiitocotylcdoiis  (Itidloo). 

niatornal  tifisues,  the  circnlation  of  the  villi  coining  int(»  close  ap]>ro.\imation 


^ 


i)i:vi:i,(>r.MKNT  or  tiik  rirn  s  and  ris  ai'1'i;m»a(;i:s.    |'i.\ti:ii. 


tlio  rcccj)- 


iMiII  niKlcrfd 
i»  xriiliim ;  x, 
"  K'l'-i.',  Mir- 
iitii. 


'IIS  ill   t\ 


le 


I 


■/.  T    1, 


5  3   * 


-  »  i 


•  ^»  — 


C  .  'r 

C:T    3 


—  r  -I 


~  r  i  :: 


1  si--  ■■ 


I."  (Hidldo), 

iniiitioji 


Ci5! 


!         ■! 


,Twr- 


I 


rilVSlOUKlY    or    I'UFJiNAycV, 


89 


with  tlic  ciiliirfr^Hl  l)l<MHl-V('ssrls  uf  the  nictlicr.  Tliosf.  simple  relations 
iM-c.Dic  c..m|.li."ite.l  ii.  the  hi^rluT  inaii.inals  an.l  in  man  l.y  the  .-..mplcx 
ehaiaeter  of  the  ehoiionie  villi,  whose  im>jr„lar  fonn  and  <lisi)ositi..n  are 
fin-ther  masked  l.y  iutual  attaeliments  formed  between  the  tips  of  many  largo 
villi  and  the  maternal  tissne  (I'l.  14). 

The  disappearance  of  the  epithelial  portions  of  the  nterino  mneosa  hrinjrs 
the  ti'tal  villi  into  close  relation  with  the  prnlilcrate<l  connective  tissne  of  the 
mneosa,  with   a  diminution   in   the  structures  separating'  the    fetal  and   the 


Fig.  T'.t.— Plncontn  at  full  tiTm.  showing  supcrflclnl  ilistributinn  of  lilood-vossi-lji  (MinotV 

maternal  circulation.  Coincidently  with  the  chansies  atfectint^  the  decidua 
serotina,  the  capillary  hlood- vessels  of  this  part  of  the  uterine  mucous  mem- 
brane underifo  enormous  expansion,  so  that  finally  they  arc  converted  into  the 
lartre  and  conspicuous  blood-spaces  occupyinu;  tlio  intervals  between  the 
attached  chorionic  villi  and  the  adjacent  maternal  tissue.  These  intervillous 
blood-spaces,  the  enormously  dilated  maternal  capillaries,  an-  supplied  by 
arterial  twigs  and  are  draine<l  by  corresponding  vcikjus  truidvs  connected 
with  the  larger  uterine  vessels.  Notwithstanding  the  attachment  of  many 
large  villi,  the  greater  number,  coiiiprised  by  the  smaller  villi,  are  not  so 


' '  ■"  m 


90 


AMK/i'K'Ay    TKXT-JiOOK    OF    OBSTETIUVS. 


I  1 


/ 


i    ;    iV 


hound  down,  their  fVoo  omls  floatiiiij  within  tho  largo  lakes  of  maternal  blood, 
in»rn  whieh  they  are  separated  bv  the  attenuated  and  atropine  endothelial  wall 
of  the  spaee  alone. 

The  human  plaeenta  at  full  term,  as  soon  after  the  expulsion  of  the  after- 
birth, is  a  diseoidal  mass,  usually  t)val,  sometimes  eireular,  but  often  irregular 
in  outline,  about  18  «'entinieters  in  diameter  and  2.5  to  •">  centimeters  in  thiek- 
uiss.  It  pre>eiits  an  inner  smooth  siu'faee,  eovereil  by  the  amnion  and  look- 
ing toward  the  fetus,  and  an  outer  rough,  spongy,  uterine  surface  of  attaeh- 
nu'iit  sidulivided  by  furrows  into  numerous  more  or  less  distinct  areas  or 
votjilalonx  (Fig.  "8)  composed  of  the  lacerated  decidual  tissue  and  vessels  torn 
through  at  the  time  of  the  separation  of  the  placenta,  the  decidua  serotina  split- 
ting, one  |)art  adhering  to  the  outer  surface  of  the  placenta,  the  other  remaining 
attached  to  the  lUerine  wall.  In  contrast  with  the  dark  blood-clot  hue  of  this 
tissue,  the  smooth,  shining  amniotic  surfice  appears  of  a  generally  lighter, 
somewhat  mottled  tint,  made  uj)  of  reddish-gray  patches  alternating  with 
yellowish  areas,  which  depend  respectively  upon  the  contained  blood  and  the 
fetal  villi,  whose  colors  shine  through  the  superimposed  transparent  anniion. 
riu'  j)laceutal  blood-vessels  (Fig.  7{() — the  two  umbilical  arteries  and  the 
single  umbilital  vein — s]ireatl  out  in  all  directions  from  the  usually  eccen- 
tric point  of  insertion  of  tlu-  umbilical  cord,  when  <listeuded  with  blood  their 
courses  being  readily  traced  both  by  sight  and  by  touch  beneath  the  overlying 
auuiion.  The  arterial  twigs  arc  more  superficial  than  the  veins,  which  arc 
considerably  hcger  in  diauu'tcr.  lioth  sets  of  vessels  j)ass  from  the  smaller 
to  the   larger  twigs  without   anastomoses. 

Strurtuir. —  If  the  freshly-cut  surface  of  the  thickness  of  the  placenta  be 

caretully  examined  with  the  unaided 
eye  or  with  a  low  magniiyiug  glass,  the 
entire  organ  is  seen  to  be  composed  of 
an  inner  and  an  outer  membranous 
boundary,  between  wliii-h  is  included  a 
thick  spongy  layer  contributing  almo>t 
the  entire  thickness  of  the  organ.  ( 'loM'r 
investigation  shows  that  the  spongy 
layer  is  composed  of  the  loosely  held 
masses  of  chorionic  villi  (Fig.  SO),  with 
the  intervillous  blood-spaces,  separated 
into  the  I'otyledonous  areas  by  con- 
nective-tissue se|)ta.  The  outer  mem- 
wianous  boundary  consists  of  the  con- 
densed portion  of  the  decidua  serotina, 
which  atlhcres  t(»  the  fetal  villi  and  sup- 
plies the  outer  wall  to  the  blood-spaces ; 
the  inner  boiuidarv  incluiles  the  denser  portion  ol'  the  chorion  together  with 
the  adherent  anuiiou. 

.Microscopic  examination  of'  the  spongy  placental  tissue,  as  seen  in  sections 


]•■;,;.    VII  _|>,,,-[|,in    nf    illji'clrcl    \\\\\\>    \'T'<\\ 

ii'iilii  ■•(■  nliniii  livi'  mmillis  i  Mini.t 


1.1a- 


it 


cnial  blood, 
)thclial  w;ill 

A'  tho  aftor- 
L'li  irrcfi'iilar 
ITS  in  tliit'k- 
m  and  looU- 
0  of  attacli- 
iict  areas  or 
vi'ssels  torn 
•rotina  split- 
T  rcniaininu: 
t  hno  of  tills 
idly  liii'litcr, 
iiatint;  with 
lood  and  the 
rent  amnion, 
'rit's  and  tlio 
■nally  cccon- 

l)lo(»d  tlicir 
10  ovc'rlyiiii>; 
S  wliicli  arc 

the  smaller 

placenta  l»e 

llie    unaided 

ii'lass,  the 

niposi'd  of 

nemltranoiis 

nehiiK'd  a 

iiiii'  alnio>t 

■an.    CloMT 

le    spongy 

insely    held 

iT.  SO),  with 

,  separated 

l»y    eon- 

iiitei-    iiiein- 

f  the  enii- 

la  serotiiia, 

i  and  snp- 

ind-spaees  ; 

•ether  with 

in  sections 


riiYsioiJx.y  or  i'ni':(ixAy<'y.  91 

tFi.rs.  SI    S-J),  .-hows  the  villi,  althongh  ditlering  greatly  in  si/e,  to  lu'  made 


■I 


J"i,,.  s) -..<(, ,.(j,,,|  (I,,., |||,_r)|  jiliici'iitii  <if  si'vi'ii  iiiiiMllis  in  s(VmMinnti;  .Im,  iniinliiii :  Clm,  I'luirinii ;  17, 
r(K>t  "f  :i  vinii>  ;  r/.  si'i'tidii-i  111'  niniiliciitiiiiis  nl'  Ilic  villi  iinioiis.'  Ilu'  liinli'iiinl  liluud  spiici's ;  /»,  (Ircp  liiviT 
of  the  iliiiiliia,  >liouiin.'  iciniiiii^  nl' ciilniiicd  L'lniicls  (if  sUiiHim  s|i(m);ioMiiu ;  IV,  uliriiiL"  Ii1(iuiI-vi.'ssl'1 
ConiU'i'lfil  Willi  |iliii'('iiliil  >iinis :  )li\  miiM'iiliir  wnll  of  mIitus. 

up  of  a  stroma  of  eiiihryoual  connective  tissne  containing  large  liranched  cells 


I  I 


if 


I      1 


>  1/ 


11- 


92 


A.VERIf'AX    TEXr-BOOK    OF   OBSTEmiCS. 


and  hi ood- vessel. s  ;  these  latter  consist  of  the  larger  twijjjs,  eneased  hv  the  rohiisl 
])riniary  stalks,  and  of  all  i^radations  of  size  to  the  slender  caiiillarv  lodps 
supplying  the  terminal  petal-like  processes.  The  extei'ior  of  the  very  yoiiiiu 
villi  is  covered  hv  a  layer  of  chorionic  e])ithelinni,  but  this  soon  becomes  I(  -s 
distinct,  and  after  the  fourth  month  it  no  longer  c(mstitutes  a  continuous  lavi  r 
but  is  present  only  in  patches.     The  ectodermic  epithelium  covering  the  clio- 


Klc.  sj  — A.  si'ctidii  tlirdUL'li  iimrf-'iii  nf  iilnceiitu  at  fuU  tcnii  (Miiidti:  /'.  /',  ilcop  liiycr  iif  lU'ciilim . 
)V,  c>liiirii>nic  villi  viiriimsly  cut.  Mnnil-vcsst'ls  iiijrcli'il ;  >/.  iiiiirL;iiiiil  s)iiicc  nearly  fvcc  fnnii  villi;  n, 
alrniiliic  ('Xtra-|ilai'cmal  villi:  I'h'i.  clKnidii :  h,  vi'ssel  of  uliTiiif  wall;  I'ih.  caiializiMl  tiliriiic  (UTivr.l 
ri-Miii  laiKliiiid  clKniuuic  fctoilenii.  B,  <k'cicl\ial  tissui'  I'rcim  plari'Uta  at  full  leriii :  (/,(/',  (k'l'idiial  cillv 
r,  lilixul-vi'ssi'l. 

rioM,  as  described  by  Laugliaus.  Kastscheidio,  and  ]\[iuot,  consists  oi"  a  dicp 
and  a  superficial  stratum,  the  cells  of  the  latter  assuming  a  Ihittened,  scale-likr 
form. 

Sections  of  the  ])laceuta  din-ing  the  later  months  uf  gestation  fail  to  rcvciil 
any  delinite  I'udothelial  partition  between  the  exterior  of  the  villi  and  iIk 
maternal  blood-spaces,  the  villi  seemingly  coming  directly  in  contact  witii  tln' 
blood  of  the  mothei-.  The  determination  ')f  the  existence  or  absence  of  a  ili>- 
tinctwall  to  the  bloo(l->;|)ace  has  given  rise  to  nmch  discussion  an<l  contlictiiigMs- 
sertion.  The  solution  of  the  (juestion.  a-<  so  often  is  th(>  case,  seems  to  be  fdiiml 
in  the  more  careful  study  of  the  developmcMit  of  tiic  tissues,  which  study  ha^ 
shown  that  in  the  earliest  stages  the  fltal  villi  arc  separated  from  the  maternal 
blood-vessels  bv  an  intervening  laver  of  decidua  as  well  as  bv  the  endotheliiiin 


PHYSIOLOGY   OF  PREGNANCY. 


93 


by  the  robist 
apillary  loojis 
lie  very  yoiinjx 
1  becomes  Ir^^s 
itinuoiis  lavi  r, 
erinj!;  the  cIm- 


'&<?, 


3., 


li 


1>^ 


(7 


:i^ 


liiycr  (if  <U'cii\\iii; 

fife  I'ruiu  villi:  n, 

\/.vi\  lilil'illr  (li  riv.  1 

/.  iV,  ill'cilllUll   lrH>. 


islsts  oi"  a  tli'ili 
tciK'il,  sealo-lilic 


III  fail  to  I'cvciil 
villi  and  tlic 
tiitact  with  tlic 
)seiire  of  a  (h»- 
i(l<'onrti('tiiv/:is- 
eius  to  be  Iniunl 
,hi('h  study  ii;i- 
)in  the  inatcnial 
the  eiKU)theliiiiii 


t'( 


w 


of  the  vessel-  With  the  progressively  increasing  capacity  of  the  enormously 
dilated  blood-capillaries  into  the  blood-spaces  the  compression  and  atrophy  of 
the'  interposed  structures  follow-first  of  the  decidual  tissues,  and  finally  of 
the  VKCular  endothelium,  during  the  later  months  of  pregnancy  the  external 
surface  of  the  chorii>n  and   its  villi  constituting  the  immediate  wall  of  the 

maternal  blt>od-si)ace.  ,.     ,       ,  i  -i-     i  i    • 

4  Umbilical  Cord.— The  formation  ot  the  human  umbilical  cord  is 
closelv  related  t..  the  primary  abdominal  stalk.  The  latter,  as  already  noted, 
mav  i)e  reoanlod  as  the  extension  of  the  embryo— a^  a  sort  of  pedicle  connect- 
imrits  caudal  parts  with  the  chorion  and  containing  the  allantoic  diverticulum. 
In°the  early  statics  the  somatic  folds  which  form  the  amnion  bear  the  same 
relation  to  "the  al)dominal  stalk  as  they  do  to  the  more  anterior  parts  of  the 
embryo ;  later  they  bend  around  the  stalk  to  meet  and  join  on  its  ventral 
surface,  the  amnion  in  consequence  becoming  separated  from  the  stalk,  which 
thus  becomes  gradually  enclosed  within  a  tubular  amniotic  sheath.  The  closure 
of  the  soinatoplciuic  folds  around  the  abdominal  stalk  imprisons  the  umbilical 
or  vitelline  duct  within  a  space  which  is,  in  fact,  part  of  the  celom.  This  space 
soon  becomes  giratly  reduced,  and  finally  is  obliterated.  The  foregoing  rela- 
tions point  out  the  iact,  strongly  emphasized  by  Miuot,  that  the  umbilical  cord 
is  covered  with  the  direct  extension  of  the  emltryonic  somatopleure,  and  not 
with  theanminii,  :is  is  often  asserted,  since  the  amnion  gradually  becomes  sepa- 
rated from  the  embryo  along  the  cord  as  far  as  its  distal  end,  where  it  still 
remains  eoiiiiccted. 

The  iiicst  important  constituents  of  the  umbilical  cord  in  its  earlier  con- 
dition are  flic  two  iiiiibilieal  arteries,  the  two  umbilical  veins,  the  allantoic 
diverticulum,  and  the  extension  of  the  celom  containing  the  vitelline  duet  and, 
possibly,  traces  of  the  vitelline  vessels.  Ijater,  the  umbilical  veins  fuse  and 
constitute  a  single  vessel  ;  the  allantoic  lumen  and  the  celomic  space  atrophy 
and  disap])car.  The  atrophic  vitelline  or  umbilical  duct  long  remains,  even 
after  I)irth  tlie  vesicle  ami  its  duct  appearing  as  a  minute  sac  and  stalk  lying 
between  the  amnion  and  the  chorion,  in  close  proximity  to  the  placenta. 

The  liiimaii  iimbilital  cord  at  birth  measures  about  55  centimeters (22  inches) 
in  leiio-tii.  with  tVo.'n  15  to  160  centimeters  (6  to  64  inches)  as  the  extremes  of 
its  variations  ;  its  diameter  is  from  10  to  15  millimeters  {'^  to  f  inch).  The 
cord  usiiallv  joins  the  inner  smooth  surface  of  the  placenta  eccentrically,  its 
insertion  at  times  being  marginal,  or,  in  rarer  cases,  even  altogether  outside  the 
immediate  area  of  the  placenta.  The  apparent  twisted  condition  of  the  cor'i  i.s 
often  very  marked,  the  spirals,  sometimes  to  the  number  of  thirty  or  more, 
being  ('m|)hasized  by  th(>  contained  blood-vessels.  While  this  phenomenon  has 
long  been  known,  a  satisfactory  explanation  of  the  twisted  appearance,  which 
begins  ix'fore  the  third  month,  still  remains  to  be  given,  notwithstanding  nu- 
merous theories  and  discussions.  A  point  of  especial  interest,  as  poiiit(>d  out 
by  Minot,  is  tliiit  tliere  is  no  evidence  that  i\w  entire  cord  really  undergoes 
torsion,  but  rather  that  the  blood-vessels  become  coiled  within  the  soft  ti.ssue 
as  the  result  of  an  excessive  unequal  growth  still  insufficiently  tinderstood. 


■}]' 


■■  ( 


'^r 


ff 


94 


AMU  RICA  X    Tr-:XT-JiOOK    OF   OBSTETRICS. 


The  structure  of"  the  cord  includes  an  external  covering  of  epithernuii 
directly  continuous  at  its  distal  end  with  that  of  the  amnion.  The  bulk  df 
the  cord  consists  of  the  peculiar  form  of  enibrvonal  connective  tissue  known  ;is 
the  jel/i/  of  Wharton,  rich  in  branched  cells  with  anastomosing  protoplasmic 
processes.  Shortly  beyond  the  iwnbilical  opening  both  caj)illarics  and  nerves 
are  apparently  wanting ;  lymphatics,  in  the  sense  of  definite  canals,  are  also 
absent.  In  addition  to  the  lar^e  umbilical  blood-vessels,  epithelial  mfi>-(s 
indicate  the  remains  of  the  allantoic  diverticidum  and  the  vitelline  duct. 

o.  Development  of  the  External  Form. — Adoptingthedivisionssuggotcd 
bv  His,  it  is  convenient  to  distinguish  three  stages  in  the  development  of  the 
human  subject.  Tiie  Mdfn'  of  the  orntn  end)races  the  first  two  weeks  of  gc>t;(- 
tion,  and  is  occupied  by  the  earliest  developmental  processes;  the  oiihri/nn,,! 
star/e  includes  from  the  third  to  the  fittli  week,  during  which  time  the  cliaiac- 
teristic  end)ry()iial  features  are  pronounced  and  the  principal  organs  and 
svmptoms  are  well  established;  the  remr.ining  weeks  of  pregnancy  are  devoud 
Xoi\w  fetal  .sVa^c,  during  which  the  cmbryi  lal  characters  are  gradually  replaird 
bv  those  of  the  fetus  and  the  full-term  child.  While  it  is  evident  that  iki 
sharp  demarcation  separates  these  stages,  yet  certain  well-jironounced  chaiai'- 
teristics  distinguish,  in  general  at  least,  end)rvns  of  j)articular  developmciitid 
epochs,  and  conse«piently  serve  to  determine  their  ])robable  age  nofwithstandiiii; 
individual  variation. 

Stage  of  the  Orum. — Oj)]iortunitics  for  examining  early  human  ova  are  rare, 
the  youngest  well-authciiticated  and  carefidly-observed  specimen  being  iIk 
classical  ovum  of  about  twelve  davs  described  bv  Keichert  (Fig.  H'.)).     The 


Fl(i.  K!.— nuiiinn  (iviiiii  of  iiliuut  tuflvc  diij  s  i  lii'iclu'iti  :  A.  rrmit  view  ;  H.  siile  vkw.    'I'lic  villi  iirr  xiii 
lu  bf  liiiiitcil  ill  ili.-tiil)Utiiiii.  Iriiviiii;  llic  pules  livo. 

a])pearanc<'  of  this  ovum  emphasizes  the  early  and  precocious  devcdopmeiit  nf 
the  villi  which  encircle  the  flattened  lenticular  vesicle  (o.o  millimeters  in  ih 
greatest  dianu'ter  by  '.).'.]  millimeters  in  thickness)  as  a  closely  set  e(|uatnrial 
zone.  ( )f  the  embryo  proper  no  trace  was  discoverable,  a  patch  of  thickcncil 
cells  alon<'  representing  the  embryonal  area.  The  earlier  processes  of  mu- 
mentation  and  blastulation  hav(>  never  been  observed  in  the  human  ovum, 
Sta(/f  (f  the  Kinhri/o. — The  thirteenth  ami  fourteenth  days  witness  the 
evolution  of  the  early  emi)ryonal  form  as  effected  by  the  development  of  tin 
medullary  groove  and  canal  and  their  cephalic  expansion.  The  embryo  is 
attached  by  the  allantoic  stalk  to  the  surrounding  mend)raiies,  the  axes  of  tin 


I'HYSJOLOtiy   OF  PREGNANCY. 


95 


of  epithelium 
The  bulk  nf 
ssue  known  ;is 
;  [n'otoplasiiiic 
es  iiiul  nerves 
anals,  are  siUd 
ithelial    nl!l^H■s 
■nine  (hict. 
ision8snjr>r»'>'i'il 
lojMnent  of  the 
,veeks  of  ire>lii- 
tlie  ODhrjimial 
inie  the  ehanic- 
Kil   orj^ans   iiml 
ney  are  devntiil 
ichially  replinvd 
>vi»lent  that  im 
uounced  charar- 
•  (k'velopnu'iilal 
notwitlistandiii",' 

lan  ova  are  rare, 
•inien   heinii'  tlif 

(Fiir.  h:\).    The 


IV.    'I'lu'  villi  iiri'  Mvii 

ilevelopnuMit  nl' 
i meters  in  it- 
V  set  e(|natorial 
tell  of  tliiekciiiil 
n-oeesses  of  m'i.'- 
luunan  ovuiii, 
avs  witness  tlif 
feiopinent  of  tlic 
riie  enihrv<i  \- 
,  the  axes  of  tiic 


stalk  nnd  the  npright  embryo  generally  coinciding  (Figs.  84,  85 ;  see  also  big. 
97)  •  what  flexure  exists  at  this  time  is  backward,  and  residts  in  a  concave  dor- 
sal oiitlii'ie.  The  ventral  aspect  of  the  embryo  of  this  stage  is  largely  occupied 
bv  the  relatively  huge  vitelline  sac,  which  freely  communicates  with  the  imi)er- 
fectlv  <lefinod  gut  along  almost  the  entire  length  of  the  embryo.  The  preco- 
cionslv  developed  amnion  has  completely  enveloped  tlie  end)ryo  and  its  stalk 
as  faVas  the  distal  attachments  of  the  latter.  The  heart  is  first  represented 
by  two  longitiulinal  fokls  corresponding  with  the  primary  halves  from  which 


,.«f-«",""- 


Fiii.  M.— Ilinniui  eiiiliryn  nf  iitinut  the  fiftei'iitli  iliiy  (His) :  the  cmbryu  is  nttiirhed  to  tlic  wiill  iiC  the 
blastoiltriiiic  vt>i(lc  hy  niciUis  (if  tlu'  iimliilicul  ur  iilltiiitnic  stiilk,  and  is  eiifldsi-d  witliin  tlu' auiiiicm  ; 
the  hiViXK-  vilrlliiir  snc  I'nily  niinimm  catos  with  tlu'  still  widoly  ojn'ii  gut. 

the  organ  is  foniicd  ;  slightly  lai.er,  these  folds  fuse  into  a  single  heart,  which 
then  :ij)pears  as  a  coiispicuoiis  projection  between  the  yolk-sac  and  the  cephalic 
vesicle. 

Tlic  third  week  (Fig.  Hit)  is  productive  of  many  imjiortant  additions  to  the 
exterior  of  the  embryo,  its  form  becomes  more  definite ;  the  brain-vesicles, 
together  with  the  uptic  vesicles  and  the  auditory  sacs,  are  difierentiated  ;  the 
visceral  arciies  and  the  corresponding  fiu'rowsare  formed  ;  the  yolk-sac  is  much 
more  constricted,  and  its  narrower  coimectitii  with  the  gut  foreshadows  the 
later  vitelline  stalk.  By  the  twenty-first  day  the  first  rudiments  of  the  limbs 
appear. 

The  finu'th  week  (Fig.  86)  is  marked  by  gretit  increase  in  size  and  by  conspicu- 
ous changes  which  give  to  end)ryos  of  this  age  distinctive  features,  growth  being 
relatively  more  active  at  this  period  than  at  any  other.  With  the  termination 
of  the  third  week  the  embryo  is  still  erect.     During  the  next  day  Hexion  takes 


'^  '^'^^'^m'^mmmmim 


'T 


«Hi 


96 


AJfKRICAA'^    TEXT-liOOK   OF   OBSTETRICS. 


!      •             i 

,:                1 

place  with  groat  rapidity,  so  that  during  the  tweiity-tliird  day  the  cephalic  aiul 
caudal  poles  of  the  embryo  actually  meet  or  even  overlap,  the  dorsal  outline 
approximating  a  circle  (Figs.  8G,  87).  The  individual  brain-vesicles  are  bcitci' 
developed,  as  are  also  the  visceral  arches  and  furrows,  the  eyes,  ears,  and  nn-o; 
the  heart  has  increased  in  size,  and  the  limb-buds  have  become  more  ]iin- 
nounced.  At  tiie  end  of  the  twenty-third  day  extreme  flexion  has  taken  place, 
from  which  time  until  the  close  of  the  fourth  week  the  embryo  gradually 
becomes  less  tightly  coiled  on  itself,  the  larger  and  more  conspicuous  land 
slowly  rising  and  leaving  tiie  tail. 

During  the  latter  half  of  the  fourth  week,  in  addition   to  the  iucrcax',! 
development  of  the  visceral  arches,  the  individual  cej)halic  flexures  becdiiio 


F'lii.  S').— Mumiiii  iiiiliryn  of  nhdut  the  thirti'i'iitli  day  (His):  the  cimiiiil  \\u\v  (if  tlio  inibrvd  i-imi 
iiiM'ti'il  Willi  the  lilii^tciilcniiic  vusirlf  liy  tiifiiiis  of  the  lilpcloinimil  oi-  iillantcic  >tiilk  ;  the  iiiiiiiinn  .ihiiiil; 
(MimpUli'ly  rncliiscs  tlu'  I'liiliryii,  luid  tho  lari.'f  vitclliiii'  sac  ciimimiiiii'ati'S  tliroiighout  tlit'  Krtalrr  |»iit 
cil'  t!\c  iiiitriil  siirfai'i'  liy  iiicaiis  of  the  uiicliisi'd  >;ut-tra('t. 

very  conspicuous.  These  flexures  consist  of  a  sharp  bending  of  the  aiih- 
rior  ])arts  of  the  head  upon  the  posterior  half,  resulting  in  a  chauiic  nl 
nearly  90°  in  the  cephalic  axis,  with  the  production  of  a  I'onspiciiiiii- 
^  limine  nee  marking  the  position  of  the  midbrain.  Posteriorly,  the  ccrvinil 
iC\uro  sharply  imlicates  the  junction  of  the  cephalic  and  trinik  segments; 
t;i,  the;  caudally,  the  dorsal  and  citccygeal  flexures  mark  less  pnuioMnccd 
cliiingi'-  !!i  the  direction  of  the  embrvouie  axis.  On  cither  side  of  the  (hirsil 
mid-line,  extending  from  the  cervical  flexure  to  the  tip  of  the  caudal  extremity, 
a  series  of  prominent  (piadrilateral  areas  indicate  the  position  of  tlie  somites  nr 
provertebrie  (Fig.  8(5,  11  and  12). 

The  (levelopnient  of  the  vinwnd  archeti  reaches  its  highest  expression  by  tlio 


■C- 


'^■■S. 


vs. 

the  ceplialic  and 
le  dorsal  outline 
esidos  are  boitur 
,  oars,  and  ik.-o; 
t'oiiio  more  pni- 
has  taken  place, 
nbrvo  gradually 

•OUSpicUOUS    ll(!l(l 

to  the  incrcaM',1 
flexures  beeuiin' 


•  iif  the  ciiibrvd  is  ci'ii 
;k  ;  till'  aiuiiiipu  nlriii.ly 
iKluiiit  till'  KTi'atii-  I'iifl 


lin<z:  of  the  aiiti- 
j  in  a  chaiip'  nl' 
)t'  a  eonspicium- 
iorly,  the  eerviial 

trunk  seiriiK'nts; 

less  pronoiiiKvil 
side  of  the  tlnixil 
'  eaudal  extrcniilv , 
\  of  tiie  soniitis  (11 

expression  hv  tlic 


PHYSIOLOGY   OF  PREGNANCY. 


97 


tennination  of  the  fourth  week,  when  the  series  of  arches  is  seen  in  its  best  condi- 
tion (si'c  Fijj^.  1 29).  In  man  and  in  manimals  fivearchesare  successively  developed 
from  before  backward,  the  last,  however,  being  scarcely  differentiated  and  very 
inconspicuous.  Tlie  first  arch  when  fully  formed  is  partially  divided  into  an 
upper  and  a  lower  secondary  division,  the  maxilkmj  and  mandibular  processes, 


g^'--' 


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80  eddied  from  the  parts  to  whose  construction  thev  respeetivelv  largely  con- 
tribute. The  maxillary  processes  of  the  first  arch,  in  connection  with  the"inter- 
vening  ,m.v.-/.o./a/  process,  c-ontribute  the  parts  which  eventually  become  the 
upper  boundaries  of  the  oral  cavity ;  the  mandibular  processes  of  the  same 
•rcl.jou,  to  fJ.rm  the  lower  boundary  of  the  mouth.  During  the  fifth  week 
M.e  ma.-g,ns  of  the  centrally  pnyecting  naso-frontal  plate  differentiate  into  two 


^■a' 


f 


98 


AMERICAN   TEXr-liOOK   OF   OBSTETIilC^ 


I  I 


' 


h 


secondary  processes,  the  processus  globulatrs,  forming  the  inner  borders  of  tiie 
nasal  pits,  and  the  l(((era( J'ronial  processes,  which  contribute  the  outer  wall  nf 
the  nasal  fossa)  and  separate  these  depressions  from  the  eyes.  These  proces-os 
normally  unite  co  form  the  continuous  structures  around  the  nose  and  the 
mouth. 

Faulty  union  or  imperfect  closure  of  the  interveniu};  fissures  jjives  rise  to 
the  varieties  of  hare-lip  and  cleft  ])alate  and  to  other  forms  of  congenital  facial 
defects.  The  second  or  hi/ohJ  arch,  as  well  as  the  third,  fourth,  and  filiii 
arches,  eventually  fuses  with  its  neighbors  and  loses  its  identity;  a  simihir 
fate  awaits  the  intervening  outer  visceral  furrows  or  "clefts,"  with  the  e.\((  ii- 


(• 

Fl(i.  ,h7.— lit'vclii|iiiiciit  iif  tlu'  fucc  iif  till'  liniimii  cnihryo  (Ilisi  :  A,  oiutirvd  of  alumt  twcnly-iiiiic  iliiy-. 
Till' imsci-l'ninliil  pliiti' ilillriciitiiiliiif;  iiitu  priMTssus  nl'ilnilnivs,  tnwiiril  »liicli  tlir  iiiiixillury  |inM-.-v - 
111'  lii>l  visc'cnil  iinli  iirc  cxlciuiiiin.  li,  ciiiliryu  nf  nljniit  tliirly-lniir  diiys  :  llii'  j.'lciliiiliir,  liitcnil,  IVi'iiMl, 
ami  iimxilliiry  jirdi't'sscs  lire  in  iiiiiKi.-^iticiii ;  tho  )iriiiiitivt'  npcniiiK  is  imw  bfttiT  ik'liiuil.  (',  I'lrihrjn  nf 
alicjut  the  i'if;litli  Week:  iiniiii'iliatr  Ijniiiiilarirs  of  iiiniitli  arc  iimre  lU'lliiitc  and  the  nasal  (irilicr- iirr 
jiartly  fnrratil,  cxtiTiial  ear  appearing.    !•.  eiiihryu  at  end  of  seeond  nidutli. 

tion  of  the  first,  since  they  gradually  become  obliterated  by  the  fusion  ol'  the 
surrounding  arches.  The  first  outer  furrow,  or  hjiomandlhuhtr  cleft,  coiitrili- 
utes  largely  to  the  formation  of  the  external  aiiditoiy  canal,  while  the  sur- 
rounding portions  of  the  mandibular  and  hyoid  arches  contribute  the  ti.-..«iii' 
from  which  the  external  ear  is  derived. 


'^_ 


plIYSIOLOaY   OF   I'RFAiNAXCV. 


99 


borders  of  llie 
;  outer  wall  ■  if 
l^hcse  proces-os 
!  nose  and  the 


•OS  jjivos  rise  tn 
onfifonital  faciiil 
iirtli,  and  lilili 
itity  ;  a  slniiliir 
with  the  exci  |)- 


luiit  twciily-ninc  .layv 
If  iimxilliiry  )ii-nii-M'. 

lllllllir,    lllUTIll,   I'l-nlltill, 

ik'liiu'il.    •'.  uiiiliryiMif 
1  the  niisiil  iirilicf-  iiri' 


the  fusion  of  the 
lav  cleft,  I'onlrili- 
1,  while  the  mh- 
tribute  the  ti«iie 


nc  Second  Mnnfli.— The  fifth  and  sixth  weeks  (Figs.  8G,  88)  add  to  the  size 
and  the  general  advanced  development,  altiiough  the  phenc.nienal  rate  of  growth 
of  the  preceding  week  is  replaced  by  more  gradual  increase.  The  limbs  con- 
stitute the  niost^characteristic  features  of  this  jjeriiKl,  since  what  prior  to  the 
fifth  week  were  but  rudimentary  limb-buds  now  undergo  differentiation  into 
distinct  segments,  at  first  two,  then  three.  Toward  the  close  of  the  fifth  week 
the  flattened  terminal  segments  representing  the  future  hands  and  feet  exhibit 
distinctions  as  tliin  marginal  plates  and  thicker  proximal  portions.  The 
man^inal  areas  very  soon  exhibit  traces  of  the  digits  as  small  elevations 
sepanited  by  shalktw  grooves  which  gradually  extend  toward  the  free  ends. 
The  fore  lilnl)s  appear  slightly  earlier 
than  the  hind  limbs,  and  retain  this  lead 
throughout  their  development.  By  the 
middle  of  the  sixth  week  the  fingers 
are  sufficiently  developed  to  project  be- 
yond the  hand,  although  the  toes  are 


Fir.,  ss  -lliimiin  embryo  of  nhout  six  weeks, 
ciilart-'i'il  livo  times  (lUs). 


KiG.  89— Hnmiin  emiiryo  of  nbcmt  seven  weelvS, 
onlarfied  live  times  (His). 


just  beginning  to  bo  outlined,  and  represent  a  stage  of  ten  to  fourteen  days 
later.  Coiiicidently  with  these  changes  the  general  development  of  the  embryo 
has  steadily  progressed  (Fig.  89),  with  the  result  of  supplanting  the  embryonal 
characteristics  by  those  of  distinctly  fetal  type.  The  head,  though  propor- 
tionately large,  has  become  partially  once  more  raised ;  the  boundaries  of  the 
month  have  become  definitely  located  ;  the  external  parts  of  the  eye,  the  ear, 
and  the  nose  are  well  advanced  ;  and  the  general  contour  of  the  trunk  has 
assumed  more  of  the  characters  of  the  child. 

Tlie  second  month  witnesses  the  disappearance  of  the  cervical  flexion  and 


T 


'■"^ 


100 


AMUR/CAN   TEXT-HOOK   OF   OBSTKTRICH. 


i  t 


i  i 


m 


h^ 


tlif  fiirtlier  liftinj;  of  the  head,  wliich  is  still  very  larj^e  (Fig.  90).  The  i'acc 
shows  distinct  advaticemcnt  toward  its  completed  typo,  although  the  nose  is  \v\ 
unduly  hroad,  and  indications  of  the  fissures  surrounding  the  mouth  arc  dis- 
cernible.  The  limbs  pn^joct  from  the  body,  and  the  fingers,  including  tlio 
differentiated  thumb,  and  the  toes  are  well  defined.    By  the  close  of  the  secuud 


Fio  90.— Ilunian  ciiil)rjii  of  ntioiit  lijilit  mid  n  liiilf  wcoks,  eiiliirciMl  five  times  fUis). 

month  the  fetus  measures  from  25  to  30  millimeters  (1  to  1^  inches)  in  leiiirth 
and  weighs  from  15  to  20  grams. 

The  Third  3Ionth.— The  third  month  establishes  the  htmian  form,  although 
the  head  still  unduly  preponderates.  The  limbs  have  acquired  their  definite 
shape,  and  the  imperfect  nails  are  present  on  both  fingers  and  toes.  Durinir 
this  month  the  external  organs  of  generatii>n  become  definitely  differentiated, 


?^.^.,J:^ 


:w. 


PHYSIOLOGY   OF  PRKCiXANCY. 


101 


90).  The  face 
1  the  nose  is  yet 
mouth  arc  dis- 
,  inchuling  ilie 
ise  of  the  secom] 


3 

^ 


times  (Ilis). 

inches)  in  loiii:t!i 

1  form,  althdiiuh 
etl  tlieir  dciinitr 
1(1  toes.  Diiriiii: 
Iv  ditferentiiitcil, 


;  y.it 


ahhoujrh  tlicv  niaUo  their  appearance  several  weeks  earlier.  At  the  end  of 
this  p(Ti(Hl  tiie  fetus  measures  about  7  centimeters  (2J  inches)  in  length  and 
weighs  alK)Ut  120  grams  (4  ounces). 

The  Fourth  J/o/i//*.— Short  hairs,  devoid  of  pigment,  appear  on  the  scalp 
and  on  some  other  parts  of  the  body,  which  is  now  coveriHl  with  firmer  skin 
of  rosv  hue.  The  eyelids,  nostrils,  and  lips  are  closed.  The  anus  opens,  and 
the  coils  of  intestine,  which  before  extended  into  the  und)ilical  cord,  now  lie 
entirely  witiiin  tiie  ainlominal  cavity.  The  point  of  emergence  of  the  umbil- 
ical cord  lies  low  down,  close  to  the  pnbes.  The  head  forms  about  one-fourth 
of  the  entire  body;  the  bones  of  the  skull,  while  ossifying,  are  still  widely 
separatcil.  The  sexual  distinctions  of  the  external  organs  are  well  defined.  At 
the  end  of  this  pcrioil  tiie  length  of  the  fetus  has  increased  to  about  12.5  cen- 
timeters (o  iiiciics),  and  its  weight  to  between  230  and  240  grams  (7J  ounces). 

The  Fifth  Mnnth. — Tlie  heart  and  the  liver  share  with  the  head  in  the  undue 
preponderance  wliicli  tliese  parts  present.  The  contents  of  the  small  intestiiu^ — 
the  meconiiMii — show  traces  of  l)i!e,  being  of  a  pale  yellowish-green  color.  The 
lower  extremities  are  now  longer  tiian  the  arms;  the  nails  are  well  formed. 
Hairs  are  more  plentiful,  but  are  devoid  of  color.  At  the  termination  of  this 
month  the  fetus  measures  20  pcntimeters  (8  inches)  in  length  and  weighs  about 
600  iTams  ( 1  ixtuiid).  The  fetal  movenu^nts  are  now  distinctly  felt  by  the  mother. 

The  Si.rth  .Uoiifli. — The  surface  presents  many  wrinkles  and  a  dirty-reildish 
hue-  the  sebaceous  coating,  the  veniix  cascona,  begins  to  appear.  This  whitish 
substance  is  composed  of  the  dead  and  shed  surface-epithelium,  mingled  with 
the  secretions  of  the  sebaceous  glands;  its  primary  function  is  the  protection  of 
the  fetal  integument  fnmi  maceration  by  the  amniotic  Hnid.  Eyebrows  and 
eyelashes  begin  to  grow.  The  length  of  the  fetus  by  the  end  of  this  period  has 
increased  to  ."iO  centimeters  (12  inches),  and  its  weight  to  about  1  kilogram  or 
1000  grams  (2  pounds). 

The  Scmitk  Month. — The  continued  deposition  of  subcutaneous  fat  causes 
a  general  appearance  of  greater  plumpness,  although  the  surface  is  still  some- 
what wrinkled  ;  hairs  about  5  millimeters  (^j  inch)  in  length  ;  eyelids  arc  now 
permanently  open.  The  liver  is  still  relatively  large  ;  meconium  occupies  the 
entire  large  intestine ;  the  testicles  have  descended  as  far  as,  or  even  into,  the 
inguinal  canals.  Children  born  at  the  end  of  this  period  may  survive, 
although  they  usually  succund).  The  fetus  now  measures  about  35  centi- 
meters  (14  inches)  and  weighs  about  \h  kilograms  (3  pounds). 

The  Ehjhfh  Moiith. — This  and  the  succeeding  month  are  occupied  by  in- 
crease in  bulk  rather  than  by  great  gain  in  length.  The  skin  assumes  a 
brighter  flesh-color ;  the  scalp  is  plentifully  supi)lie(l  with  hair ;  the  nails 
almost  reach  the  finger-tijis.  The  vernix  casensa  forms  a  complete  coating ; 
the  lanugo,  or  embryonal  down,  iK'gins  to  disappear.  The  subcutaneous  fat 
has  increased,  giving  less  harsh  outlines  to  the  body.  The  close  of  this  month 
finds  the  fetus  measuring  about  40  centimeters  (16  inches)  and  weighing  from 
2  to  2|  kilograms  (4  to  5  jKtunds). 

The  A'inth  Month. — The  fetus  at  full  term  presents  usually  a  well-rounded 


102 


AMKRWAN   TKXr-nOOK   OF   OIlSTKTRICfi. 


body,  from  wliicli  tlio  lamifio  lias  almost  entirely  ilisappearod.  The  skin  is 
loss  highly  colorwl,  and  is  covered  in  places,  particularly  the  head,  the  axilla, 
the  groin,  and  the  flexor  surfaces,  with  u  layer  of  protecting  irruix.  Both  l(>.s. 
tides  have  descended  into  the  scrotum  ;  in  the  female  the  labia  niajora  an  in 
contact.  The  intestinal  tract  contains  the  dark-greenish-colored  mrcnn'n'm^ 
consisting  of  the  setfretiuus  of  the  intestines  and  the  liver  niixttl  with  the  (pi- 


Ki(i.  '.II.— Diatrriini  illustnitinn  tlic  outlines  (if  tlio  limiinii  futus  at  viiriDUs  stai^oB,  from  the  end  uf  iliv 
seeiind  tu  the  end  of  the  eiglith  week,  niHuiiilii'd  live  times  imoditied  nfler  Midi). 

tholium  from  the  digestive  tube,  together  with  epidermis  and  lanugo  •swalluwi'd 
by  the  fetus.  The  umbilicus  has  reached  a  position  aImo.st  exactly  in  tlic 
middle  of  the  body.  The  first  epiphyseal  o.s.sification  to  apj)ear,  that  of  tlio 
lower  end  of  the  femur,  is  often  ti»e  oidy  erne  present,  but  ossification  niiiy 
have  commenced  also  in  the  upper  epiphyses  of  the  tibia  and  the  hum(m>, 


'4l... 


v. 


I'liYsioLOdv  or  piii'MXAyry. 


\0'.\ 


The  skin  i< 
[•ad,  till'  axilla, 
nix.  Both  tos- 
,  majora  ait  in 
red  mrcnii'h'iii, 
il  with  the  (  pi- 


from  tlio  end  '■I'llie 
fter  Mi'.U). 

!lIlUfr<)  SWallnWi'd 

t  exactly  in  tlic 
)ear,  that  of  tlif 
ossification  iiiiiy 
11(1  the  hunicniN 


\  ro.iveiiicnt  •^impl''  '"•■tl""l  *•»'  deteniiiiiing  the  approximate  length  of  the 
A-tiis  at  a.iv  period  duriiiL^  g.-tation  has  Ihk,...  given  by  iraasc.  The  length  in 
c^.n(inu.t..rs  ..lav  roughly  he  estimated  np  to  the  ..i.l  of  the  fifth  month  by 
,<jum-i„!,  the  month;  beyon.l  the  (-nd  of  the  fifth  month,  by  mnlhplyim,  the 
month  "l)V  the  eominoii  .•...•llicit'nt  5.  •       ,         ,       .. 

Computed  hy  this  method,  the  approximate  greatest  or  entire  lengtlis  ol 


the 


fi'tiis   for  the 

At  till'  t'lld  lit' 


^(■vera!  months  are : 


MlOIll 


h  the  lin«tli  =    1X1=^    1  ci-ntimetor   =    I  iiu-li. 


'J  iiiontlis 
••{       " 


S 
10 


-    '2  X-  =    -1  coiitiuieten)  -=    1'  iiiilieH. 

=    3S       " 

=  H     " 
=  10 
--=  12 
=  14 

=:    l(i 

=  IS 
=  20 


3   <  3 

=    » 

4X4 

r=    l(i 

oX'^ 

=  25 

liX'-> 

-:30 

TXT) 

=r  35 

S  X  •'> 

^40 

i)  X  5 

^-  4.-) 

0X5 

r=   oO 

The  full-term  fetus  measures,  on  an  average,  iihoiit  50  centimeters  (20 
inches)  in  its  entire  length,  and  weighs  from  3  to  ^  kilograms  (from  0  to  7 
ponnds),  the  average  weight  for  boys  being  ;}340  gnims  (7  pounds,  (J  uiinees), 
and  that  fiir  girls  3190  grams  (7  pounds).  The  individual  variations  in  weight 
of  new-born  eliildreii  include  a  wide  latitude,  as  indicated  by  the  extremes 
of  717  urams  (1  pound,  }>i  ounces)  and  ()123  grams  (13  pounds,  8  (-(inccs),  as 
accepted  by  Vierordt.  Cliildrcn  really  exceeding  5  kilograms  (about  10  pounds 
at  birth  are  very  rare,  notwithstanding  numerous  reputed  eases.  Waller,  how- 
ever reports  a  case  of  a  living  infant,  delivered  by  him  with  fi)rceps,  that 
weighed  lo  pounds  15  ounces!  [n  addition  to  sex,  boys  being  heavier  than 
ifirls  the  size  of  the  child  is  materially  influenced  by  the  conditions  ot  ma- 
ternal parentage;  thus:  (1)  Young  mothers  have  the  smallest  children,  and 
mothers  i»et\veeu  thirty  and  thirty-five  years  have  the  heaviest.  (2)  The  weight 
of  the  child  increases  with  the  number  of  previous  pregnancies,  providing  that 
the  successive  children  are  of  the  same  sex  and  that  the  pregnancies  do  not 
follow  too  rapitlly  ;  the  children  of  primiparte,  therefore,  average  less  tliiin 
these  of  miiltipaiw.  (3)  The  weight  of  the  child  increases  with  the  weight 
(Gassner)  and  the  length  (Frankenhausen)  of  the  mother.  In  addition,  ob- 
viouslv,  all  causes  adversely  afi'ecting  the  physictil  condition  of  ilther  parent  may 
exert  an  iiiifavor  hie  influence  on  the  vitidity  and  develo])nient  of  the  fetus. 

6.  Development  of  the  Circulatory  System. — The  vtiscnlar  system  is 
formed  by  the  development  of  two  parts,  at  first  entirely  distinct — the  extra- 
embryonic blood-vessels,  and  the  central  circulatory  apparatus  re{)resented  by 
the  heart  and  the  great  primary  trunks.  The  extra-embryonic  blood-vessels 
constitute  successively  two  distinct  systems,  the  vHcUlne  and  the  (dhnfoic  cir- 
culation. The  first  of  these  in  mammals  and  in  man  is  comparatively  unim- 
portant ;  the  second  is  of  the  utmost  importance,  since  it  takes  an  active  part 
jgk  securing  the  nourishment  of  the  embryo  from  the  maternal  tissues  by 
means  of  the  formation  of  the  placental  circulation  which  it  becomes. 


m 


104 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


i     ,b 


m 


Very  early  in  the  development  of  the  embryo  the  germinal  area  becoiiios 
mottled  by  the  appearance  at  its  periphery  of  an  irregular  network  of  braiK  h- 
ing  patches  of  darker  *int  than  the  surrounding  tissue,  due  to  the  active  0(  11- 
prolifenulon.  These  patches  are  the  blood-itilamh  of  Pander,  so  called  fntiii 
the  active  rdlc  playetl  by  them  in  the  production  of  vascular  tissue — vessels 
and  blood-cells.  By  tiie  extension  of  the  blood-islands  an;1  the  newly-foriiuHJ 
vessels  the  circulation  within  the  area  vasculosa  (PI.  15)  rapidly  extends  ci  n- 
trally  and  toward  the  embryo,  with  which  communication  is  later  established 
by  the  vitelline  arteries  and  veins,  large  trunks  which  connect  with  the  cephalic 
and  cauilal  extremities  respectively  of  tlie  primitive  circulatory  apparatus 
which  has  meanwhile  been  developed  within  the  embryo.  The  significance 
of  the  vitelline  circulation  in  mammals  is  probably  merely  suggestive  of  its  lar 
greater  importance  in  the  lower  types,  where  absorption  of  nutritive  materials 
from  the  large  and  conspicuous  yolk  constitutes  an  evident  reason  for  its 
development.  In  man  and  in  mammals  it  is  doubtful  whether  the  vitclliiu' 
circulation  contributes  mitritive  substances  in  any  appreciable  degree. 

Coincidently  with  the  decrease  in  the  yolk-sac  and  its  vitelline  circulation, 
the  vessels  supj)lying  the  allantoic  tissues  become  more  prominent,  the  growth 
of  the  two  systems  proceeding  in  inverse  order.  The  conversion  of  a  portion 
of  the  vascular  chorion  into  the  fetal  contribution  of  the  placenta  advances 
the  imjiortance  of  these  vessels  to  that  of  the  placental  circulation,  as  iirst 
represented  by  the  two  umbilical  veins  and  the  two  umbilicid  arteries,  tiic 
latter  the  direct  continuations  of  the  intra-embryonic  hypogastric  arteries. 
Later,  the  two  veins  fuse  within  the  allantoic  stalk,  thereby  producing  a  sinjrlc 
venous  trunk  which  accompanies  the  arterial  stems.  Within  the  body  of  the 
fetus,  however,  the  umbilical  veins,  which  there  remain  separate,  develop 
unequally,  the  right  suitering  atrophy  and  finally  disappearing,  while  ilic  left 
increases  in  size  and  persists  until  birth  as  the  important  umbilical  vein  euii- 
veving  the  blood  to  the  liver. 

The  Heart. — t\)incidently  with  the  formation  of  the  j)rimarv  extra-einhrv- 
onic  blood-vessels  within  the  vascular  area,  the  heart  early  begins  its  deveiop- 


Kl<:.  !i'J.— Section  nf  iiirly  cmliryo  (if  riilihit  d'HTsoli,  sluiwlm;  tHu  Mimnitc  liciirt  tulics  (//,  //i:  •. 
Iiriniiti\c  ciKldllicliiiiii:  cm,  iiu'sndcrm  loniiiiii,'  cure  line  wiill  ;  ic,  i  ctiMlcrin  ;  cii.  cMHiiIcnii ;  <(^',  tolil>  |iri- 
(luciiiK  ventral  wall  nf  ^tit-tract ;  lnj,  luad-KUt ;  <i.  n',  priiiiitivc  anrta  ;  ii,  iicnral  canal. 

mont.     The  first  trace  of  this  im])ortaut  <n-gan  appears  as  a  folding  off  ami 
hollowing  out  of  a  limited  mesodcrmic  area  on  each  side  ;  the  two  heurt-liilKs 


vs. 

al  area  becomes 
ivork  of  braiidi- 
the  active  cdl- 
•,  so  called  frmn 
r  tissue — ve^^^l'ls 
lie  iiewly-foriiK'd 
(lly  extends  ci  u. 
later  establislicd 
with  the  cephalic 
latory  apparatus 
Tlie  significaiu'c 
fgestive  of  its  tar 
itritive  materials 
it  reason  for  its 
her  the  vitellino 
degree. 

illine  circulation, 
mcJit,  the  growth 
sion  of  a  portion 
>lacenta  advaiioos 
•culation,  as  lirst 
lical  arteries,  tlio 
)ogastric  arteries. 
iroducing  a  siiii^lc 
II  the  body  of  the 
separate,  develop 
ng,  while  the  hit 
inbilical  vein  cdM- 

lary  extra-em lirv- 
)egiiis  its  devclop- 


VITKLUNE  ClRCrLATION. 


Plate  15. 


r  lii'iirttulH'S  (//,  II r.  f, 
fi\ic«lcriii ;  ;;/',  I'nliU  |ir"- 
'iiiiiil. 

a  ft  tiding  off  ami 
he  two  heart-tiilx* 


'''■'■'///>,,, 


Vas..,n,u' ,,n^M  nf  H.vriMlny  rnl,l,i(  vnihryu  MC.  V.  ll,.n,.,l,.,Mn,,l  .iuli,-,,n  :  .•,,|,ill,,ri,  s  Mnt  vhnu 
'ji  sinus  is  strii  to  hi.,  iiilciiiil. 


II :  till'  li'i'iiiiMiil 


I'-1.- 


Tn 


PHYSIOLOGY   OF  PREGNANCY. 


105 


tlins  formed  lie  within  the  .splanchnic  mesoderm  and  are  at  first  widely  sepa- 
rated from  each  other  (Fig.  92).  With  the  bending  together  and  approxima- 
t"  1  .)f  the  visceral  layers  in  the  formation  of  the  gnt-tract  the  heart-tubes  are 
brought  into  apposition,  and  finally  fuse,  the  union  resulting  in  the  production 


■1 


"m 


Fig  03— niiiu'iaiiis  iiiiislratiiiff  arrnngoment  of  primitive  heart  and  aortic  arches  (modified  from 
AWcn  Tliuiii|i<niii;  1,  \  itilliiu'  viiiis  rfturninK  tilood  from  vjisculnr  nron ;  L',  venous  segment  of  heart- 
tube'  It  iiriinilivi' viiilriclc;  1,  tniiicus  arteriosus  ;  .">,  5,  upper  and  lower  primitive  aorta;;  5',  .V,  continu- 
ation of  iloublc  aorta  as  vessels  to  eatulal  pole  of  embryo  ;  li,  vitelline  arteries  returning  blood  to  vascu- 
lar area. 

of  a  short,  straight  reooptacle,  into  the  caudal  end  of  which  empty  the  vitelline 
veins    and  from   the  cephalic  extremity  pass  the  primitive  arterial  trunks 

(Fig.'o;]). 

This  early  straight  heart-tube,  lying  attached  to  tlie  floor  of  the  pharyngeal 
region,  is  very  transient,  since  the  rapidly  increasing  length  of  the  organ,  its 

A  n 


Fill.  HI.— .\,  ;  .  of  human  embryo  of  li.iri  mm.  (His) :  n,  truncus  arteriosus ;  b,  |)rimitive  ventricle ; 
C,  vencais  sitfi,  "'  it.  Iieiirt  of  human  eml)ryo  of  about  3  uim.  (His) :  a,  truneus  arteriosus;  6,  venous 
Mgnient  ibihii.  r      , '   ii  litivi  vi'utriele  (in  front). 

ends  luing  rela»iv('ly  fixed,  soon  necessitates  tlexion,  which  take.s  place  in  l)oth 
aagitta!  :ind  ti'ansver.>;e  planes,  and  results  in  giving  to  the  tube  the  S-form. 
The  lower  and  posterior  limb  of  the  heart  receives  the  great  veins  and  is  the 
ajnjts  irnotiiLs  (Fig.  94) ;  the  lower  and  anteriorly  directed  loop  is  the  auricular 


106 


AMElilCAN    TEXT-BOOK    OF   OBSTETRICS. 


or  venous  conipartiueiit ;  the  upiier  and  posteriorly  ilireoted  loop  is  the  vcnti  iV- 
ular  or  arterial  compartment  j  the  upper  limb  is  the  tvuncm  artcr'wims,  innw 
which  arise  the  jirimitive  aortic  arehen.  The  heart,  therefore,  at  this  stage — 
about  the  fourteenth  day — consists  essentially  of  two  imperfectly  separntid 


Fiti.  95.— A,  lu'iirt  of  human  oinbryo  of  about  -..a  mm.  (His):  n,  atrium;  f(,  portion  of  atrium  cnrn.. 
spoiulinK  with  auricular  appendage ;  c,  trunt'us  artcriosu.s  ;  (/,  nuric\ilar  canal ;  c,  i)rimitivc  vi'ntricli .  ij 
heart  of  huma  cmliryo  of  about  the  lil'tli  week  (His):  a,  left  auricle;  b,  right  auricle;  c,  trunci'S  iirlirid- 
sus  ;  '/,  intorve-  tricular  groove ;  c,  right  ventricle  ; .;',  left  ventricle. 

divisions — a  lower  and  posterior  venous  chamber  and  an  upper  and  anterior 
arterial  compartment — into  and  from  which  pass  the  larger  primitive  venous 
and  arterial  trunks. 

The  venous  or  auricular  division  during  the  third  week  develops  two  con- 


I        !'.. 


Kiii.  %.— A,  section  of  heart  of  Imnian  embryo  of  10  mm.  (His) :  n.  septum  spurium  :  h.  iiiterauricular 
septum;  c,  mouth  of  siiuis  reunieiis;  »^  right  auricle;  c.  left  Jiuriclc  ; /'.  auricular  canal;  ;/,  ri^-lit  vin- 
tride  ;  It.  interventricular  septum  ;  /,  left  ventricle.  It.  section  of  heart  of  human  embryo  of  abmit  tin 
fifth  week  (His):  ii,  septum  spurium:  h,  auricular  septum;  c,  opening  of  sinus  reunieus  (leader  piissts 
through  foramen  ovaho;  (/.right  atrium;  (.left  atrium  ;/,  sci)tuni  intermedium:  ;;,  right  ventricU':  J. 
ventricular  septum  ;  (,  left  ventricle. 

.spiciions  lateral  dilatations  which  assnme  a  position  above  and  behind  thco^imv- 
ing  arterial  chamJK'r.  The.se  dilatations  are  the  uuricnfa)'  appanhtf/rs  (Fiir.  951. 
which  ft)r  some  time  are  the  most  conspicuous  parts  of  the  auricles.     At  tlii- 


PHYSIOLOGY   OF   PliKGXANCY. 


107 


s  the  veiitric- 
teriosus,  IVdin 
;  this  stagi  — 
ctly  scpariUuil 


tion  of  iitrium  cim- 
■iiuitivi.'  vi'UtrirU'.  It. 
li; ;  c,  truncfs  iirHTio- 


per  and  antoridr 
primitive  venous 

levelops  two  con- 


T  "^ 


■urium  ■•  ('.  inU.nuir.cuto 
ll.iv  -MiiiiU;  ;/.  rii:M  v>* 
,u  .•ml.ryo  >,f  «l'"iitili' 

1„-  .„  rlKl.t  vi'Ulriulo;).. 


|l  behind  the  ^nt.w- 

kvuriclcs.     At  till. 


time  the  auricular  and  ventricuhir  portions  of  the  heart  are  imperfectly  sepa- 

,..,ted  bv  a  marked  constriction,  the  canalis  auvkulark. 

Diii-iii"'  the  Iburth  week  the  conversion  of  the  single  into  a  double  heart 
iiu'Uf's  bv  the  gi'adual  growth  of  jjartitions  from  above  downward  within 

tlie  auricle,  and  from  below  upward  within  the  ventricle  (Fig.  9G,  a)  ;  in  addi- 
.  ^  '  ^1^^.  p,-iiiiitive  auriculo-ventricular  canal  becomes  divided  by  the  formation 
f  .'  '-inecial  i):irtition,  the  ncptum  intermedium.  The  division  of  the  heart- 
1  •  uibcr-  proLnv><es  to  complete  separation,  with  the  exception  of  an  orifice  in 

tl     lower  part  nt' the  interauricular  septum,  which  orifice  remains  until  shortly 
ft>-  birth  a-  the  foramen  ovale.     The  entrance  of  the  venous  blood  into  the 

auricula!'  c.Miij.artiueut  is  effected  for  some  time  through  the  single  opening  of 

tl  e  sinus  veiiosus.  Guarding  this  orifice  are  folds  of  the  cardiac  lining,  one  of 
which  foMs  becomes  prominent  as  the  Eustachian  valve,  directing  the  blood- 
current  tlirouuli  the  foramen  ovale.  Later,  the  sinus  venosus  becomes  included 
witliiu  the  wall  of  the  heart,  and  the  three  principal  venous  trunks  emptying 
within  tlie  sinus — the  two  ducts  of  Cuvier  and  the  primitive  inferior  vena 
cava— open  direct Iv  into  the  auricular  cavity  by  as  many  separate  orifices; 
that  ol"  1  lie  left  Cuvierian  <luct  is  represented  by  the  mouth  of  the  coronary 
fiinti-  which  this  trunk  eventually  becomes.  The  truncus  arteriosus,  the  ante- 
rior priiiiaiv  nrtcrial  trunk,  undergoes  an  indep(!ndent  division  by  the  forma- 
tion of  the  (lorfic  siptinn,  the  partition  beginning  at  some  distance  from  the 
heart  and  ai)pi'oaching  the  latter  from  above  downward.  The  vessels  residting 
from  tlic  division  of  the  single  trunctis  arteriosus  afterward  become  the  aorta 
and  the  i)idnionarv  artery,  and  are  limited  respectively  to  the  left  and  right 
halves  ot'  the  ventricidar  compartment  by  the  simultaneously  developed  inter- 
Ventricidar  septum. 

The  primitive  heart,  as  well  as  the  earliest  blood-vessels,  consists  of  a 
doulile  wall,  tiie  outer  layer  representing  the  muscular  and  fibrous  tissue,  and 
the  inner  laver  representing  the  endothelial  lining.  These  two  coats  are  for  a 
time  entirelv  distinct,  the  endothelial  heart  representing  the  general  arrange- 
jBient  and  division  of  the  organ,  and  lying  within  the  surrounding  layer  as  a 
ihrunkeii  east  within  a  mould  (see  Fig.  lOS).  The  interval  separating  the  endo- 
thelial from  the  nmscnlar  heart  later  becomes  bridged  by  numerous  comiecting 
bands  of  tissue,  the  network  of  trabeeuhe  becoming  closer  and  the  intervening 
maces  smaller  as  development  ]>rogresses.  The  consolidation  of  the  cardiac 
walls,  however,  never  is  coiv  detely  accomplished,  indications  of  its  imperfec- 
tions heiiig  clearly  seen  in  the  arrangement  of  the  conspicuous  columH(V  carneic 
of  the  adidt  oriran,  in  which  the  more  or  less  isolated  bands  represent  the 
thickened  remains  of  the  bridging  trabeeuhe  connecting  the  endothelial  heart 
tjrith  the  denser  surrounding  capsule. 

«  Artcrii's  nf  flic  luinx. — The  early  arterial  circulation  of  the  fetus  dif- 
fers in  many  details  from  that  of  the  later  .stages.  C\)nspicuous  among  these 
^ffer(>nres  is  the  development  of  the  series  of  aortic  arches  which  extend  fnmi 
the  anterior  end  of  the  truncus  arteriosus  around  the  primitive  pharynx, 
^thin  the  visceral  arches,  and  converge  into  the  dorsal  longitudinal  vessels, 


'     I 


r; 


•i' 


108  ami:ricax  text-hook  of  obstetrics. 

tlic-  primlUvc  aort<r,  on  each  sitlc.     Five  pairs  oi'  aortic  arches  (Figs.  93.  97)  .ire 


Vui.  '.17.— Ilmiiiin  t'liihryci  of  hImmu  tlinc  wot-ks,  showiiitf  vi.sceriil  arclips  iiiul  furrows  Hiid  tlici;  nli 
liims  to  aortic  iinlu's  i  lli.si :  nix,  inn,  mii.xilliiry  iiinI  iimiulilmliir  proci.s.si'.s  of  first  visceriil  arch  ;  (i  /-ii  '■ 
lirst  to  foiirlli  aortic  arches  :Jr,  rv,  primitive  jiiniilar  ami  cardinal  veins  ;  ilf,  ihict  of  f'uvicr;  al.  i;  atri.i 
and  vcntri(dc  of  primitive  heart :  v,  vitelline  sac ;  vn,  iln,  ventral  anil  ilorsal  aortic ;  or,  ot,  optic  iM\"k 
vesicles  ;  iir,  ud,  nmliilical  veins  and  artcrii's ;  ir,  vitelline  vein  ;  nl,  allantolH. 


fornu'tl,  the  first  pair  lying  witiiin  tiic  (■()rre.<p(»n(.liiig  niaiulibuhir  arch,  tlR'l;L>; 


J'JirSIOLOGV   OF  riiEGNANCY. 


109 


within  the  tissues  of  the  imperfectly  defined  fifth  visceral  bow.     The  first  jjair 

•r  '^t  •ipiH'iirs  and  soonest  disappears,  all  five  at  no  time  being  found  simul- 
<lv  fiillv  (Ic'Vt  loped,  since  by  the  twentieth  day,  when  all  are  present,  the 

.••,  1-  ucIhs  have  already  partly  atrophied.  These  aortic  arches  in  man  and 
in  nianinials  transiently  represent  the  branchial  circulation  of  gill-bearing 
f  •  ■  ■  ilioir  identity  in  the  higher  animals  is  lost  in  the  metamorphosis  which 
tiiermi.lergo  in  the  devel.)pment  of  permanent  trunks. 

Til '  I'lte  of'  the  several  aortic  arches  and  their  relations  to  persistent  struc- 
tures is  l)rictly  iis  i'ollows  (Fig.  98) :  ^ 

(])  Tiie  lirst  or  mandibular  aortic  arch  early  in  the  fourth  week  loses  its 
midille  segment,  th(!  anterior  limb  taking  i)art  in  the  formation  of  the  external 


-zur 


■iiC 

-vv 
uv 


-—aL 


•■Ud 

-UV 


1(1  furrows  iinJ  thci.-  nla 
1st  visceriil  iirch  :  n  '-" '' 

li,t(.f(""vier:  nM.Hlri.m 
Inrtii-,  <»■,«(.  opt ii'iiii'l"!' 


ibular  arch,  tlio  In- 


G'W"'-"'  111  ID/ /i/ 

Right  siiKiavHi'!. 


/tinofiiiniifr  iirityy. 


As^Ohlillg  illOtil. 


^    External  carotiii. 
_    Intfriuil  earot'ui. 

I  't'rtcbial  artery. 

Arch  of  aorta. 
Lt'ft  su/h'iavitiH. 


Ductus  arteriosus. 


Pulinonary  trunk. 


Desceniiiu^  aorta. 


Fio.  as— I>iiii;raiii  illiislnitiim:  llio  Into  ol'tlio  aortic  arches  in  mammals  and  man  fraodifieil  from  Rathkc). 

carotid  artery  and  its  brauchcs;  the  posterior  or  aortic  limb  aids  in  forming 
pe  internal  carotid  artery. 

(2)  The  seooiid  arch  has  a  fate  identical  with  that  of  the  first,  its  straighter 
▼entral  and  dorsal  limbs  taking  part  in  producing  the  carotids. 
'    (3)  Tiie  third  arch,  whieli  remains  almost  comj)lete,  gives  rise  to  the  connec- 
flon  iM'twcon  the  external  and  internal  carotid  arteries,  to  the  latter  of  which 
the  arch  particularly  contributes. 

(4)  The  fourth  arch  undergoes  important  changes  resulting  in  its  retention 
on  the  two  sides,  since  from  it  are  largely  derived  the  innominate,  together 
ifith  the  subclavian  and  vertebral  arteries  on  the  right  side,  and  the  important 
ilbh  of  the  aorta  on  the  left. 


>  i 


110 


AMKIilCAX   TEXT- no  OK   OF    OBSTETRICS. 


(o)  The  fifth  ai'cli  is  devoted  to  the  production  of  the  pulmonary  arteries,  a 
small  portion  of  tlio  right  areh  persisting  as  the  right  pulmonary  artery,  inul 
a  larger  part  of  the  left  giving  origin  to  the  corresponding  pulmonary  arti  ry 
and  the  duetus  arteriosus. 

During  the  fifth  week,  as  betbre  noted,  the  truneus  arteriosus  undergoes  dl\  is- 
ion  into  two  tuhes  by  the  formation  of  the  aortic  septum  ;  the  resulting  aortic 
tube  retains  connection  with  the  fourth  arch,  becoming  the  ascending  portion 
of  the  arch  of  the  aorta,  while  the  right  tube  becomes  connected  with  the  filth 
arch  and  fornis  the  pulmonary  vessel. 

The  two  primitive  aortae  for  a  time  extend  on  each  side  of  the  notochurd 
as  longitudinal  vessels  which  almost  completely  terminate  in  the  large  omphalo- 
mesenteric or  vitelline  arteries  supplying  the  circtdation  of  the  yolk-sac,  tiip 
early  continuation  of  the  aortic  stems  being  slender,  relatively  insignificaDt 
branches  which  extend  toward  the  caudal  pole  of  the  embryo.      With  the 
develt»pment  of  the  earliest  allantoic  structures  the  posterior  segments  of  tlio 
two  primitive  aortse  unite  to  form  a  single  trunk,  the  dorsal  aorta,  the  fusion 
beginning  about  the  junction  of  the  cervical  and   thoracic  regions  and  |)ro- 
cceding  caudally.     At  a  slightly  later  period  the  aortic  trunk  divides,  at  the 
end  of  the  lumbar  region,  into  the  allantoic  arteries,  which  pass  along  the 
allantoic  stalk  and  are  distributed  to  the  chorion,  and  later  to  the  fetal  placenta; 
thcv  are  then  known  as  the  umlnlical  arteries  as  far  as  the  bodv-wall,  bcintr 
continued  within  the  embryo  as  the  hypogastrics.     The  primitive  allantoic 
arteries  eventually  become  the  common  and   the  internal   iliac  arteries,  the 
external  iliaes  being  formed  as  new  branches  when  the  limbs  arc  developed. 
After  birth,  when  the  fetal  placental  circulation  ceases,  the  distal  parts  of  tlie 
hypogastrics  beyond   the  bladder  atrophy  and  remain   as  solid  fibrous  cords 
passing  to  the  und)ilicus  ;  the    proximal    |)arts  of  these  vessels  retain  their 
lumina  and  persist  as  the  superior  vesical  arteries. 

Vcinx  of  the  Fetus. — Toward  the  close  of  the   embryonal   period,  about 
the  fourth  week,  the  venous  arrangement  includes  three  distinct  sets  of  vessels 
rct'irning  the  blood  to  the  heart  (PI.  16) ;  these  are — (1)  The  Cuvierian  vein?, 
returning  flic  l)lood  from  the  body  of  the  embryo;  (2)  the  vitelline  veins,  re- 
turning the  blood  from  the  circulation  of  the  yolk-sac;  (3)  the  allantoic,  later 
the  umbilical,  veins,  returning  the  blood  from  the  chorion  and  the  developing 
placental  structures.     The  early  systemic  veins  consist  of  an  up])er  trunk,  the 
anterior  eardinnl  or  primitive  jugular  veins,  by  which  the  blood  from  the  liciiil 
is  carried  to  the  heart,  and  the  jtnsferior  earifinafs,  collecting  the  blood  Inmi 
the  triuik  and  the  important  Wolffian  bodies.     These  vessels,  along  with  the 
viti'lline  and  allantoic  veins,  pour  their  blood   into  a  common  receptacle,  the 
sitiiis  reiiiisits,  which  opens  directly  into  the  primary  auricular  division  of  the 
heart.     For  a  short  time  these  veins  are  about  etpial  in  size  and  are  evenly 
developed  on  the  two  sides  ;  soon,  however,  the  results  of  unequal  growth  become 
manifested  in  the  disproportionate  advance  of  some  and  the  retrogression  of 
others. 

The  vitelline  veins  in  man,  as  may  be  anticipated  from  the  relative  insig- 


res. 

nonary  arterit ^ ,  a 
)naiy  artery,  iiiul 
juluionary  artery 

i  undcrf^oes  «li\  is- 
e  resulting  aortic 
isoending  portion 
te<l  with  the  iiftli 

of  the  notoeliuril 
le  hu'ge  oraphalo- 
the  yolk-sae,  tlic 
vely  insignificant 
l)ryo.  With  tiie 
'  segments  of  tlio 

I  aorta,  the  fiisidii 
regions  and  pro- 
ik  divides,  at  the 
li  pass  along  tlic 
the  fetal  placenta; 

body-wall,  being 
rimitive  allantoic 

iliac  arteries,  tlie 
lbs  arc  developed, 
listal  parts  of  the 
lolid  fibrous  cords 
}ssels  retain  tlioir 

nal  period,  about 
inct  sets  of  vessels 
e  Cuvierian  veins, 
vitelline  veins,  ic- 
the  allantoic,  hiter 
nd  the  developing 

II  upper  trunk,  the 
lood  from  the  lieiid 
ng  the  blood  IVoin 
ds,  along  with  the 
lion  receptacle,  tlie 
lar  division  of  tbo 
^ize  and  are  evenly 
ual  growth  become 
le  retrogression  of 

the  relative  insig- 


:•'* 

i 


''  !«' 


!1 


i  1 


DEV! 


li! 


ir 


ill 


Ilnmnii  (Miihryci  ircciiiistriicli'il)  of  twciitv-six  ilnys,  viowofi  fnim  the  li'ft  siilc;  niiiKiiiliiMl  'jn  (limiutcrs 
(iifdi-  I".  Miill  ;  ///.  til  Xll.,  Ilir  cnmiiil  iicrvrs  :  1,  s,  fj.  iiml  5,  rcsprclivrly  llir  liisl  rcrviciil.  Ilic  i'it,'lilli  icr- 
vii'iil,  llic  tufll'lli  lliniiicic.  inul  tlir  lll'ih  lii.iilnir  spiiiiil  iicivi';  ,1.  I'.,  tln'' innlitury  vrsirli';  1,'J,  ;t,  I,  n>|ii'('- 
tivi-ly  lir-t,  scc'oiiil.  iliinl,  iiinl  rniiiili  plmi-yiiL'ciil  imiUcIics;  7',  lliy''"iil  l)iiily ;  W,  lii'iincliiis;  /..liver;  A',  kid- 
iii'y. "  'I'lii'  ildttcil  liiK's  iiiiliciito  tlii.'  f.\livmitii.'S. 


"»Jl., 


I>EV! 


F  THE  FETUS. 


Plate  16. 


i^k 


i-m 


m 


mniiirnMl  'jr)  (liiimclcis 
rvinil.  llK'  finlitli  'IT- 

lius;  /„  Mvit;  A',  ki'l- 


Iltimnn  embryo,  same  ns  prcreriin,!);  fisure,  b>it  tnken  nt  a  deeper  plniie  (nftcr  F.  Mall):  //,  divcrtieulum 
contriliiitiiii,'  tlu'"iiral  iinrtinii  ul'  tlic  pituitary  liody;  Jl  iiilmvi'l,  nriiiiitive  imiiitli;  1,  '_',  If,  1,  pliiiryiideal 
poiiclii-.s:  /;,  liriiiiilius ;  /',  pancreas;  /,.  liver;  II'.  /.'.,  Wnlltiaii  liddy;  II'.  /».,  Wdllliaii  ihiet ;  K,  kidiiey;  C, 
cloaeii ;  o,  (ipeiiiiigs  liy  wliieli  pleuru-iiorituiieul  ciivitio.s  eoiiuiuiiiicaie  ;  l\  papilUrunu  projection  into  lower 
opeiiiii),'. 


M    !'■' 


m 


''iik.i 


niYSIOLOU  Y    OF   PltEGNAXCY. 


Ill 


nifi.an.-c  of  tl.o  lutuninalian  yolk-snr,  novor  roach  tho  .lovclopmont  .seen  in 
lowiT  tV|H-<  M'lcr  l)a>siii<,^  aloii^r  tlio  vitclliiit'  stalk  and  iiitonn^r  at  the  unibil- 
ionl  ..|)enin.r.  the  veins  im.  in  In.nt  and  then  at  tho  sidos  <.f  that  part  of  the 
priniitivo  .mt-tract  oorrospon.Unf;  with  tho  (hiodonnin,  and  bcoonic  dosoly  asso- 
ciated with  the  Hvor  (Fi)?.  99).  The  vitelline  veins  become  connect(Hl  by  three 
newlv  formed  transverse  trnnks,  thns  establishing  two  vascnlur  ring's  which 
-•^"irele  the  ^\\\.     The  early  direct  connniniication  above  these  rings  with  the 


^s' 


VA" 


TS 


l-f 


iVD 


VA' 


yy 


Yia.  '.111.— Povfliipnu'iit  uf  the  |»irtiil  <'irrulation  of  tlio  human  cmliryo  df  iilidUt  thnu  und  ii  half  woiks 
(Marsha  I'l,  a  ft  IT  Mis) :  /'.I.  paiurfas;  7*/,  i  litest  iiu's  ;  7'.s',  st(iiiia<'h  ;  117),  l>ili'(lu('t ;  T.l,  left  nllantdic  vein  ; 
Kd'.  rij-'lit  allaiitnic  vein:  I'.l",  anterior  detaehed  pDrtimis  of  the  allantnic  veins  ;  r/C,  diietiis  venosus ; 
VO,  portal  vein;   IT.  vitelline  vein;  VV,  portions  of  sinus  annulares  which  disapj)ear;  H",  liver. 

sinus  venosiis  becomes  lost,  and  at  the  same  time  pctrtions  of  the  remaining 
parts  of  the  vitelline  veins  become  interrnptod,  while  a  new  capillary  system 
appears  within  tiie  hepatic  tissue,  whieh  lias  meanwhile  surrounded  the  vessels, 
and  provides  coinmiinication  l)etween  the  veins  themselves.  Those  portions 
of  the  vitelline  vessels  that  ])ass  from  the  up])er  venous  ring  to  the  capillary 
network'  are  known  as  the  vemv.  advc/icntes :  they  become  the  branches  of  the 
|K>rtaI  vein  ;  those  ])ortions  which  pass  from  the  capillary  network  to  the  sinus 
yenosus,  forming  now  relations,  an;  the  twmr.  revehente.s  and  they  become  the 
hepatic  reins.  The  vitelline  veins  at  their  lower  communication  become  com- 
pletely I'liscd  and  receive  veins  from  the  intestinal  tract,  thus  forming  the  main 
portal  trunk. 

The  allantoic  veins  after  the  establishment  of  the  placental  circulation  are 
loiown  as  the  umbilicnl  vcinn,  of  which  for  a  time  there  are  two.  They  fuse 
within  the  allantoic  stalk,  but  remain  as  distinct  vessels  within  the  embryo, 
IfOnniiig  within  the  lateral  walls,  for  a  much  longer  period.  During  the 
Iburth  week  the  comicction  of  the  allantoic  veins  with  the  siims  venosus  is 
•lljet,  and  shortly  afterward  the  right  vein   becomes   much  smaller  than  its 

ow,  and  finally  undergoes   atrophy.     The  mueh   larger  left  allantoic  or 


..iSiS**' 


,^ 


1  . 


V 


1^ 


I 


1^ 


i|l!i 


t?, 


;) 


112 


AMKniCAX   TEXT-nOOK    GF   OBSTETRICS. 


umbilical  vein  joins  the  primitive  purtal  vein  jnst  as  this  vessel  enteiv  the 
hepatic  tissue. 

The  early  condition  of  the  placental  circJilation  for  a  time  is  siich  tliat 
all  blood  retnrnini!;  by  tlie  allantoic  vein  must  traverse  the  ca|)illary  netwink 
of  the  liver  in  order  to  <>;ain  access  to  the  heart,  since  both  vitelline  and 
allantoic  veins  have  lost  their  direct  communication  with  the  sinus  vcnusus. 
After  a  time,  however,  the  liver  is  no  longer  capable  of  givint;  passage  to  the 
rai)id]y  increasing  volume  of  the  placental  circulation,  and  then  a  direct  (nin- 
munication  is  establislied  between  the  portal  vein  and  the  right  hepatic  vein. 
This  new  jiassage  is  the  duclus  venoms,  by  which  the  greater  ])art  of  the  Mdud 
is  carried  to  the  heart  without  traversing  the  hepatic  snbstance. 

The  systenn'c  veins  arise  partly  from  the  primary  venous  trnnks  ami 
jwrtly  as  new  vessels.  The  ducts  of  Cuvier  receive  the  primitive  jiiuular 
veins  above  and  the  cardinal  veins  below.  The  primitive  jngulars  lat(>r 
become  the  permanent  external  jngnlars,  the  internal  jngulars  being  formed  a« 
new  trunks.  The  Cuvierian  ducts,  which  undergo  change  of  direction  and 
lengthening,  take  a  position  almost  vertical,  becoming  the  superior  t'emr  rdni, 
of  which  tiiere  are  at  first  two.  The  develoiiment  of  tiie  heart  induces  tin- 
disappearance  of  the  greater  part  of  the  left  superior  cava,  the  proximal  end, 
however,  remaining  as  tlie  insignificant  coronary  sinus  which  directly  (i|)(ii< 
into  the  right  auricle.  >i  itli  the  atrophy  of  the  left  caval  trunk  a  ikw 
transverse  communication  is  necessitated  to  convey  the  blood  from  the  left 
side  to  the  remaining  and  enlarging  superior  cava\  This  need  is  su])]ilie(l  liv 
the  formation  of  the  transverse  ju;/H/ar,  which  later  becomes  the  greater  pan 
of  the  left  innouiinate  vein. 

The  fiite  of  the  once  important  posterior  cardinal  veins  is  linked  with  tin 
history  of  the  Wolflian  bodies,  whose  venous  outlet  these  veins  largelv  mv. 
AVith  the  atro])liy  of  the  Wolt!ian  bodies  the  cardinal  veins  become  Ks. 
important,  their  final  fate  being  ])artial  disappearance  and  partial  pcrsistcncv 
as  the  a/ygos  veins  of  adult  anatomy. 

The  inferior  vena  e<tva  j)resents  a  complicated  development,  for  the  detail- 
of  whicii  we  are  largely  indebted  to  the  recent  investigations  of  lloclistettir. 
The  infi'rior  cava  is  developed  partly  as  an  independant  trunk,  and  [cirtiv 
depends  upon  the  ap])ro])riation  of  already  existing  veins.  A  new  vosd  i- 
formed  from  the  proximal  end  of  the  ductus  venosus,  from  the  point  wlm. 
that  canal  joins  the  hepatic  veins,  downward  as  far  as  the  superior  mesentnii 
artery,  when  it  divides  into  two  brandies  which  join  the  ))rimitive  cardinal-, 
This  new  vessel  contributes  the  he|)atic  ])ortion  of  the  inferior  vena  cavn. 
The  further  course  of  the  latter  vessel,  as  well  as  of  the  right  common  ili;i' 
vein,  is  provided  for  by  the  enlargenuMit  and  extension  of  the  lower  part  nt 
the  right  i>rimitive  Cardinal  vein,  that  of  the  opposite  disappearing.  Tin 
external  iliacs  and  tlie  greater  part  of  the  left  common  iliac  vein  are  ikh 
vessels. 

7.  Development  of  the  Digestive  Tract. — The  formation  of  the  digestive 
tube  consists  essentially  in  the  fbhling  otf,  closure,  and  isolation  of  that  iimi: 


esscl  enters  tlic 

lie  is  siich  that 
ipillary  notwdvk 
th  vitelline  ami 
e  sinns  veiinsus. 
itr  passage  In  the 
icn  a  direct  cDm- 
rlit  hepatic  vein, 
part  of  the  lihiml 
anee. 

nous  trunks  ami 
primitive  juiiular 
vc   jugulars   later 
5  being  formed  ;i> 
of  tlirectioM  aiul 
\pct'ior  vcmr  runi, 
heart  induces  tlio 
the  proximal  cml, 
ich  directly  njxn. 
ival   trunk  a  luw 
ood  from  the  lift 
eed  is  supplii'd  l>y 
es  the  greater  \K\n 

is  linked  with  tin 
veins  lai'gely  aiv, 

veins  become  hv 
partial  persistcmv 


Pin'SIOLOGV   OF  PREGNANCY. 


113 


( 


tn 


nt,  for  the  (lct:\il- 
s  of  Iloclistctt.r, 

trunk,  and  paitK 
V  new  vi'-si'l  i> 
1  the  point  wlidv 
uperior  mesciiti'iii 

irimitive  cardiiiak 

lierior  vena  i-ni 

o-ht  common  ili;i'' 

the  lower  p;ui  "t 


isappearing. 


Th 


iliac  veni  arc  m« 

ion  of  thediut'^tivt 
dation  of  timl  i<;ir; 


of  the  v(dk-sie  innncdiatelv  in  contact  with  the  axial  portions  of  the  ento- 
derm ''rhi<  ditrcrcntiation  is  efleeted  by  the  ventral  extension  and  appn)xi- 
niation  of  the  widclv  expanded  splanchnopleure,  which,  bending  together 
mir  JOG)  .n-ad.iallv  doses  to  form  the  primitive  gut— at  first  freely  openuig 
into  the  yorU-sac,  finally  completely  isolated  from  the  latter  except  through 
the  communication  maintained  by  the  narrow  und)ilieal  duet. 

Bv  the  fifteenth  dav  the  gut  has  become  defined  to  such  extent  that  three 
parts"  are  distiniruishahlc-the  fore-gut,  the  mid-gut,  and  the  hind-gut.  The 
fore-<inf  whicii  includes  the  cephalic  third  of  tiie  tube,  gives  rise  to  the  phar- 
ynx 'the  esophaoiis,  and  the  stomach,  the  latter  organ  early  appearing  as  a 
fusiform  enlariic.nent  of  the  i)rimitive  canal.  The  anterior  end  of  the  fore- 
gut  reaches  a.^Tfar  forward  as  the  marked  cephalic  flexure  opposite  the  mid- 
brain, and  at  Hrst  is  separated  from  the  primitive  oral  invagination,  or  sto- 


Atttni,*». 


Mesoiiiim. 


Pa}  U'tal 
ntfsoJt-rm. 


ntt-sotit'f  III. 


i/iiil  ca7'ily. 
Fi(i.  loo.-TriiiisvtTse  soction  nf  ii  sixtoon  ami  a  half  <lny  shei'p  cmtiryo  (Bonnet). 


Ejctensioit 
of  leli'iii. 


matoihrum  (Fig.  101,  A,  w),  by  a  septum  consisting  of  the  opposed  eetoderinie 
and  entodcrmic  layers.  After  the  rui)ture  of  this  partition,  which  hapj)ens 
during  the  fifteenth  day,  the  primitive  jiiiarynx  and  oral  cavity  are  directly 
continuous. 

A  scries  of  four  diverticula  (>xtend  bet'.v(>en  the  visceral  arches,  and  constitute 
the  p/i<ir!/)i</((tl  jwiicJic-y  or  in >i'r  riscrml  furvowi^  [F\^.  lOG  ;  IM.  IH).  Tiiese 
evaginations  of  the  pharyngeal  lining  are  of  interest,  since  the  first  pouch 
becomes  converted  into  tiie  Kustachian  tube  and  the  tympanic  cavity,  the  third 
pouch  into  the  early  epithelial  tiiymus  body,  and  the  fourth  pouch  into  the 
Jateral  ))ortion<  of  tiie  early  thyroid  body.  From  the  ventral  surfiice  of  the 
fore-gut,  at  the  end  of  its  pharyngeal  division,  there  grows  out  the  diverti'U- 
fatm,  which  gives  rise  to  the  respiratory  tube  and  the  epithelial  parts  of  the 
julnionary  tissues. 

8 


1 


if 


I 


i|l(i 


114 


AMERICAN   TEXT- BO  OK   OF   OBSTETRICS. 


The  mid-gut,  at  first  in  free  communication  with  the  yolk-sac  through  tho 
wide  yolk-stalk,  gradually  becomes  tubular  and  elongatetl,  forming  a  narrow- 
V-shaped  loop  whose  straight  and  almost  parallel  limbs  are  attached  behind  to 
the  dorsal  wall  of  the  body-cavity,  above  to  the  terminal  part  of  the  fore-gut 
at  the  stomach,  and  below  to  the  hind-gut  (Fig.  102).  The  apex  of  the  loop 
receives  the  reduced  yolk-stalk  or  umbilical  duct,  thereby  becoming  attached 

A  '5 


-  -->-v 


Fii;.  101.— RoronstriK'tiona  of  huiiinn  emliryo  of  nbcmt  liftei-n  rinys  (His) :  nn\  mci\  pcv,  anterior,  mid- 
ille,  Hiiil  iiiislerior  inimiiry  tpriiiiivi'siclts ;  nr,  n/,  iiptic  iiiwi  otic  visiclcs ;  ^^  soptuin  lictwifii  jjriiinlivc 
(iriii  cavity  mid  liciidtrut ;  /»/,  iiriniitive  mil;  r, /ii.  vciitriciiliir  iiiid  iiortic.'  si'tiiiii'iits  ol' liciirt ;  n',  iiorlic 
iirrl) :  ivi,  <lii,  ventral  mid  di)r!-nl  iKirtii' ;  /,  liver;  //<;,  liiiiduid  ;  "C  luitdeluird  ;  s,  Sdiiiites;  <»•,  sinus  reimieii>; 
IT,  vitelline  veins;  »r,  un,  uiiihilieal  veins  mid  arteries;  it!,  allantois. 


to  the  ventral  body-wall.  The  mid-gut  gives  rise  to  the  entire  small  intestiiio 
and  to  the  greater  ])art  of  the  large  intestine.  The  liver  and  the  pancreas  aic 
formed  as  diverticida  and  outgrowths  from  tho  lumen  and  the  epithelial  lining 
of  the  duodenal  portion  of  the  mid-gut. 

T/ic   hind-f/nt    soon    loses    its    individuality   and     contributes    the     lower 
segment  of   the   large   intestine.     In    its   j)rimitive   condition    the   hind-gut 


PHYSIOLOGY  OF  PREGNANCY. 


115 


ough  tho 
a  narrow 
jehind  to 
5  fore-gut 
'  the  loop 
'  attached 


hi 

-a 

^ 

-  tV 

^ 

-,/,/ 

i.:.. 

• 

• 

•"1 

—  V-, 

y 

ti, 

r^.._ 

ir, 

,  iintcrior,  mii\- 

wt't'ii  (iriiuitivc 

iirl ;  'i',  iinilii' 

sinus  rt-'Uiii"."*; 


lall  intestine 
)ancreas  arc 
lelial  linin.i; 

the    h>\v<r 
le    hind-giit 


i„.h,des  that  portion  of  the  g«t-traet  lying  behind  the  open  mid-gut  and  ter- 
minating blindly  in  the  sharply  flexed  caudal  pole  of  the  embryo  ;  the  greatly 


stomach. 

/.I'ssi-r  Clime   _ 
of  stomach. 

thl'lltt'f  Clli'Vt 

oj  sioiutich. 


-^Aortii. 

Atei^ogiis- 
triiim. 
Sfilecii. 


Esophagus. 


Stomach. 

Lrs.'icr  cur-'a- 
tut'C. 


^Celiac  a.vis. 
J\incrcas. 


lUh-diict, 


Sufieriiir  nii\<:eii-  i,tiiall  in- 

teric  artciy.  testinc. 

Mcscntci  V. 


Inferior  mesen- 
teric artery. 

Rectum. 


Fig.  K)2.-Intestinnl  .'nnnl  of  luimnn  embryo  of 
six  wc't'ks  ^'i'ulllt^ 


Amis. 
Cecum. 


Vitelline  duct. 

Fig.  103.— Digestive 
the  sixth  wcelv  (Tolilt) 
visceral  peritoneum. 


Mesogastriuiii. 

S/>leeii. 

Greater  curva- 
ture. 
Pancreas. 


Duodenum, 

Posterior  body- 
ivaii. 

Large  intestine. 

/tectum. 


trnet  of  human  embryo  of 
:  arrangement  of  primitive 


dilated  clo.sed  end  of  the  tube  constitutes  the  cloaca,  the 
for  a  time  of  the  excretions  of  both  the  alimentary  and 

A  Lung.    Stomach. 


common  receptacle 
the  urinary  tracts. 

B 


Bile-duct.  -. 


Vitelline  diu     -—.. 


Rectum.     Pancreas. 


Rectum. 


Fi(i.  101.— A,  alimentary  tract  of  human  embryo  of  thirty-two  days.    H,  alimentary  tract  of  human 

embryo  of  thlrty-tive  days  ^His). 

Tlie  lumen  of  the  allantoic  sac,  surroiuided  by  the  tissue  of  the  allantoic  stalk, 
extends  from  the  ventral  aspect  of  this  space.  At  a  later  period  communi- 
cation with  the  exterior  is  established  by  the  formation  of  the  anal  oririce. 
The  external  position  of  this  opening  is  indicated  by  the  anal  invaf/ination  of 
tlie  ectoderm  or  >   jctodcmii. 


■'rTT 


'1 


r:> 


m 


1,1  ■  1 
I.   i 


I*'        :1 


116 


AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 


During  tlie  early  part  of  the  fourth  week  the  intestinal  tube,  composed  of 
its  several  characteristic  segments,  lies  in  the  sagittal  plane  attached  to  the 
dorsal  wall  of  the  body-cavity  by  the  straight  primitive  mesentery  (Fig.  10;)). 
A  few  davs  later  a  period  of  rapid  growth  is  inaugurated,  the  intestinal  tiihe 
increasing  in  length  with  far  greater  rapidity  than  the  abdominal  cavi'v 
expands.  In  consequence  of  this  inequality  in  growth  the  small  intestines 
become  twisted  and  coiled,  while  the  large  gut  takes  up  a  position  in  fidiit 
or  ventrally,  and  above  the  turns  of  the  smaller  tube. 

During  the  fifth  week  (Fig.  104)  the  esophagus  elongates  and  the  stomnch 
acquires  its  characteristic  form  as  well  as  an  obliquely  transverse  position,  its 

A 


Fig.  lori.— a,  nutliiio  of  iiliiiu'iiliiry  <'iiiiul  of  Inimnn  Piiibryo  of  Iwi'iity-t'inlit  iliiys  (His);  i>h,  pituitiiry 
fiissn  ;  ^/,  tciiitnii.' ;  /j-,  priiiiitivo  larynx;  (i,  csoiilianus  ;  //■,  traclioa  ;  hj,  Imifr ;  .-•,  .stiiiiinch  ;  >),  pancri'iis,  M, 
lii'iiatic  iluct;  vil.  viti'lliiic  liiict;  al,  Hllantuis;  /(</,  liiiid-KUt :  H'rf,  WnUVum  duct;  k,  kidiify.  H,  oulliin' 
of  alinu'iitary  canal  of  liunian  emtiryo  of  tliirtytivi'  clays  iHls) :  ph,  iiituitary  fossa  :  tp,  tonniii' ;  Ix.  iniiiii- 
tivu  larynx;  o,  t'S()i)hanns;  t,-,  traclioa;  Ig,  Iiuik;  n.  stoiiiacli ;  ;),  pancreas;  lul,  lic]>ati{,'  duct;  p,  ccriini: 
ri,  climca;  A-,  kiilncy;  ii,  anus;  ,<;;y,  Kciilal  eminence  ;  (,  caudal  process. 

former  left  side  becoming  directed  anteriorly  and  upward,  its  former  right  >i(lc 
looking  backward  and  downward.  The  cecum  for  a  time  is  situated  high  ii|i 
and  in  dose  reiatittn  with  the  transversely  ])]a('ed  jtortion  of  the  large  intestine; 
later  the  blind  end  of  this  part  of  the  gut  de.'^cends,  owing  to  the  developnuiit 
of  an  intermediate  portion  which  a.ssumes  the  position  and  characteristics  of  the 
ascending  colon.  The  cecum  for  a  time  is  of  uniform  size  ;  its  further  growth, 
however,  is  marked  by  the  failure  of  the  apical  p<trtion  to  keep  pace  with  the 
increase  in  size  of  the  remaining  parts  of  the  gut ;  in  consequence,  that  portiou 
which  morphologically  represents  the  end  of  the  cecum  remains  as  a  naridw 
tubular  attachment  connected  with  the  head  of  the  large  gut,  this  apj)eii(higo 
constituting  the  appendix  vcrmifoniiis — the  oldest  part  of  the  cecum. 


"t»-i.A 


.'oniposed  uf 
iched  to  tlie 
^  (Fig.  lO:^,). 
testinal  ttilio 
iiinal  cavity 
»11  intestines 
;ioii  in  fn.iit 

the  stomach 
position,  Its 

li 


lis) ;  })>>,  piliiitiiry 

;),  pilniTl'lls  ,  hd, 

liiii'y.     1!,  outliiK' 

tmiKiiL' ;  Ix,  iiriiui- 

duct ;  c,  ci'iMim: 

ner  right  >itli' 
latod  high  up 
rtrc  intostiiu'; 
clcvclopiiunt 
(U'istics  ol'tlif 
rthcr  growth, 
pace  with  the 
,  that  portion 
as  a  narmw 
lis  appemhiiije 
11  m. 


PJIVSJOLOGY   OF  PREGNANPy.  117 

The  connection  of  the  yolk-stalk  or  vitelline  duct  (Fig.  105)  with  the  intes- 
tinal canal  rapidly  hcconies  less  conspicuous,  and  by  the  end  of  the  fifth  week 
the  yolk-stalk  has  but  slight  connection  with  the  gut.     The  position  of  the 

A  h 


Viv,.  KW.— lU'CMiiistructioiis  of  human  embryo  of  iibout  sovontoiMi  Jiiys  (His):  or,  optic  and  nt,  otic 
vesicles;  ni\  iic',  luitoeliord  ;  hil<f,  heiulgul;  y,  mid-KUt ;  hit,  iiiiidgiit ;  vk,  viti'lliiio  sac;  I,  liver;  r,  In, 
primitive  ventricle  and  trnneiis  arteriosus;  ra,  lid,  ventral  and  iloisal  aorta^;  mi,  aortic  arches;  jv,  primi- 
tive jugular  vein  :  cr,  cardinal  \ein  ;  dc,  duct  of  Cuvier;  iiv,  iiu,  umhilical  vein  and  artery  ;  al,  allantois  ; 
Id',  umbilical  curd. 

jimctuio  of  the  vitelline  duct  with  the  intestinal  tract  varies  greatly,  but  usually 
corresponds  with  a  point  within  the  small  intestine  from  40  to  60  eentiineters 
(1(3  to  24  inches)  from  the  ilio-eecal  valve.  When  the  usually  atrophic  cord  is 
replaced  by  a  tubular  rece.ss,  the  persistent  portion  of  the  duct  con.stitutes 
^Teckel's  diverticulum,  a  structure  of  interest.  The  vitelline  duct  may  remain 
pervious  throughout  its  iiitra-embrvonal  extent,  resulting  .'sometimes  in  congen- 
ital umbilical  (i.stula.    The  ventrally  situated  intestinal  loops  lor  a  time  extend 


"TT^smmmwm 


I        I 


i  > 


^m^. 


118 


AMERICAN  TEXT-nOOK   07'   OBSTETIilCS. 


through  the  uinbilit'al  Dpciiiiig  into  the  alhintoic  stalk,  in  which,  up  to  t!ie 
twelfth  week,  t  ley  are  normally  present;  after  the  third  month,  however,  the 
coils  are  permanently  withdrawn  into  the  abdominal  cavity. 

The  liver  first  apj)ears  about  the  fifteenth  day  as  a  diverticulum  (Fig.  Kiii) 
from  the  ventral  wall  of  the  fore-gut,  surrounded  at  its  end  by  a  thick  la\i'r 
of  cells.  The  organ  is  rapidly  formed,  the  single  diverticulum  almost  iminc. 
diately  dividing  into  two,  which  in  turn  send  ott"  secondary  and  tertiary  spront- 
like  extensions  of  solid  cell-masses.  These  cylindrical  masses  anastomose  and 
form  networks  of  cells  throughout  the  mesodermic  tissue  assigned  to  the  pro- 
duction of  the  liver.  The  spaces  within  the  meshworks  are  occupied  by  the 
ricldy  vascular  mesodermic  tissue  which  suii])lies  the  connective  tissue  and  tlie 
contained  blood-vessels  and  bile-ducts. 

The  pancreas  (Fig.  105)  and  the  salivary  glands  are  developed  as  solid 
outgrowths  from  the  epitheliuiu  of  the  digestive  tract.  The  cylindrical  ceil- 
masses  at  first  are  slender,  solid,  and  rather  dub-shapod  at  their  free  ends. 
They  later  acquire  a  lumen  and  expand  into  the  characteristic  compartments 
of  a  racemose  ghi'.i. 

8.  Respiratory  Tract. — The  respiratory  tract  is  closely  related  in  its  devel- 
opment with  the  digestive  canal,  since  it  is  formed  by  a  direct  evagi nation  from 
the  ventral  wall  of  the  lower  portion  of  the  ])rimitive  pharynx.  The  primitive 
trachea  grows  downward  for  some  distance  parallel  with  the  esophagus,  ami  tlicn 
divides  into  branches  which  correspond  to  the  primary  and  secondary  bronchi 
(Figs.  104,  105);  subsequently  each  of  these  undergoes  repeated  dichotoinoiis 
division,  the  resulting  twigs  in  turn  giving  rise  to  smaller  branches  until  the 
ultimate  compartments  of  the  pulmonary  tissue  are  developed.  The  smailci- 
primary  bronchioles  are  solid  cylinders  at  first,  their  lumina  appearing  later. 
The  cntodei'niic  jiortion  of  the  res])irat()rv  iivict,  directly  derived  from  that  of 
the  j)riniary  digestive  tube,  forms  the  epithelial  parts  of  the  organs,  the  cdii- 
nective  tissues  and  vascular  constituents  of  the  same  being  products  of  tlie 
mesodermic  tracts  into  which  extend  the  epithelial  masses. 

9.  Development  of  the  Genito-urinary  Organs. — The  early  stages  of 
the  human  end)ryo,  as  well  as  of  other  mammals,  mark  the  a[)pearance  (u' 
the  paired  Wolffian  bodies  and  the  Wolffian  ducts,  which  for  a  time  repre- 
sent a  functionating  excretory  apparatus  (IM.  16),  the  ancestor  of  the  per- 
manent kidneys. 

The  Wolffian  duct,  appears  about  the  fifteenth  day  as  a  longitudinal  cell- 
mass  extending  throughout  the  posterior  half  of  the  end)ryo.  The  duet  is 
fi)rnied  by  the  evagination  and  isolation  of  ])ortions  of  the  mesothelial  liniiii; 
of  the  body-cavity,  the  resulting  cylindrical  cell-mass  forming  a  cord  that 
extends  at  first  to  the  surface  ectoderm,  with  which  it  has  temporarily  close 
relations  (Fig.  107).  These  a|>pearances  have  given  rise  to  the  views  advanced 
by  sev(!ral  investigators,  according  t(»  which  the  Wolffian  duct  is  ectodermie  in 
origin.  Careful  examinations  of  suitable  |)reparations  show  that  the  relations 
of  the  developing  Wolffian  duct  to  the  ectoderm  are  only  secondary,  and  that 
the  initial  steps  in  the  formation  of  the  duct  occur,  as  stated,  as  evaginations  ot' 


t  '        ■' 


"'!*. 


PHYSIOLOGY   OF  PREGNANCY. 


119 


1,  tip  to  tlie 
owever,  tlie 

1  (Fig.  lOi!) 
thick  layer 
nu).st  iniiDc- 
iary  sproiit- 
stoinose  and 
I  to  the  piD- 
ipiod  by  tlio 
ssue  and  the 

ped  as  Sdlid 
imlrical  n  II- 
ir  free  cuds. 
arapartaK'iits 

in  its  devcl- 

;ination  fmin 

'he  priiuilivo 

giis,  and  tlit'ii 

dary  bronclii 

dichotoiiioiis 

les  until  the 

The  snialh'i' 

leaving  later. 

from  that  of 

uns,  the  t'oii- 

)ducts  of  the 

y  stages  of 

)pearance  oi' 

time  ro|>ro- 

of  the  pei- 

itudiiial  ecll- 
The  duct  is 
helial  liiiiiiir 
a  cord  that 
)orarily  close 
Avs  advanced 
'ctodermic  in 
the  relations 
ary,  and  tiiat 
iigiuations  of 


the  inesotlicliuin  ;  the  Wolffian  duct  therefore  is  a  product  of  the  mesodorn.. 
After  a  time  the  blindly  terminating  distal  ends  of  the  duets  sink  centrally 
and  accpiire  a  communication  with  the  cloacal  expansion  of  the  hind-gut. 
At  first  the  ducts  are  solid  cylinders ;  subsequently  they  possess  a  lumen. 


Fi(i.  HIT— Transverse  section  of  sixteen  day  sheep  embryo  (Bonnet) :  ec,  ectoderm  ;  en,  entoderm ; 
pm,  pn'rictiil  inesdilerni ;  rm,  viscernl  mesoderm;  am,  amnion;  nrnx,  amniotic  sac;  t,  »',  somites;  a,  a', 
aor'tie ;  «( ,  nutocliord ;  »,  neunil  cuiial ;  Wd,  Wolffian  duct ;  \Vb,  Wolffian  body. 

Some  days  later,  usually  about  the  eighteenth  day,  the  Wolffian  bodies 
appear  as  a  scries  of  short  cylinders  (Fig.  108)  which  form  as  buds  from  the 
mesotiiclium  of  the  body-cavity  entirely  independently  of  the  development  of 
the  Wolffian  duct.  These  rcxls  of  cells  at  first  are  solid ;  during  the  fourth 
week  tiicv  acqiiire  lumina  and  become  the  Wolffian  tubules,  and  later  grow 
toward  and  join  with  the  Wolffian  ducts.     The  closed  ends  of  the  tubules 


iiw 


IIW 


IVb 


Kit;.  IDS.— Transverse  section  of  seventeen  day  sheep  embryo  'Honnet) :  n»i,  amnion  ;  ns,  amniotic  sac; 
n,  neural  canal ;  x,  smiiite  <lill'erentiated  into  muscle-plate;  IIV?,  Wolffian  duct;  H7i,  Wolffian  body;  pm, 
parietal  mesoderm  ;  vm,  visceral  mesoderm  ;  n,  n,  fiisinn  i>rimitive  aortic ;  i,  intestine. 

become  expanded  and  then  invaginated  by  the  apposition  of  blood- veis.sels  sent 
into  the  bodies  from  the  aorta.  The  tufted  blood-vessels  and  the  invaginated 
tubule  constitute  the  Malpighian  bodies  of  the  W^olffian  bodies,  the  predeces- 
sors of  the  similar  structures  of  the  permanent  kidney.  All  parts  of  the 
Wolffian  bodies,  therefore,  are  derived  from  the  mesodermic  tissues.  Second- 
ary tubules  are  formed  as  outgrowths  from  the  primary  ones  whose  origin  has 
been  sketched  above. 


Trf^¥J^: 


I.     .1 


120 


AMERICAN    TEXT-BOOK    OF   OBSTETIIICS. 


The  Wolffian  bodies  iiicrea.se  rapidly  during  the  .second  month,  ganiinff  in 
size  by  tlie growth  of  the  primary  tubules  and  by  the  formation  of  new  ones. 
These  bodies  act  for  a  time  as  fiuietionating  excretory  organs,  the  period  of 
tiieir  greatest  development  l)eing  about  the  eighth  week.  After  this  time  tlioy 
undergo  retrogressive  change,  so  that  by  the  fifth  month  the  Malpighian  bodies 
have  largely  disappeared  and  the  eiitire  organs  become  atrophic. 

In  view  of  important  ditferences  in  growth,  functional  activity,  and  UKtr. 
phological  signiticaiit-e  of  various  parts  of  the  Wolffian  body,  there  are  reeog. 


^i      I 


Fl(i.  init.— Heoonstnicti'd  luimnn  embryo  of  nbcmt  twenty-cinht  days  (His):  /-/I',  brnin-visicUs, 
»ii',  nriinil  canal;  ncli,  nutuclKiril :  nt.  (illlutury  )iit ;  i\itu,  cardiac  ventridt'  and  anridc;  rii,tln,  ventral 
and  dcirsal  aorta' ;  dn',  termination  of  dorsal  aorta  ;  th,  median  jiart  of  thyroid  body  ;  Ir,  larynx  ;  In,  liiii); 
,■.■,  stoniHcli :  ;i,  imncreas;  /,  Intestine:  /'.  intesto-vitelline  duct:  nl.  allantoic  duct;  k.  kidney;  nv,  li.ft 
superior  vena  cava  :  cr,  cardinal  vein  :  ;ir.  portal  vein  ;  iii.«,  vena  ascendens,  collecting  blood  from  iniiliil 
leal  and  jiortal  veins  ;  ui\  iiniliiliial  vein. 

iiized  an  anterior  xcgmcnt,  corresponding  with  the  head-kidney  of  lower  types, 
always  backward  in  its  deve]t)pment  in  mammals  ;  a  middir  scfpneiif,  wliidi 
from  its  relation  to  the  generative  organs  in  their  formation  may  be  regiudoil 
as  the  sexual  portion  of  the  orgtui ;  and  a  posicrior  xri/mrnf,  likewi.se  nuli- 
mentary  in  development  and  in  the  nature  ol' the  organs  to  which  it  contributes. 
The  middle  .segment  is  of  most  imi)ortance  both  functionally  and  mor|)lio- 
logically  :  this  portion   is  sometimes  designated  the  mefioncphron. 

The  Mitlkridii  JJucf. — Coincidentlv  with   the  ibrmation  of  the  WolHiaii 


>^i!A»jlL. 


PHYSIOLOOY   OF  PREGNANCY. 


121 


ga'Ping  in 
f  new  ones, 
i  period  (if 
IS  time  tlicy 
;hian  bodies 

,-,  and  nior- 
•e  are  recog- 


-da 

-th 

-ti 

-va 

-cv 


■P 
P' 


-da 


,  brnin-vi'sick's; 

:  I'd,  </(!,  vi'Utiiil 

liiryiix  ;  ';/,  liini.'; 

kiiliii'V  ;  I'lv,  Kit 

bluoil  friiiii  iiuil'il- 


lower  tyjHs, 
tf/menf,  whicli 

be  rejiiii'dod 
ikewise  nidi- 
it  contributes. 
and   nioriilio- 

the  WuliViaii 


duct  dnrin<r  the  fourth  week,  an  extended  ridge  of  thickenetl  me.sothelium 
appears  along  the  outer  side  of  each  Wolffian  body,  from  whicli,  however,  this 
rid.rc  is  entirciv  independent.  These  ridges  represent  tiie  early  condition  of 
thc^MiiiU'riiiii  ducts,  the  luiuina  appearing  within  the  cell-cords  about  the  fifth 
week.  The  .Miillcrian  duct  ends  blindly  below,  and  later  po.ssesses  an  ex- 
panded, truuipet-siuipcd  anterior  end.  Its  important  morphological  relations 
are  considered  in  subsequent  paragraphs. 

Tlie  permanent  excretory  organ,  the  kidney,  and  its  duct,  the  ureter,  are 
derived  primarily  as  outgrowths  from  the  lower  end  of  the  Wolffian  duct  (PI. 
16  h;  Figs.  105,  109).  About  the  fourth  week  a  diverticulum  grows  from 
the  hinder  end  of  the  duct  forward  and  dorsally  into  a  mesodermic  area  close 
to  and  beiiind  the  lower  end  of  the  Wolffian  body.  The  tube  thus  formed  is 
tlic  primitive  ureter,  which  extends  within  the  mesodermic  ti.ssue,  where,  after 
expanding  into  the  immature  pelvis,  it  breaks  up  into  a  number  of  tubes  cor- 
responding with  the  cftlices,  from  which  pass  epithelial  cylinders  representing  the 
epithelial  portions  of  the  uriuiferous  tubules.  Later  the  vascular  mesoderm 
contributes  the  primitive  glomeruli,  which  meet  the  expanded  ends  of  the 
tubules  and  take  |>art  in  the  further  development  of  the  Malpigliian  bodies  of 
the  kidnev.  Bv  the  end  of  the  second  month  the  definite  character  of  the 
renal  structure  has  become  established.  As  tiie  permanent  organ  increases  in 
size  and  functional  importance  the  Wolffian  body  rapidly  atrophies,  so  that  by 
the  end  of  tlie  fonrtli  month  its  activity  as  an  excretory  organ  has  disappeared, 
the  parts  still  remaining  bearing  relations  to  the  sexual  apparatus  alone. 

The  bladder  is  the  j)ersistent  and  expanded  proximal  j)ortion  of  the  allan- 
toic duct  which  retains  its  lumen,  while  that  of  the  distal  segment  of  the  same 
duct  lo.ses  its  lumen  about  the  fifth  week,  becoming  converted  into  a  solid 
fibrous  cord,  the  Hrachi(i<,  which  stretches  from  the  summit  of  the  urinary  blad- 
der to  tiie  umbilicus.  Tiie  bladder  therefore  differs  from  the  kidney  and  the 
ureter  in  possessing  a  lining  derived  from  the  entoderm,  and  in  not  being 
entirely  of  mesodermic  origin. 

The  formation  of  the  internal  generative  organs  consists  of  two  distinct 
developmental  processes,  the  development  of  the  sexual  glands  and  that  of 
their  excretory  passages.  At  the  end  of  the  first  month  the  mesothelial  cover- 
ing of  the  Wolffian  bodies,  along  their  inner  borders,  shows  an  extended  area 
of  thickening  and  proliferation,  the  resulting  elevated  bands,  the  genital  ri<h/es, 
being  the  earliest  traces  of  the  sexual  glands.  For  a  short  time  these  glands 
are  of  an  indiffi'reut  type  (Fig.  110),  the  diffi'rential  charaeteri.sties  of  the  two 
sexes  not  being  manifested,  seemingly,  for  .some  days  ;  the  primitive  male  gland 
then  exiiiiiits  a  disposition  to  form  networks  of  tortuous  anastomosing  cell- 
cords  (Fig.  Ill),  the  fcn'eriMiners  of  the  .seminiferous  tubules  ;  the  female  gland, 
on  the  contrary,  possesses  a  larger  number  of  the  primlt'n'c  sexual  cellf<,  and 
evinces  a  tendency  of  its  elements  to  arrange  themselves  into  grou]>s  in  which 
the  larger  primitive  (.v;i  I'ccinne  central  figures.  Microscopical  examination  of 
the  .sexual  primitive  glands  even  at  the  end  of  the  fifth  week  is  capable  of  dis- 
tinguishing the  future  sex  of  the  being.     It  is  highly  probable,  as  emphasized 


f? 


'  v 


122 


AMJ':n/f'A.\  TExr-itooK  or  onsrETnrcs. 


End  ,■/  Mtil- 


1)\  Xiifjol,  that  inherent  sexual  differenees  exist  in  the  glantls  Irom  their  oarli(-t 
appearance,  and  that  the  recognition  of  the  indiflerent  stage  depends  large  Iv 

upon    our    iuiperlivt    appreciation    if 
these  distinctions. 

The  development  of  the  second  ]>;iit 
of  the  sexual  apparatus,  the  system  cf 
excretory  passages,  depends  upon  the  ;i|)- 
])ropriation  and  modification  of  alrcalv 
existing  tubes,  the  tuhules  of  the  Wolil'. 
ian  l)(Kly,  the  WoltHan   duct,  anil  the 


Gi'Mitat  process 

( /<■«;>  or  c/itoris). 


Genital 

fohls. 


Fig.  110.— iJiiiKram  roprcscntiiiR  tlio  inililTirciit 
stnge  in  the  devoli)i)iiu'iit  of  tlic  KiiiiTiitivu  uigiiiis 
(modifiiMl  from  AUl'Ii  Tlioniiisoiii. 


Kio.  111.— Intcrnnl  penerative  orgnns  of  a  luiile 
fi'tiis  of  i\t)out  fourtoi'ii  weeks  (Wiildeyer,  ■  t,  Ws- 
tick';  >,  epididynils  ;  «■',  Wipllliim  duct;  «•,  ;,  /..r 
jiiirt  of  WoHlinn  body;  [U  Kii'ierimculiim  tc'sti^. 


^rrdlerian  duct.     The  fate  of  these  .structures  varies  with  sex.     In  the  feniiijo 
(Fig.  112)  the  Miillerian  ducts  are  mo.st  important ;  they  develop  into  the  ovi- 


t'intbria. 


Piirfi-uriiini  _^^ 


I'tiroophoron. 
llicl. 


Bartholin  s 

l^iitiui. 

Fiii.  ll'J.— iJianrnm  illustriitiiif:  cliinii,'cs  tiiliiiic 
place  in  dovelopinent  of  female  u'ciierative  ornaii.s 
Uiioditied  from  Allen  Thompson  i. 


Kif^  IIH.— IntiTiial  orcans  of  a  female  fitusnf 
nhoMt  fcjnrteen  weeks  (Waldeyer):  o,  ovary;  '.ipo- 
iiplioron  or  parovarium  ;  ic',  Wollliaii  duct ;  w,  .Miil- 
lerian dnct ;  u\  lower  part  of  the  Wdlllum  l.nilv. 


ducts,  and,  after  becoming  fused,  into  the  uterus  and  the  vagina,  while  tlic 
Wolffian  bodies  and  duct  give  rise  at  best  to  atrophic  structures.     The  \\M- 


1     I  » -* 


iicir  oarli(  -t 
>iuls  largely 
ociation   <<i 

second  pa  it 
(>  systom  t't' 
upon  the  :i|)- 
n  ot"  ali'oaily 
,fthoWolli- 
Lict,  aiul  the 


e  (iri;nns  <(  »  "i"le 
Wnldfyor,  '.  tis- 
m  duct  ;  "■,  ''■  ■•■r 
iiu'uliim  testis. 

In  the  toiiiale 
)  into  the  nvi- 


if  a  fumnle  fitns nl 
■  r):  o,  ovary  ;  c,  I'l'O- 
lllian  iliict ;  m.  Mul- 
II'  Wuiman  Imdy. 

;ina,  while  tlic 
The  Wclrt- 


riTYSIOLOGY   OF  PRKGNANCY.  1'23 

i'ln  hodv  ill  the  female  contributes  the  transverse  tubules  of  the  parovarium  or 
e',)oo|)horon  the  upper  part  of  the  WoltHan  duct  renuiining  as  the  head-tube  of 
the  same  atropine  organ  (Fig.  113).  When  the  Wolffian  duct  persists  it  con- 
stitutes Gartner's  duct.     In  the  male  subject  (Fig.  114),  on  the  contrary,  the 


E/iiiliih'inis. 


liiilymis. 


heryans. 


Flo.  lU— Pingrani  illustratiiiK  chnnfjcs  tnkiiK;  pl'icc  in  devclnprnont  of  male  generative  ot.'ans  (modified 

from  Alien  Tlunnpson). 

Wolffian  tubules  and  the  Wolffian  duct  contribute  the  important  system  of 
excretorv  tubes  represented  by  the  vasa  effisrentia,  the  coni  vasculosi,  the  tube 
of  the  e-Mdi(lvmis,  and  the  vas  deferens,  while  the  Miillerian  duct  is  atrophic, 
its  extreme  eiuls  alone  remaining  as  the  sessile  hydatid  of  IMorgagni,  closely 
connected  with  the  globus  major  of  the  epididymis,  and  as  the  sinus  pocularis 
or  nternx  nnm-nVinuii,  o])ening  into  the  prostatic  portion  of  the  urethra. 

The  atrophic  tubules  of  the  lower  segment  of  the  Wolffian  body  in  both 
sexes  contribute  rudimentary  organs,  the  'pnrndldxjmh  and  the  parodjtlioron 
resiteetivelv,  which  consist  of  a  few  tortuous  tubules  situated  in  the  epididymis 
and  in  the  broad  ligament  near  the  parovarium.  The  stalked  hydatids  of 
Morgagni,  which  are  common  to  both  sexes,  probably  represent  portions  of 
the  atrophic  liea<l-ki(lney  and   its  duct. 

The  External  Genital  Orr/ans. — Until  the  ninth  or  tenth  week  the  external 
genitalia  affi)rd  no  positive  information  as  to  sex,  since  these  parts  until  this 
time  represent  a  practically  indiffiiM'cnt  type  (Fig.  115). 

Up  to  the  sixth  week  the  external  openings  of  the  gut  and  of  the  urinary 
tract  are  received  within  a  common  cloacal  recess  whose  recto-urogenital  orifice 
is  siu'moiinted  by  a  small  conical  elevation,  the  r/enital  tubercle ;  the  lower  and 
posterior  surface  of  this  eminence  is  divided  by  a  furrow,  the  e/enital  groove, 
bounded  by  thickened  lijis,  the  c/enital  foUh ;  outside  the  latter  a  less  con- 
spicuous elliptical  fold  constitutes  the  genital  ridc/es.  The  end  of  the  genital 
tubercle  enlarges  and  forms  a  knob-like  expansion,  the  primitive  glans  either 
of  the  future  penis  or  of  the  clitoris.     Toward  the  end  of  the  second  month 


1"! 


'T/T^r 


124 


AMKIUCAX    TKXT-IiOOk'    OF    OliSTETItlCS. 


51 


the  imporfl'rtly  foniKHl  septum  bctw-'on  the  rpctiim  and  the  iiriiio^ciiitnl  pis. 
snge  rosu'lu's  pt'rfi'ctioii,  wlicrcby  tlio  coniplcte  separation  between  the  alinit  ni- 
arv  anil  genito-urinarv  canals  is  .'tleete*!. 

In  tiie  male  (Fig.  1 15,  c,  i;,  (i)tlii' genital  tiiberele  elongates  to  form  the  jwuls 
while  the  lips  of  the  genital   furrow  on   its  under  surface  unite  to  form  the 


penile  portion  of  the  urethra ;  eoint-idently,  the  closure  of  the  edges  of  tlio 
urinogenital  passage  takes  jilaee,  the  tube  thus  formed  becoming  continuous 
with  the  anterior  part  of  the  urethra  just  formed.  The  primitive  genitiil 
ridges  or  outer  genital  folds  grow  together  and  eventually  form  the  scrotiiin, 
into  which  the  testicles  descend  shortly  before  birth. 

In  the  female  (Fig.  115,  D,  F,  h)  the  genital  tubercle  remains  relatively  small 


PH YSIOLOa  Y    OF  PliKaXA NCY. 


12C 


)}]jt'iutal  pis- 
thf  aliiui  iit- 

I'ln  tlic  ptiiix, 
to  form  I  lid 


1/ 

-</ 
— 'V 
-A'- 


nonitiil  riiliii-;  ■ 
ital  ritino ;  ;;''.  ;;ii 

1),  F,  11,  iTtllll 

re ;  Ji'i'.  lu'riiu'iiiii 
Id!/,  viijiina. 

nj^  contimioib 
initive  fii'iiitnl 
11  the  scrotiiiii. 

elativelv  small 


and  Loconio^  the  elitori.s  ;  thr  fio.utal  furrow  roninins  open,  tho  boi.n.mj;  Rental 

i    fo\ih  f..rn.inir  th."  h.l.ia  ...inora  or  the  ny.nplias  a.ul  the  external  fohl.  tornnng 

''     the  I'lhi-i  i.njorn      At  first  the  elitoris  i.s  disproportionately  largo,  but  later  it 

•^     becomes'ove.^sluuloNve.1  hv  the  rapidly  growin-  labia.     Usually,  by  the  end  of 


A/ti/u/Mrj/ 
furrow. 


£  teiitrm. 


Cmh-fl 
tHiiDiitrm. 


A»iniim 


FiirieUil 
iiiisoilerm. 


Cdi'iii, 


mesuiierm. 


iXotochfli;/.  S,'i)iitf.     Gilt  entoiierm. 

Fig.  llti.-Transvirsr  sictidii  (if  a  sLMuen  ami  a  half  .lay  sliiH'l)  finbryo  i.osst'SslnK'  six  scmiitos  (llimiu't). 

the  third  niontli  tlie  e.xteriial  sexual  characteristies  of  the  fetus  are  e,stabli.she<l 
beyond  doubt.  Jmperfk-t  develo])iueiit,  especially  faulty  union,  of  certain 
parts  of  the  primitive  genitalia  produce  the  condition.s  which  give  ri.se  to  ap- 
parent herinaphroditisni :  true  hernia|)hrodites,  while  not  imjiossibilities,  are 


Edoiiirm 


Amnion. 


raru-tal 
mesoderm. 


Cell-tiiass/or 
U  'oljfia  »  ioify. 

Celom  ■ 
MesothcUiim. 

J'rimithif 
indothiliuvi. 

luSL<-r,t/ 
mesoderm. 


A'otOi'hord. 

B.  117.— Transverse  sortion  I'f  a  fiftooii  and  a  half  day  sheep  embryo  possessing  seven  somites  (Bonnet). 

;^^^ainong  the  rarest  maliorniations,  since  in  them  the  formation  of  true  sexual 
organs  of  both,  sexes  nin.st  take  ]dac(>  in  tlie  same  individual. 

10.  Development  of  the  Nervous  System. — The  initial  stage  in  the  pro- 
duction of  the  great  <<M'ebro-.spinal  nervous  axis  is  the  formation  of  the  medul- 
lary folds  and  groove  ^^Figs.  116,  117),  one  of  the  earliest  of  the  fundamental 


126 


AMKIilCAX    Ti:XT-liOOK    OF   OBSTEritlVS. 


'■■. 


h'' 


processes  in  the  development  of  the  embryo.     At  the  thirteenth  day  the  neural 
groove  is  widely  open  throughout  its  extent ;  two  days  later,  by  tiio  beginiiinif 

of  the  third  week,  the  groove  has  becuino 
converted  into  a  closed  canal  by  the  ai)- 
proxinuition  of  the  thickened  neural 
plates  along  the  dorsal  mid-line.  Tlic 
cephalic  extremity  of  the  neural  ciiiial, 


Antt'irr  /•raiii-Trs/c'/f. 

.l//(/,//.'  I'raiiii'fsklf. 
/'usti)  h>r  /'rain-7'esich-. 


l-'ore-brai>i. 

Primary  optic  I'esicic. 

Stalk  0/  o/'tic  ■■i-siile.^  --' 
into -brain 

Miii-brain 

Uiittihrain 


Intel 'hi  ain^ 


Cefhalicfl,: 


Fofi'-brain. 


Ol/actoiy 
lobe. 


OftiL  stalk: 


Ml,i-h.,in. 


llln.l: 


[t'tn-  I'.iin 


Ccicbral porlin  ,/ 
pituitary  Iviiy. 


Pontine 
Jh.xiirc 


\'\i..  US.     liiiiiinims  ilUistriitiiii;  tlio  iiriniiiry  iiiicl  soc- 
uiuliirv  si'iiimiitiilinii  ul'  tlu'  Imiiu-tulu'  iHniiiU't). 


l"i(i.  llii.— Diiinrain  shdwiiiK  rolntimis  nf  liiain- 
vi'siclos  anil  lU'xuros  (lidiiiuH. 


even  before  closin*e,  becomes  expanded  into  three  jtriiuarj/  bfdiii-rcxirliK,  tin. 
anterior,  tiie  middle,  and  the  posterior.  The  anterior  and  the  posterior  nf 
these  vesicles  very  soon  subdivide  into  sccoixhtri/  compartments,  the  arraiii;v- 
ment  of  the  brain-segments  then  being,  from  before  backward,  tho  forc-hriiin, 
the  iiif('i'-/>r(ilu,  the  iiiid-hniiii,  the  liiiid-bnuii,  and  the  (iftcr-hrain  (Fig.  IIS), 
Coincidently  with  tliese  changes  the  cerebral  axis  has  sntFered  marked  tl(- 
flection  (  Fig.  11!*)  from  its  original  aliiK^st  straight  condition.  By  the  lllicciitli 
day  the  cranial  tlcxure  is  strongly  jironounced,  a  bend  of  almost  00°  tiikiiis; 
place  opposite  the  mid-brain  (Fig.  120,  a).  During  the  fourth  week  fnrtlur 
marked  changes  appear;  the  bend  opposite  the  miil-brain,  or  mcKou'CjilKili,' 
Jfc.i'Uir,  has  increased  almost  to  180°,  so  that  the  ventral  surfaces  of  the  iiitn- 
brain  and  the  hind-brain  lie  nearly  in  contact  (Fig.  I'iO,  n).  The  jiiiiitinii 
ol'  the  brain  and  the  sjtinal  cord  is  marked  by  the  ccrfli'dl  Jlcrtirc,  wliiih 
forms  ail  angle  of  about  !(0°.  A  third  bend,  the  miiourplid/ic  or  froiitnl  tli.r- 
lire,  apjM'ars  oj)posite  the  primitive  cerebellum  and  the  pons,  and  has  its  ciiii- 
vexity  directed  ventrally  or  in  a  manner  opposite  to  the  disposition  of  tin 
other  curves  (Fig.  1*20,  r). 

The  development  of  the  individual  jiarts  of  the  brain  dejiends  lariiclv 
upon  local  thickenings  of  j)arts  of  the  walls  of  the  cerebral  vesicles,  wlicivliy 
areas  of  notable  thickness  arc  produced,  as  in  those  which  give  rise  to  tin 
corpus  striatum  and  the  optic  thalamus  ;  the  cleavage  of  the  fore-brain  and  iL 
ingrowth  of  connective-tissue  structures  accompauying  the  growth  ol'  tin 
l)rimitive  falx  likewise  exert  a  profound  iiiHuence  in  shajiiug  the  parts  ardiiiii 


lay  the  no;;ral 
the  l)eginirmg 
vc  hasbeconio 
mil  by  the  uji- 
■keiictl  utiinil 
litl-iine.  Tlu' 
>  neural  canal, 

Cephalic  flc.xu  'v. 
MU-l'.iin. 
llitui-.  utiii. 


.Af'tcrhain 


:  r-'liitious  of  I'laiii- 

rdiii-vrxiclix,  \\w 
]w  ]n>storior  dt' 
nts,  the  arraiiiii. 
the  fori'-lmiiii. 
In  (Fiii'.  H^l 
rcil  nuivkiHl  do- 
\y  the  tit'ti'iMitli 
lost  00°  takius: 
til  week  t'urtliiT 

■OS  ol'  the  illtrr- 
The  jmiitiiin 
flexure,  wliiili 
('  or  frouliil  thi'- 
xud  has  its  cou- 
sposition  oi"  tlii' 

depends  lari;ilv 
vesicles,  \vluT(l>y 
jrive  rise  to  tin' 
.re-hraiii  ami  tli' 
ivrowlh  I't  till 
the  )»arts  avdUiM 


J'JIYSIOLOdY    OF  PRKUyA.WY.  127 

the  lateral  and  tl.ir.l  ventrieles.     The  ai>pearanee  of  sueh  eou.miss.n-al  bands 
as  the  corpus  calk.sum  and  the  fornix  still  further  njodilies  the  adjacent  struy- 


Fl(i  iL'd— Hriiiiis  (iriiiniiiiii  fiiiliryos  I'niiii  rt'constniclii'iis  liy  His.  A,  hmiii  fnuu  lil'tcfii  diiy  iMiil)ry(); 
B,  from  tliivi"  niui  .1  linU-vvofk  nnl.ry.. ;  C.  from  sovon  iiii.l  a  hiilfwook  fetus  ://.,  il<,  mh.  hh.  „h.  foiv-.  inter-, 
mid-  hind-,  mill  alU'rl>riiin  vesieles  ;  -).  optie  vesicle;  or.  otie  vesiele;  in.  infnnililmlnm  :  in.  nuiinmilliiry 
process;  ;)/',  pontine  tlexniv;  IVr.  I'onrtli  ventriele ;  )''.-,  eervieiil  lloxure ;  ul.  ollaetory  lolie;  h,  basilar 
artery  ;  ;),  pituitary  reeess. 

tures.     Tlie  brain-vesicle  UMderu;oinf>:  least  chanjic  is  the  niid-braiu,  since  its 
walls  remain  niiclct't  and  retain  their  primary  relations  to  (he  enclosed  canal. 

I! 


•3v—  c/t 


</.._ 


^  l-'io.  IJl.— A,  mesial  seelion  thronnh  Imiiii  of  a  linnnin  felns  of  (hh  ami  a  half  montlis  i  iiisi :  cli,  cere- 
,))rai  In  luisphere ;  u.  opti<'  thalamns  ;  ,//»,  foranu'M  <if  Monro;  ol/.  oil'ae!i>ry  lolie:  ;>,  pitniliiry  luuiy  ;  nii), 
Jncdiilla  ohliincala  :  iv/,  corpora  iiMaiiriucniimi ;  eh.  cen'liclUim.  II,  lirain  of  linnnui  t'elns  of  three  nmntlis 
■iJHish  (i/>'.  iill'aetory  lohe;  Cfl,  corpns  striatum;  ii/.  I'orpora  iiiniclrij-cinina ;  e/i,  cereln'Uum;  vio,  nu'iluUii 
siblonj;ala. 

mhe  relative  position  of  tlit>  initl-brain,  however,  iin<lei'ii;oes  jri-cat  ehaiiii'c,  its 
original  situation  as  the  liijrhest  part  of  tiie  entire  encephalon  being  gi'aduaiiy 


'n... 


128 


AMERICAN    TEXr-BOOK    OF   OBSTETRICS. 


it 


(  ? 


I  t'      f '! 
5!      i  S 


J;  I 


appropriated  by  the  enormously  developed  eerebral  mantle  formed  by  the  raiiid- 
growing  cerebral  hemispheres ;  in  eonsequeiice  of  tlic  covering  in  of  the  mid. 
brain  thus  effected,  the  derivatives  of  this  segment,  as  the  corpora  qundri- 
gemiiia,  occupy  a  ])()8ition  in  the  base  of  the  adnlt  brain  instead  of  liicii' 
morphologically   normal   place.       The  extent  to  which   the  cerebral    miniilc 


/hV 


Flii.  VJJ— Kitiil  brain  at  llio  lii'Kinniiit;  (if  thi'  einlitli  iikpiiIIi  (Mihalkovics) :  A,  supiTior,  H,  latinil.c, 
nu'sial  Mirtacc  :  U.  lissiircof  Itolainln  :  yirc,  iirocciitral  lit^snri' :  S//,  Sylvian  lissiirc  :  ii'li>.  iiittTparictal  lissurc ; 
jii/c,  iiariito-uccipilal  lissiirf  ;  p//,  purallel  lissuri' ;  calhii,  calldso-niarfiinal  lissure;  uiw,  uncus;  ('(i/c,  cilou. 
riui'  li.<suro. 

covers  the  remaining  parts  of  the  enceplialon,  including  the  cerebelhini,  is 
distinctive  of  the  luiman  brain  (Figs.  121,  r22). 

The  inter-brain  undergoes  great  ditlerentiation,  its  derivatives  forming  niiincr- 
ous  highly  specialized  organs,  among  which  are  the  eyes  and  the  pineal  and 
j)ituitarv  bodies.  For  the  con)plicatcd  details  of  the  development  of  the 
various  parts  of  the  brain  the  reader  must  be  referred  to  the  special  works  im 
embrvology.  The  following  table,  however,  modified  from  liertwig,  will  scrvf 
as  a  general  indication  of  the  genetic  relations  existing  between  the  more  im- 
portant parts  of  the  enceplialon  and  the  primary  cereiiral  segments: 

Dl'.VKLOrMF.NT   <1V   THK    HfMAN    I')KAIN. 


I'ltlMAKY 

Vesiclks. 


I. 

AntiTiiir 
|)riinary 
hrain- 
vi'sicji'. 


SErosnAKY 

VEfilCI.KI*. 


Floor. 


KooF. 


Sides. 


n. 

Middle 
iiriinaiy 
iiriiiii- 
vcsiclc. 


Ill, 

I'dsliTiiir     i 
liriiiiary 
hrain 
visiclo. 


1.              Anti'rioriKTt'nr  (inat  ccnliral  niantlt".  corpiis     Lateral 

Korebrain.        ab'il     spaces;  eiillusuni;  fiinii.x.                            veiitri 
(ilfaelnry 
lubes. 

Optie     eliiasiii  :  I'iiieal       bndy  ;  ;  I  iptii' tlialaini.     I'liirdven 

Inter-brain.       luber       eine-  pusierinrenin- 

reuiii  :    iul'iui-  iMis>.iiri-  ;     ve- 

dibiilinii ;  I'or-  liiiii  iiitrrpiis- 

piira  nuiiiiniil  iluni. 

:!.               Cerebral  pedini  CurpnrM     (|uad-     ilenieulale          .\(|Ue(luet 

.Mill-brain.         eles ;         pusle  riueniina.           i      bodies:           ,      of     Syl- 

ri(ir  perliirated  i      braeliiil.         i      vius 
laniinit. 


I.              Tuns  \'arn!ii.         .Xnli'rlnr     nieil-  Superior   anil 

llind-braiu,                                       ullin  y  mIuiii  ;  middle    pe- 

eeri-b'eillllil  ;  dlllleles      id' 

i                                       |His|eriiir  tiled  ei'reliellmii. 

!                                     iillarv  velum.  Kuurtli 

venlri- 

(de. 

Ji.                .Medulla   ublnU-     'lliiu     e..\eriiiL'  Ilileriiir       pe- 

After-bniin.        pita.                        of      pn-lerinr  diiiiele«     nf 

purl  111'  I'liinill  eereliellum. 
ventrli  li'. 


PHYSIOLOGY   OF  PREGNANCY. 


129 


by  the  rajiid- 
of  tlio  \\\\i\. 
pora  quinlri- 
toad  of  tiioir 
L'bral   inantlo 


ii'rior,  B,  liiliiiil.c. 

itrrparii'tiil  li-Mirc. 

uncus ;  cah\  mXai 


cerebellimi,  U 

ornnn^ntiiiMT- 
tho  piiK'iil  and 
)|)ment  of  tlio 
)ceial  works  (ni 

witr,  will  sci'vc 
n  the  more  iiii- 

nts: 


A. 

HriiiiiiiiiuitUv 


id 


li, 
Uniiii  "l"lk 


i- 


I 


The  spinal  cord  i.<  formed  primarily  by  the  thiekening  of  the  lateral  wall 
of  the  neural  tube,  the  latter  becoming  reduced  to  a  narrow  passage,  later  the 
centrd  oaual  At  first  grav  matter  alone  exists,  but  with  the  formation  of  the 
nerve-fibres  the  white  tracts  appear  (Fig.  123).     The  nerve-fibres  connected 


Ecttidirm. 


White 
matter. 

\ 


Dorsal 
commissure 


Spin'ilga 


Di'isat  root. 
l\ii:>itl  >i«'t: 

S/>iiial  nerzc. 


,/^^ 

^m^'' 


/ 


Outer  mei/nliitrv  :oi:e.     Central  ciinui.       S'otochord.         Ventral  commissure. 
Y\\\.  IJM.— Traiisvor^f  scLtiou  of  (Ifvoloping  spinal  coril  (if  a  twenty-two  day  sheep  embryo  (Bonnet). 

with  the  spinal  cord  ditfer  in  origin  according  to  their  function  whether  they 
are  motor  or  soiisorv,  the  former  proceeding  as  outgrowths  from  the  nerve-cells 
within  the  cord,  the  latter  as  processes  from  tiie  cells  of  the  spinal  ganglia  ; 
these  latter  centres,  in  addition  to  the  sensory  fibres  i)assing  into  the  cord,  send 
to  the  lU'iipiicry  fil)rcs  l)y  which  sensory  impressions  are  conveyed.  The  s\jm- 
patludc  iicrroiiti  si/stcin  originates  from  the  spinal  ganglia,  from  which  portions 
are  separated  as  tiic  organs  of  the  sympathetic  ganglia.  It  may  therefore  be 
acce|)tcd  as  an  axiom  that  all  nerve-fibres  are  produced  as  direct  outgrowths 
from  j)rc-c.\istiiig  nerve-cells,  and,  further,  that  all  portions  of  the  great 
nervous  svstcm  mav  he  referred  to  the  primary  neural  folds. 

1 1 .  Development  of  the  Organs  of  Special  Sense. — The  history  of  the 
specialized  organs  of  touch,  taste,  and  smell,  as  represented  by  the  various 
forms  of  tactile  lu'rvc-endings,  such  as  the  corpuscles  of  Mei.ssner,  Vater,  etc., 
the  taste-buds,  and  the  Schneiderian  mucous  mendirane,  belongs  to  a  consider- 
ation of  the  histogenesis  of  these  structures  rather  than  to  a  brief  outline  of 
salient  featiwes  in  general  development;  suttiee  it  here  to  add  that  the  organs 
of  taste  and  smell  consi,<t  essentially  of  tissue  which  has  become  specialized 
into  iieMro-e|»itlielium,  the  perceptiv(>  elements  consisting  of  modified  epithelial 
cells  bearing  close  relations  to  the  nerve-fibres.  The  various  forms  of  tactile 
corj)nscles  receive  more  or  less  highly  developed  sheaths  from  mcsodermic 
tissues.  The  organs  of  sight  and  of  hearing,  on  the  contrary,  claim  greater 
attention  on  account  of  the  profound  embryological  proeei^ses  in.stituted  in 
Itheir  formation. 

The  development  of  the  cjic  consists  e.-;sentially  in  the  formation  of  two 


ni 


Ml  I 
[Mil 


t      I 


!  (■ 


i 


i 
.•'I' 


130 


.lJ/J5'/?/CJ.y    TEXT- BO  OK   OF   OBSTETRICS. 


ectodermic  epithelial  pDiiclies,  the  optic  vesicle  and  the  lens-sac,  around  wliili 
the  adjacent  luesoderm  dilierentiates  into  vascular  and  fibrous  envelopes.     '!  ho 


Fig.  I'Jl.— Scotioti  through  Fic.  12'v— Se(  uon  through 

lu'iiil   of  ton  day  nibliit    I'lii-  (ievi'lopiii),'  ojo  cif  ulfvoii  diiy 

liryo.o.xliiliitiiit-'priinary  nptic  riibliit    inihryo    (I'iursol) :    H, 

vi'ssc'l    (Oi    ]initni(linK    frniii  fnii'-liriiiii  ciuini'cttMl  by  stalk 

fore-lirniii  (7)t  iiiul  cciminjr  in  with  ojitic  vosii'lo  (o),  whose 

oontnct  withsurfiic'ei'Cto('.orni  antoridr  wall  Is  partly  invaRi- 

(f);  m,  surrounding  mesodorm  natod:    /,  thickenod  and  du- 

(Piersol).  prtssod  lonsareii. 


Fl<;.  12fi.— Suction  through  dcvil.  ),i||,_, 
cyo  of  ck'von  and  a  half  day  rahlii;  ,1,1. 
bryo  (Tiorsol):  IS,  foro-bniin  coniirrud 
with  dptii'  vesicle  (<;),  nearly  etlin-..!  |,y 
ap|iositinn  of  Invnninated  anterinr  x;.. 
nient  u'l  with  jposterior  wall  (/<i;  /,  hnv. 
sa"  eonipletely  closed  and  separati'il  rn.ni 
ectoderm  ;  I.  tissue  within  secondarj  upii,. 
cup  derived  from  stirroundinn  niescUrm. 

first  trace  of  the  visual  organs  appears  very  early — at  the  fifteenth  day — as  tlie 

conspicuous  optic  vesicles  (Fig.  lJ8i 
v.'iiich  are  formed  as  lateral  evaoiim. 
tions  from  the  hinder  part  of  the  ante- 
rior primary  l)rain-vesicle  ;  later,  w Ikm 
the  optic  vesicle  oi>ens  into  the  ccicbial 
cavity  by  means  of  the  o])tic  stali<.  tlir 
latter  communicates  with  the  inter- 
brain.  The  original  optic  vesicle  -noii 
exiiibits  indentation  <jf  its  anterior  \\;ill 
(Fig.  r2o).  the  invagination   iinioio.- 

A 


Fro.  127.— Section  through  developing  eye  of 
thirteen  day  rabliit  emliryo  il'iersoli :  »,  eiloderni : 
/,  lens,  consistiiit.'  of  anterior  inicleated  division 
reprt'sentinu'lliiii  IronI  «all  of  lenssae,  and  ^'really 
thickened  posterior  division  coniplelely  lill  in;.' ciiv- 
ity  of  sac  by  eloniiated  lilires  whose  nui'iel  present 
creseentic  zone  (J) ;  /i,  posterior  iiiunieiileil  layer: 
r.  specialized  anterior  ri^tiiial  layer:  /.  jioinl  w  here 
layers  ofoptjr  vesseN  become  continMous  :  »,  ex- 
tri'MU'  peripheral  seeticiu  of  tissue  of  primitive 
optic  nerve  connected  with  vascular  tunic  in  oecu- 
pyiuK  posterior  surface  of  lens:  ni.  surroundinir 
mesoderm,  which  (at  t)  nro«s  between  lens  and 
retina. 


V\i,.  li;s,-.\,  brain  of  two  ilay  chick  eiiihryu: 
li,  brain  of  human  embryo  of  three  week^  dli,«' 
Shows  the  developuuMit  of  the  optic  vesicles  aiiij 
liniin-vesicles:  //),  fore-brain:  ;",  inter-brain.  •«. 
optic  vesicles. 


ing  until  the  displaced   layer  conies  in  contact  with  the  posterior  and 


iiiitir 


»l_. 


'•!^|' 


round  wl.iili 
elopes 


''.'he 


liriiiij;li  ilt'Vil'  (.ills; 
lilt'  ilay  ralil.ii  <ii;- 
v-bniiii  I'diiinciid 

IK'lirly    OlVlin-,1   hy 
llltl'd     HIltlTinl      >,;.. 

ir  wall  (  id:  '.  Inis- 
imii  soimniti'il  rn.iu 
hill  si-'('(iii(Iar\  'iptic 
lUiidiiiuinfMiiliTiu. 

th  tlay — :i>  tliu 
es  (Fig.  1-J8I, 
iteral  ov;ii:iii:i- 
rt  of  the  aiitc- 
Ic  ;  later,  \\  lien 
ito  the  eerel)ral 
optic  stalk,  tiir 

ith  the  iiitcr- 
tic  vesicle  m"iii 
ts  anterior  \v;ill 

ition   pro<j,r(>>- 


,l:iy   chick    I'lllliryir 

ilircc  wci'k^  dlis' 

(ijltic   Vl'sirlcSUIl'l 

,h,  iiitiT-brain.  "'. 


erior  and  mitrr 


PHYSIOLOGY  OF  PREGXANCY. 


131 


undi<tiirl)ed  segment.  The  cavity  of  the  original  vesicle  is  now  represented 
by  the  hemispherical  cleft  between  the  two  layers.  The  cavity  newly  formed 
by  the  invagination  of  the  ])riniary  vesicle  becomes  the  optic  cup,  antl  repre- 
sents the  space  later  occupied  by  the  crystalline  lens  and  the  vitreous  body. 

Coincidcntly  with  the  changes  of  the  optic  vesicle,  the  surface  ectoderm  at 
first  exhibits  a  depression  lined  by  thickened  cells;  this  recess  or  pit  rapidly 


.-^/ 


'  r^t-s' 


I'n;.  Vl'.K  Ilmiiaii  ciiiliryn  nf  atiout  twmty-i'iKliI  ilays  iMis);  l-V,  tirain-vcsicU's  ;  P,  /-,  J"',  /'. 
cuplialic,  ciTvical,  iliirsal.  ami  Uiiiihar  lU'Xiin's  ;  d/i,  eye;  o/,  ciptic  vt'siclc  ;  o/.  iiUaclnry  pii;  hij-,  mi/,  max- 
illary and  niamlilmlai' prnccssfs  (pf  lli'st  visceral  urcli ;  ,</),  ^•iIlll^  iircccrviculis;  li\  li".  heart;  /, /',  liiiihs  , 
n(8,  alliiMtnic  !.|ulk  ;  lii,  villmi-,  churidii. 

deepens  ami  expands,  and  finally  becomes  the  closed  and  isolated  lens-sac,  lying 
within  the  month  of  the  (tptic  cnp,  which  it  largely  Hlls  (Fig.  120). 

The  fate  of  the  layers  com|)osing  the  optic  cup,  bricHy  statetl,  is  the  forma- 
tion of  the  various  parts  of  the  retiiu.l  tract,  the  outer  and  posterior  layer 
becoming  the  characteristic  -;heet  of  retinal  [jigment  ;  the  blood-vessels  antl  the 


m^' 


flu: 

1  ■   I  i; 


m 


!■< 


132 


AMJ'JIx'JCAy    TEXT-BOOK    OF    OBSTETlilCS. 


connt'ctivo-ti.s.<ue  elements  of  the  retina  are  secondary  ingrowths  (Fig.  127), 
The  hinder  wall  oi'  the  lens-sac  nndergocs  great  proliferation,  growth,  aiid 
thickening,  and  eventually  tills  the  entire  sac,  the  lens  then  continning  as  a 
solid  body  composed  of  specialized  epithelial  elements. 

The  surrounding  mesoderm  contributes  the  blooil-vessels,  the  vitreous  bo,]  ; 
the  choroid,  and  the  sclerotic  coat,  including  the  iris  and  the  cornea  with  llm 
exception  of  the  anterior  epithelium  of  the  latter,  which  is  ectodermic  in 
origin.  The  eyelids,  which  appear  toward  the  entl  of  the  second  month,  aio 
developed  as  duplicaturcs  of  skin  above  and  below  the  eye  ;  about  the  end  of 
the  third  or  the  beginning  of  the  fourth  month  the  lids  meet  and  unite,  tlic 
eyes  remaining  closet!  until  near  the  end  of  gestation,  when  the  lids  peniia- 
nently  separate. 

The  ear  includes  several  distinct  developmental  processes,  since  the  gcii('si> 
of  the  auditory  apparatus  of  man  includes  the  formation  of  the  external,  the 
middle,  and  the  internal  ear. 

The  external  ear  is  closely  related  to  the  history  of  the  first  outer  visceral 
furrow,  the  external  canal  being,  with  some  minor  variations,  the  representa- 
tive of  this  cleft,  and  the  expanded  parts  constituting  its  pinna,  resultiiii.r 
from  the  fusion  and  metamorphosis  of  the  auditory  tubercles  (Fig.  129)  >iir. 
rounding  the  outer  end  of  the  visceral  furrow. 

The  middle  ear  is  formwl  by  the  persistence  and  further  expansion  of  tlio 
first  pharyngeal  pouch,  hence  possesses  an  entodermic  lining.  The  tyiii|)aiii( 
membrane  includes  contributions  fntm  all  three  layers,  its  outer  epitlicliinn 
being  ectodermic,  its  inner  epithelium  entodermic,  and  its  fibrous  tissue  niexi- 
dermic,  in  origin. 

The /;(/'r/(a/ rrn- consists  of  the  morphologically  older  ectodermic  ])orti(iii, 
which  is  rejiresented  by  the  complicated  membranous  labyrinth,  and  the 
surrounding  mesodermic  cnvelojic,  which   becomes  the  bony  capsule,  and  \\\v 

connective-tissue  structures  intlnddl 
between  the  osseous  and  the  nieinlna- 
nous  labyrinth. 

The  earliest  appearance  of  the  ear< 
takes  place  about  the  fifteenth  dav, 
when  on  each  side  of  the  hind-brain  ;i 
depression  lined  by  thickened  ectoderm 
(Fig.  130),  the  (ific  pit,  is  formed.  Al- 
m(»st  immediatcdy  these  pits  becmn' 
converted  into  sacs,  the  otic  ve.vrle.s,  In 
the  closure  of  their  mouths,  and  sodii 
lose  all  connection  with  the  ectodenti, 


't'j.A.jNa.  ■•,1     ..■„ 
4/   \-^*rf-, '  X 


ii 


Flii.  l:W.— Si'ctiiin  tliriiuj.'h  <U'vi'I(iiiiiiir  nir  nf 
niiR'  Mini  a  liiilf  iliiy  niMiit  iMuKryu  i  I'iiTsiil' :  ., 
(•ctcMkTiu  tliickclii'il  1111(1  iiiviij;iiiiilcil  to  firru  iiu- 
<li|(iry  pit  (at  oi :  iii,  siirrciuniliiij;  siill  iiinliiriTcti- 
tiatcil  iMi'Scidoriii ;  >i.  liiiiiif;  nf  iicunil  tiihc;  r. 
bliMiil-vrssel. 


King    entirelv    surrounded    bv    iiic-d- 


dermic  tissue  some  little  distance  hc- 
neatli  the  free  surface.  The  otic  vesicle 
appears  pyrifi)rm,  that  part  corresponding  with  the  closed  mouth  becoming  ex- 
tended ;  this  elongation  soon  becomes  more  pronounced,  so  that  the  now  sumk- 


PHYSIOLOGY   OF  PREGNANCY. 


133 


i  (Fig.  127). 
growth,  and 
tinning  as  a 

itreous  bodr, 
nea  with  llio 
ct'.Mlerinic  in 
(I  luontli,  arc 
it  the  end  of 
nd  nnite,  the 
3  lids  poriua- 

ce  the  geiusiv 
!  external,  tho 

outer  vis('(>ral 
he  reprcsciita- 
nna,  resuhine 
Pig.  129)  Mir- 

pansion  of  tlic 
The  tyniitanic 
tor  opitlicliiim 
IS  tissue  iiu'>(i- 

orniic  portinn, 
intli,  and  \\w 
psulc,  an<l  tin 
urcs  iiirliidcil 
1  tlie  uii'inlira- 

nce  of  the  cars 
Hftoc'iitli    day. 
10  hind-hraiiia 
oiiod  ootodci'ia 
ornicd.    Al- 
pits    hcciiiiii 
oiU'  irxicli'x,  liy 
lutlis,  and  >m\ 
tho  octiidt'iiii. 
lod    l)v    iix'Sd- 
(>   distanrc  lit- 
riio  otic  vcsiclf 
II  hoooininir  ''X- 
tlie  now  sdiiii- 


what  flattened  sac  presents  a  conspicuous  outgrowth,  the  reccsms  labyrlnthi 

(Fig.  131,  a). 

The  otic  vesicle  a.ssnnies  greater  irregularity  on  account  ot  the  appearance, 
durin.r  the  fifth  week,  of  a  blunt  diverticulum,  anteriorly  and  vontrally 
directed,  which  is  tlie  earliest  trace  of  the  future  nienibranous  cochlea,  and, 
shortly  after,  of  dorsal  projections  on  its  outer  side,  which  foreshadow  tho 
scniiciVci.lar  'canals  (Fig.  131,  H,  c).  Before  the  end  of  the  fifth  month,  the 
chief  coinpartiuent  of  the  vesicle,  by  this  time  of  considerable  size,  undergoes 


Km.  iai.-I)L'vi'l('|iiiU'nt  dltlie  mcmViranous  lahyrintli  of  tlie  human  ear  (W.  ITis,  ,Ir.1.  A.  lift  laby- 
rinth of  eniliryi)  of  ahoiit  four  wooks.  outor  .sitie :  v.  c,  vestibular  and  cochlear  portions;  rl,  reees>us 
labyrinthi,  H.  Kit  liibyriuth  with  parts  of  facial  and  auditory  nerves  of  embryo  of  about  four  and  a  half 
weeks:  r/,  recessiis  labyrinthi;  ,»,■.(■,  jiw,  esc,  superior,  posterior,  and  external  seniicirc\ilar  canals;  .'-■.sac- 
cule; f,  cochlea;  rn.jn,  vcstibulnr  and  facial  nerves;  vg,  eg,  gg,  vestibular,  cochlear,  anil  geniculate  tian- 
glift.  (',  left  labyrinth  of  embryo  of  about  five  weeks,  from  without  and  below  :  labelling  as  in  preceding 
figure. 

subdivision  by  the  formation  of  a  coiLstricting  fold  into  a  dorsal  division,  the 
priinitivo  utricu/ut^,  and  a  ventral  division,  the  primitive  sdcciilm.  Tho  nidi- 
mentary  .soniicircular  canals  and  tho  jirimitive  ooohloar  duct  open  rospectivoly 
into  the  ntriclo  and  the  saccule.  Tho  rece.<sus  labyrinthi  has  become  nioan- 
\vhilo  greatly  elongated,  and  its  proximal  end  cleft  into  diverging  tubes  at  tho 
formation  of  a  .septum.  Those  limbs  of  the  recess  open  into  diil'oront  spaces, 
one  entering  into  the  saccule,  tho  other  into  the  utricle. 

The  jiermaiiont  arrangoniont  is  now  establi.<hod  whereby  ctmimunioatioii 
betwoon  tho  divisions  of  tho  membranous  vestibule,  tho  utricle  and  the  sac- 
cule, is  ctfcctod  only  by  tho  indirect  pas.«ago  through  tho  limbs  of  the  ductus 
endolymphaticiis.  Tho  primary  otic  vesicle  thus  becomes  tho  complicated 
nieinl)ranoiis  labyrinth,  and  the  octo'^^rmic  epithelial  lining  undergoes  ditVcr- 
entiation  in  the  formation  of  the  highly  specialized  structures,  as  tho  organ  of 
Corti  and  tho  macula>  acusticre,  for  the  perception  of  transmitted  stimuli. 

The  mosoderm  immediately  surrounding  tho  membranous  labyrinth  later 
undergoes  imjiortant  oliaiigos,  whereby  tho  tissue  next  the  opitludial  structures 
is  converted  into  the  connective  ti.ssuo  enveloping  and  supporting  the  delicate 


I&0' 


f''-^  ^ 


mI 


i  in 


f 


l;]4 


AMERICAX    TEXT-BOOK    OF   OBSTETIilCS. 


DESCilDING.«t 


VENA 
CAVA 


Flii.  I3'.'.— i)i;iL;r;ii]i  nC  fftiil  circiiliiticiii  ln'luri'  liirtli  ;  tin'  iirinws  iiidiciiti'  tlii'  cuiirsi'  (if  Ihu  tiluoil- 
cumTit ;  the  i-iilcirs  slmw  llic  (■ImnicliT  'if  the  lilncul  ciirrifil  liv  tlic  ililfcTriit  vi'ssrls. 


I   »'»"-'  - 


m-^^ 


*^l 


m 


PHYSIOLOGY   OF  FREG.XANCY. 


135 


mmi 


liirsodf  the  blucil- 
•nt  vcssi'ls. 


Fig.  IX).— Diagram  of  eirculatiim  aflor  liirtli ;  llic  ihictiis  votinsus.  the  fniamon  ovalo,  and  the 
iluctus  arti'iiiisus  arc  now  clostHl  and  iin  hinjior  tnii.siiut  iMirtimis  of  tlio  bhiud-current. 


136 


AMEIilCAy    TKXT-liOOK    OF   OBSTETlixCS. 


II 


I  . 


/ 


I  •      ,t 


1 


1 1.-  ■  I 
''I 


cpitliolial  labyriiitli,  wliilc  tlif  tissue  slightly  removed  ^nves  rise  to  the  periitio 
cartilaginoiis  eapsule  which  later  is  replaeed  by  bone.  The  important  spicks 
oceupietl  by  the  perilymph  are  formed  relatively  late,  since  the\  arise  by  ih,, 
breaking  down  and  channelling  of  the  mesoderm  surrounding  the  j)itli' linl 
tubes.  In  the  cochlea,  for  example,  the  ductus  cochlearis,  with  its  epitli.  lial 
lining,  represents  genetically  the  oldest  l)art,  while  the  scala  vestibuli  ami  tlic 
scala  tympani  are  of  more  recent  origin,  since  they  are  formed  by  partial  ills. 
ajipearance  of  the  mesodermic  tissues. 

2.  Physiology  of  the  Fetus. 

Nutrition  and  Growth. — It  is  evident  that  the  life  of  the  ovum,  what- 
ever its  character,  whether  vertebrate  or  invertebrate,  picean,  amphilujin, 
reptilian,  avian,  or  mammalian,  can  only  be  maintained  when  the  fundaiiK  ntnl 
necessities  of  life — adetpiate  supplies  of  oxygen,  water,  and  suitable  noiiiisli- 
ment — are  provided.  The  ovum  and  the  early  embryo  being  witliout  means  df 
securing  these  advantages,  such  provisions  must  be  ensured  by  the  arraiigenu'iu 
of  the  immediate  environments,  whether  these  be  within  the  maternal  tissue. 
or  within  the  protecting  structures  (»f  the  shell  or  the  surrounding  medium. 

The  loss  of  yolk,  which  there  is  good  reason  for  believing  the  mammalian 
ovum  has  suffered  during  its  evolution,  is  compensated  by  the  nutritive  inato- 
rials  supjdied  to  the  developing  ovinn  by  the  adherent  discus  proligerus.  and 
by  the  secretions  of  the  oviduct  and  uterus  which  are  taken  into  the  intciiur 
of  tlie  egg  by  osmosis  through  the  zona  pellucida  and  the  jirimitive  ehdridn, 

The  Fetal  Circulations. — The  earliest  circulation,  the  vitelline  (PI.  15),  j, 
well  established  during  the  third  week.  The  blood  passes  from  the  network  i>\' 
the  vascular  area,  by  means  of  the  large  vitelline  or  ompliah-mcscnfcric  irin^. 
into  the  sinus  vcnosus,  and  then,  after  mingling  with  the  blood  returned  Iv 
the  systemic  veins  from  the  body  of  the  embryo,  into  the  auricular  seginent 
of  the  young  heart.  From  the  anterior  or  ai'terial  end  of  this  organ  tin 
blood  is  carried  by  the  truncus  arfcr'iosus  into  the  aortic  arches,  hence  into  tin 
])rimitive  aortte,  a  small  portion  ])assing  into  vessels  su])plying  the  enihrvu, 
while  the  greater  part  enters  the  vitelline  arteries  and  once  more  gains  tlu 
vascidar  area. 

The  development  of  the  allantoic  vessels  and  the  jilacental  circulatidii 
necessitates  additional  blood-currents,  in  the  direction  of  which  the  imw 
rapidly  developing  heart  and  liver  exert  an  important  influence.  For  a  tinu 
all  the  bloml  returning  from  the  placenta  passes  through  the  liver  iiclinv 
reaching  the  heart ;  later,  when  the  hepatic  capillaries  can  no  longer  aecoimiid- 
date  the  entire  placental  circulation,  the  <Jiictn.s  irnosus  is  established. 

During  the  later  months  of  gestation  the  so-called  "  fetal  circulation  "  (Fig«. 
132,  133)  presents  the  following  details:  After  purification  by  the  respiratdiv 
interchanges  carried  on  within  the  jilacenta  by  association  with  the  matcimil 
circulation,  the  blood  is  conveyed  by  the  single  umbilical  vein  to  the  nndt  r  sur- 
face of  the  liver  ;  here  the  current  divides,  one  part  Joining  the  venous  IdiMil 
within  the  portal  vein  collected  from  the  intestines,  and  traversing  the  hepatic 


:o  the  pcvlitir 
portaiit  spicis 
\  arit^c  In  tlio 
the  })ith'  lial 
I  its  opith(  liiil 
itibiili  and  tlic 
hy  jnu'tial  ilis- 


D  ovum,  wliat- 
n,   amphili'mii, 
le  tundaiiHiital 
liable  noiirisli- 
thout  means  (if 
le  arrangcnu'iit 
laternal  tis-tio- 
idhig  nicdiuni. 
he  nuiniinaliaii 
nutritive  luatr- 
proligerns,  and 
iito  the  intcriiir 
mitive  clinridii, 
ine  (PI.  15),  i. 
the  network  dt' 
ncscntvric  cf //i.<, 

k1  returned  ly 
rieukvr  segiuom 

this  organ  tlic 

.  henee  into  tin- 
isr  the  enihrvo, 

more  gains  tlu 

ntal  cirenlatiiiii 
vhieh  the  imw 
L-e.  F<-U'  a  liiiii' 
lie  liver  hotiji'i' 
niger  aeconiiiin- 
ished. 
•ulation  "  (Fig^. 

tlie  respiratory 
h  the  maternal 
0  the  under  snr- 

le  venous  lilnml 
sing  the  lieimtk' 


I'livsioLOdY  OF  piij:..XAycy 


137 


capi  1 


i Maries  to  reach  the  liepatie  veins,  tlie  other  jiart  passing  into  these  vessels 
direet'lv  hy  means  ..."  the  thietus  venosus.  On  reaehing  the  inferior  eava  tl»e 
arterial  piarcntal  hi^Mxl,  i)iit  slightly  euntaminated  i)y  a(hnixture  of  the  contents 
of  tiie  portal  vein,  is  pound  into  the  stream  of  venous  blood  returned  by  the 
inferior  eava  from  tlie  lower  parts  of  the  b(Mly,  and  is  carried  into  the  heart  as 
part  of  the  mixed  stream.  On  entering  the  right  auricle  a  fold,  tlie  Eusta- 
'•liian  valve,  directs  the  blood  l)rought  i)y  tlie  infe'-lor  eava  across  the  auricular 
cav'itv  through  the  forameti  ovale  into  the  left  auricle.  Mingling  with  the 
small  (luaiititv  of  blood  returned  from  the  uninflated  lungs  by  the  pulmonary 
veins,  the  blood-current  passes  through  the  auriculo-ventrieular  opening  into 
the  left  ventricle,  by  the  contractions  of  which  it  is  propelled  into  the  aorta, 
and  distribntcil  bv  the  branches  of  that  vessel  to  all  parts  of  the  body. 

The  blood  <iatliered  from  the  head  and  the  upper  extremities  and  returned 
to  the  ri'dit  auricle  by  means  of  the  superior  eava  passes  directly  through  the 
auricle  and  right  auriculo-ventrieular  orifice  into  the  right  ventricle,  crossing 
in  its  course  the  blood-stream  entering  by  the  inferior  cava.  The  contractions 
of  the  ri'dit  ventricle  send  the  blood  thus  returned  by  the  superior  cava  into 
the  pulmonary  art<'ry  and  on  to  the  lungs.  These  organs,  being  still  unin- 
flated are  incapable  of  receiving  more  than  a  small  part  of  the  blood  supplied 
from  the  ventrii-le;  the  excess,  however,  is  carried  by  means  of  a  newly- 
formed  channel,  the  durtw  nrkrionm,  which  extends  from  the  beginning  of 
the  left  pulmoiiarv  artery  to  the  aorta.  The  blood  carried  through  this  canal 
niino-lcs  with  that  descending  the  ixovhi ;  on  reaching  the  hyjiogastric  arteries  a 
large  part  of  the  current  passes  to  the  placenta  for  oxygenation,  only  a  small 
proportion  of  the  stream  continuing  within  the  systemic  arteries  for  the  supply 
of  the  lower  parts  of  the  trunk  and  the  inferior  extremities.  It  will  he 
noticed  tliat  after  joining  the  current  within  the  inferior  vena  cava  the  blood 
circulating  within  the  fetus  is  nowhere  purely  arterial,  but  is  always  ccmtami- 
nated  hv  the  admixture  of  blood  already  distributed  to  other  parts. 

The  distinctive  features  of  the  fetal  circulation  are  the  ductus  venosus.  the 
ductus  arteriosus,  the  tbramen  ovale,  the  hypogastric  arteries,  and  the  umbili- 
cal vein.  After  birth,  with  the  establishment  of  the  res])iratory  function  and 
the  pulmonary  circulation,  the  accessories  to  the  arrangement  of  the  placental 
blood-current  umlcrgo  atrophy  and  largely  disappear.  While  immediately 
instituted,  these  changes  are  not  fidly  efleeted  until  some  time  after  birth. 
Obliteration  of  the  distal  ]>arts  of  the  hypogastric  arteries  first  occurs,  and  is 
usually  completed  by  the  third  or  the  fourth  day  after  birth.  The  ductus  veno- 
sus and  the  umbilical  vein  are  generally  closed  bv  the  end  of  a  week.  The  duc- 
tus arteriosus  usually  closes  within  a  few  days,  and  is  completely  impervious 
by  the  third  week  after  birth.  I'ermanent  closure  of  the  foramen  ovale  is 
delayed  for  some  time,  the  blood  being  excluded  from  the  left  auricle  by  the 
Upposition  of  the  edges  of  the  valve,  which  are  kept  in  jdace  by  the  increasing 
pressure  from  the  left  side  exerted  by  the  blood  rettu-ning  from  the  lungs. 
:After  a  time  the  edges  of  the  valve  coalesce  with  the  margin  of  the  foramen 
ovale  and  the  opening  becomes  permanently  closed ;  not  infrequently,  how- 


jT-'-'TYTm 


l:\H 


AMi:ni('Ay  ti-lvt- no oa'  or  oustktiucs. 


i       ! 


f 


i 


)  i| 


^"  I  I       M...-^ 


I'vcr,  iiioiitlis  elapse  belore  the  union  heeonies  eoniplete.  In  ea.se  tliis  union  j^ 
never  perfeetlv  elleeteii,  ii  suiiill  e(iniinnnieation  may  remain  tlinaigliont  111;  as 
a  eonjfenital  deteet,  of  sli^'lit  or  grave  import  depending  upon  tlie  extent  uf 
the  fanhy  union. 

Tlie  estahlisliiiient  of  tlio  vitelline  eireulation,  the  Hrst  one  of  the  pnilnyo, 
marks  the  introdnetion  of  an  important  nutritive  apparatus  in  animals  jKKssessiiijr 
large  volks,  which  in  tiiem  eonstitute  sourees  of  nourishment  of  great  eoiise- 
(pienee.  In  man  and  other  mammals,  however,  the  appeiU'ance  of  the  vitelline 
eireidation  must  be  regarded  rather  as  the  expression  of  formative  proe(  sses 
whose  usefulness  has  largely  disappeared  in  eonsequenee  of  the  profound 
modifieations  whieh  the  diminutitm  of  yolk  and  the  greater  dependence  on  tlic 
maternal  tissues  have  witnessed.  ^Vhile  in  mammals  the  exposure  ot  the 
fetal  blood-stream  over  the  extended  walls  of  the  vitelline  sac  or  umbilical 
vesicle  affords  an  opportunity  for  a  limited  exchange  i)f  gases,  the  amount  of 
nutritive  materials  directly  taken  up  and  appropriated  by  the  end)ryo  nui>i  li|. 
very  insignificant. 

The  deficiencies  of  the  vitelline  circulation  in  mammals,  iiowever,  are  coin. 
pensatcd  by  the  active  development  of  the  allantoic  ves.sels  and  their  fuitiiei' 
specialization  into  the  all-important  placental  circulation,  whereby  the  nspi- 
ratory  and  nutritive  necessities  are  secured  to  the  fetus  throughout  the  last 
two-thirds  of  gestation. 

The  j)lacental  eireulation,  by  means  of  which  the  respiratory  interchange  nt' 
gases  and  the  passage  of  nutritive  sul)stances  from  the  maternal  blood  to  tiiat 
of  the  fetus  is  effected,  is  undoubtedly  the  principal,  and  practically  the  sdlc, 
source  of  those  substances  necessary  to  maintain  the  life  of  the  developing  ani- 
mal. The  /it/KO)'  (tiniiii  has  long  been  regarded  as  an  additional  source  of  initii- 
tive  materials,  in  view  of  the  fact  that  this  ffuid  is  undoubtedly  swallowed  by 
the  embryo  and  taken  into  its  intestinal  canal,  as  .sliown  by  its  presence,  a< 
well  as  the  presence  of  hairs  and  epidermal  cells  at  a  later  .stage,  within  the 
gut.  The  comi>osition  of  this  fluid,  however,  renders  it  highly  improbi.!;!;i 
that  it  contributes  in  any  appreciable  degree  to  the  nourishment  of  the  (ctiis. 
containing  as  it  does  nearly  90  per  cent,  of  water.  Tlic  liciuor  aninii,  never- 
theless, serves  an  important  purpose  in  supplying  the  water  neees.sary  fur 
the  fetal  tissues,  since  the  latter  must  contain  \>ater  in  excess,  according  to 
Preyer,  in  order  to  extract  the  albumen  and  the  salts  from  the  blood  broujrlit 
by  the  umbilical  vein. 

The  fetal  jdacental  vessels  convey  albumen,  salts,  and  water  from  the  mater- 
nal blood  into  the  circulation  of  the  fetus,  as  well  as  the  oxygen  absorlKiJ 
by  the  red  blood-cells  during  their  sojourn  in  close  proximity  to  the  siriuse* 
filled  with  the  blood  of  the  mother.  The  soluble  .salts  probably  pass  Inmi 
the  maternal  blood  into  the  fetal  blood  by  simple  osmosis.  That  the  alliii- 
minous  substances,  however,  are  so  transferred  is  very  doubtful,  but  the  soliitinii 
of  this  question,  it  must  be  admitted,  so  far  has  been  unsatisfactory.  The 
ingenious  explanation  advanced  by  Rauber,  that  a  physiological  transmigration 
of  leucocytes  from  the  maternal  tissues  into  the  fetus  furnishes  the  means  of 


this  union  is 
iighout  lil  us 
the  extent  nf 

f  the  onil)rv(i, 
luls  possessing' 
t'  jrrcat  cdiise- 
;)f  the  vitelline 
itive  proe(  >sw 
the  proi'diiiiil 
cmlenee  on  tlic 
cposiire  oi'  the 
:;  or  iunl)ilic;il 
the  ainoiiiit  of 
inhrvo  nui-(  lie 

«r 

I'over,  are  cmn- 
d  their  fiirtlur 
■reby  the  rcspi- 
itlhont  the  \a>\ 

interchaii^o  of 
»1  blood  to  tiint 
tieully  tli<>  siilf, 
developinji  ani- 
souree  of  niiti'i- 
V  swaUownl  liy 
its  presence,  ;i< 
tage,  witliin  tlio 
dy  iinprobi.M" 
3nt  of  the  fetus, 
anmii,  never- 
r  necessary  fur 
!,  aeoordini;  to 
blood  bronirht 


Tom  the  inatcr- 
xvgen  absDi'bcil 
to  the  siinifc* 
ably  pass  fiMiu 
That  the  alltii- 
biit  the  solntinii 
isfaetory.  Tlii' 
transmigration 
!S  the  means  of 


V 


rjiYSJOLoav  or  PUKaxAXCV. 


r.vj 


trans) 


nsportation  of  particles  of  albumin,  fat,  lecithin,  and  similar  substances, 


lacks  eontirniati(Ui.  15y  some  the  evidence  is  regarded  as  strong  that  they 
pass  over  in  tlu-  form  of  soluble  peptones. 

That  substances  in  solution  pass  from  the  maternal  circulation  into  that  of 
the  fetus  has  been  provetl  by  direct  exiwrimcnts  with  iodin  ((Jusserow,  Kru- 
kenlurg,  Ilai.llcn),  salicylic" acid  (Henicke),  and  pc.fassium  ferrocyanid  (Fehl- 
ing).  The  investigations  of  /weifcl  demonstrated  the  free  and  rapid  passage 
of  chloroform  administered  during  parturition  from  the  maternal  blood  into 
the  uml)ilical  circ.dation,  and,  cousecpiently,  the  highly  pn.bable  inHuence  of 
the  anesthetic  upon  the  fetus.  The  result  of  attetupts  t(.  introduce  substances 
in  a  condition  of  fine  division,  but  not  in  solution,  such  as  vermilion,  India 
ink,  fat,  etc.,  have  been  negative,  the  seeming  exceptions  where  such  particles 
were  found  in  tlu,'  fetal  circulation  after  injection  being  attributable  to  injury 
of  the  blood-vessels. 

Tlie  migration  of  formed  elements,  such  as  the  pathogenic  bacteria  of 
anthrax,  typhus,  etc.  or  the  colorless  blood-corpuscles,  from  the  circulation 
of  the  motlier  into  the  ti'tal  blood  is  a  (piestion  about  which  there  is  nuich 
dirtcrence  of  opinion.  Regarding  the  blood-cells,  moreover,  the  investigations 
of  Sanger  point  to  the  improbability  of  such  migration  taking  place,  since  in 
leukemic  conditions  of  either  mother  or  child  the  blo{Hl  of  the  remaining 
organism  may  retain  its  normal  proportions.  The  experiments  of  Savory 
and  (Jusserow  have  shown  that  in  animals  in  which  the  fetus  is  poisoned 
by  strycliiiia  the  poison   may  pass   from   the  letal   circulation   into  that  of 

the  mother. 

Certain  substances  administered  to  the  mother  pass  into  the  liquor  amnii,  as 
in  the  case  where  iodin  is  given  (Krukenberg).  That  the  fetus  takes  no  part 
in  producing  this  eifect  is  shown  by  the  fact  that  the  drug  is  found  in  the 
liquor  amnii  even  when  the  product  of  conception  is  dead  (Haidlen) ;  further, 
that  coloration  of  the  amniotic  Hnid  after  the  injection  of  sodium  sulphindigo- 
tate  into  tiie  jugular  vein  of  the  mother  is  unattended  by  the  presence  of  the 
substance  within  either  the  kidneys  or  the  lu-ine  of  the  fetus  (Ziuit/).  The 
staining  of  tiic  maternal  tissues  composing  the  decidua  by  the  pigments  con- 
tained within  tiie  meconium  emphasizes  the  fiiet  that  substances  within  the 
liquor  amnii  may  in  turn  affect  the  mother. 

The  respiratory  and  metabolic  changes  within  the  fetus  are  carried  on  by 
means  of  the  oxygen  taken  up  from  the  maternal  circulation  by  the  fetal 
blood-stream  in  its  passage  throtigh  the  placenta,  in  exchange  for  the  carbonic 
acid  and  other  products  of  tissue-change.  So  long  as  this  interchange  of  gases 
takes  place  without  interruption  in  the  placenta,  the  fetal  circulation  contains 
an  excess  of  oxygen,  since,  notwithstanding  the  small  amount  derived  from  the 
mother,  the  (piantity  of  this  gas  thus  obtained  more  than  snttices  for  the  nectls 
of  the  embryo,  and  induces  a  condition  of  apnea.  When  the  placental  circu- 
lation is  interrupted,  however,  as  by  compression  of  the  umbilical  cord  or  bv 
premature  se])aration  of  the  placenta,  the  fetus  perishes  with  all  the  symptoms 
"of  asphyxiation. 


140 


A  ME  RICA  X   TEXT-BOOK   OE    OBSTETIUCS. 


I 


i 


Till'  direct  jinidf  of"  the  source  of  oxygen  from  the  ulaeenta  has  been  .-up. 
plied  bv  the  investigations  of  Colinstein  and  Znntz,  who  examined  the  blodd 
of  the  umbilical  vein  in  sheep,  and  found  it  richer  in  oxygen  than  tliat  wiiliin 
the  umbilical  arteries,  although  the  difference  between  the  arterial  and  the 
venous  blood  during  intra-uterine  life  is  nuich  less  marked  than  after  liiith 
(Ilallibin-ton).  The  sj)ectroscopic  analysis  of  blood  from  the  human  umbilical 
vessels  bv  Zweilel  showed  the  presence  of  the  oxyhemoglobin  bands  before 
respiration  was  established. 

The  consumj)tion  of  oxygen  by  the  fetus,  as  measured  by  the  necessities  of 
its  own  heat-production,  is  relatively  small,  since  the  maintenance  of  its  tem- 
perature is  greatly  facilitated  by  being  surrounded  by  the  lifpior  amnii,  the 
warmth  of  which  is  almost  0(]ual  to  that  of  the  fetal  blood.  The  fetus  is  still 
further  favored  by  being  sjiared  the  necessity  of  taking  within  its  lung-  and 
alimentarv  tract  substances  which  nuist  be  warmed  to  its  own  temperatun'  at 
the  expense  of  its  own  heat.  The  presence  of  the  warmed  liquor  amuii  als, 
prevents  caloric  loss  by  cither  radiation  or  evaporation. 

The  pre-natal  functions  of  the  fetus  include  limited  activity  of  the  ki(hi(v> 
and  preparatory  exercise  of  the  organs  and  glands  connected  with  the  alimentarv 
tract  an<l  the  integument. 

The  early  excretory  apparatus  of  the  embryo  is  represented  by  the  WolfViaii 
bodies  and  their  ducts  and  the  allantois.  The  yellowish  fluid  collected  witliiii 
the  allantoic  sac  after  its  secretion  by  the  Wolffian  bodies  camiot  be  reganldl 
as  urine  in  the  strict  sense  of  the  term,  since  its  elaboration  long  ]>recedc-  tlio 
development  of  the  fetal  kidneys.  There  is,  however,  a  similarity  between 
the  usually  alkaline  allantoic  fluid  and  the  later  secretion  of  the  fetal  kidiiev-, 
the  fluid  often,  i)ut  mtt  invariably,  containing  m-ea,  uric  acid,  the  alkaliiu 
chlorids,  phosphate*,  and  sidphates,  as  well  as  iron,  calcium  carbonate  ami 
allantoiil.  The  early  jiresence  of  urea  an<l  the  urates  renders  it  highly  |iivli- 
ai)le  that  the  decomposition  of  albumin  with  oxidation  begins  at  an  early  [teridd 
of  intra-uterine  life,  the  excreted  substances  being  taken  from  the  still  ini]Hr- 
I'cctlv  ditl'erentiated  fetal  blood. 

'J'lie  tpiestion  whether  the  kidneys  under  normal  conditions  re<rularly  seenti 
iM'ine  l)efore  birth  has  receiveil  much  attention  and  various  answers.  Tin 
weight  iif  evidenec  und(inl)tedly  establishes  the  exercise  of  such  fimctldii,  inn 
exactly  the  periml  at  which  the  secretion  of  urine  first  takes  ])lace  is  still  midi- 
termincd.  .\ftcr  the  estaitlislimeiit  of  coinnninication  i)etween  th"  bladder  ainl 
tiic  cxterinr  uf  the  body  bv  the  formation  of  the  urethral  canal,  the  lu'iiic  i- 
discharged,  during  the  later  weeks  of  gestation,  into  the  amniotic  fluid,  with  wlndi 
it  is  in  part  swallowed  by  tlii'  fetus.  The  coloring  matters  of  the  urine  aiv 
elaborated  uidy  in  vci'v  liniitcil  (|iianlities.  as  shown  by  the  well-known  pali 
tint  of  the  fluid   voided   liy  the  new-born  child. 

niijislirc  Triii-f. — The  pre-n:ital  activity  of  the  glands  connected  with  tin 
fetal  alimentary  tract  is  a  matter  of  nuicli  interest  in  view  of  the  deinainl- 
made  upon  these  organs  immediately  after  birth  to  supply  I  he  ferment-  nen- 
sary    in  the  procc-.-  of  digestion   and    assimilation.      Tiie   inherent   ditliiiillii- 


■M 


i 


rilVSIOLOGY    OF   PREayAXCY. 


141 


liuji  been  >np- 
loil  tl'o  li'udd 
in  that  wiiliiii 
oriiil  ami  the 
lan  aft  or  I'irtli 
man  uniliilicnl 
bands  b(  lovo 

^  ncoc'Sfiitic-  of 
lice  ol"  '\y  tiiii- 
nor  aninii.  ilic 
ho  ibtus  is  -till 
I  its  hnisr-  ami 
toniporatiiic  m 
nor  anniii  al> . 

of  tlio  kiihu'vs 
I  the  aliiiuntarv 

bv  tho  Wolflian 
collootod  within 
inot  be  ri'irai'did 
in<r  jn'ocotlc-  the 
lihirity  bctwctn 
ic  fetal  kiilin'v-, 
id,  the  all<alim' 
arbonatr    ami 
(  it  highly  |inili- 
an  early  iicriml 
the  still  iniiM!- 

i-i'irnlarly  scci'cti' 
answers.  Tlif 
eh  i'nnctioii,  Imi 
jice  is  still  iiM'l'- 
tli'bladtlrr  ami 
nal,  the  iiriiH'  i- 
lnid,\vithwtii'li 
,,!'  the  urine  an 
well-kill >\vn   jiali 

nneeted  with  tin 
,,f  the  diiiiaiiil> 
.  ferment-  ncir- 
(■rent  ditli'iiliif 


attending  the  investigation  ..f  the  subjeet  in  the  human  fetus  have  left  our 
knowledge  on  inanv  points  still  far  from  satisfaetory. 

The  siliva  of  the  fetus  has  reeeived  mueh  attentii)n  with  a  view  of  deter- 
niiniii.-  the  p'lrseiiee  or  al.seuee  of  ptyalin.  While  the  results  of  the  observa- 
tions by  various  investigators  are  contradietory,  the  positive  evidence  of  the 
presenee  of  tliis  ferment  in  the  saliva  of  the  new-born  obtained  by  Hehiffer  is 
important.  This  olwerver  demonstrated  the  unmistakable  presenee  of  ptyalin 
in  the  salivary  secretion  of  three  new-born  children,  thus  showing  that  the 
capal)ility  of  coiivertintr  starcii  into  sugar  exists  in  the  saliva  from  birth— a 
iLt  the  more  remarkable  when  the  absence  of  the  opportunity  for  the  exercise 
of  this  power  is  icealled,  tiie  character  of  the  early  food  recpiiring  neitlier 
stareli  nor  dextrin.  It  has  been  sliown  that  the  ptyalin  i~  :  «t  elaborated  in- 
ditfereiitlv  by  the  salivary  glands,  but  that  its  presence  is  limited  to  the  .secre- 
tion and  tissue  of  the  parotid.  The  relatively  tardy  development  of  the  labial 
and  other  glands  of  the  oral  cavity  is  in  accord  witii  the  observed  slight  activity 
of  the  secretory  function  of  the  moutli  of  the  fetus. 

Tlie  trii^tric  secretions  of  the  new-born  iiave  been  fotnid  to  contain  pepsin 
and  remiiu  immediately  after  birth,  pepsin  digestion  and  the  power  of  curdling 
milk  heiiiu;  estaldislied  within  a  tew  hours.  Tlie  observed  ditferences  in  the 
amount  of  pepsin  contained  in  specimens  of  the  unicous  membrane  of  new- 
born eliildreu  probably  depend  upon  tiie  variability  in  the  development  of  the 
gastric  <rhuids,  as  luiinted  out  by  Sewall. 

Tiie  pancreatic  fl'/meuts  are  j)robal)ly  represented  before  birtli  by  the  pres- 
ence of  tri/jisiii,  wiiich  acts  especially  upon  the  proteids,  and  a  fat-splitting 
ferment  {pducirdliii,  .•<lf(tpxui),  i)ut  not  by  (imi//<>jisin,  which  resembies  ptyalin 
in  possessing  the  power  of  attacking  starch.  liangendorH'  demonstrated  the 
presence  of  trvpsiii  in  the  j)ancreas  of  the  fetus  at  tiie  fiftii  and  sixtii  month  ; 
Zw'cifel,  tliat  <if  pancreatiu  at  birtli.  The  large  amount  of  fatty  and  albu- 
minous matters  in  tlie  milk  ;it  onC'.  sug^  'sts  the  necessity  of  the  early  |)rep- 
aration  of  the  dige-tive  ii'rmeiits  rciiuiri  d  for  the  disposition  of  these  substances. 

The  iiitc'^iual  secretions  at  birth  differ  widely  from  those  of  a  slightly  later 
period.  In  t.iis  respect  the  observation  of  Werber,  showing  the  relatively 
larger  niimher  of  Briiuner's  glands  in  the  new-born  than  during  later  life,  is 
of  interest,  although  the  function  of  the  glands  within  the  fetus  is  not  obvious. 

The  liver  early  develops,  and  soon  becomes  the  most  con.-picuoiis  organ 
connected  with  the  fetal  digestive  apparatus.  Its  large  size  suggests  an  early 
activity,  which,  in  fiet.  observations  on  mammalian  (Miibryos  confirm.  A  sub- 
stance resembling  bile  has  been  found  in  the  small  iutestiues  from  the  third  to 
the  fifth  inoiith,  and  later  in  the  large  gnt ;  in  this  niMterial,  from  tt'tuses  of 
the  third  mouth,  Zweifel  found  the  bile-acids  and  the  biliary  piguients. 

The  iiiecoiiinm,  the  contents  of  the  fetal  intestinal  canal  at  birth,  jircsonts 
a  dark,  iirowuish-green  or  almost  black  appearance,  and  a  sott,  viscid,  pitch- 
like  consisienee.  Its  source  has  been  the  subject  of  interesting  investigation, 
but  much  relating  to  its  origin  still  remains  to  be  investigated.  Tlw  produc- 
tion of  meconium  seems  chiefly  related  to  the  Ibrmation  of  bile,  since  it  is 


If  '       I 


/ 


Ill' 


(■■        il;  [i/! 


142 


AMEIilCAy    TEXT-BOOK    OF    OBSTETRICS. 


'   'J 


>      I 


.    ! 


;  i 


absent  before  this  secretion  is  i)t»nre(l  into  the  intestinal  eanal,  as  well  a-  in 
eases  of  malformation  in  which  the  elaboration  of  bile  is  wantinfi:.  The  \  icw 
attribnting  to  the  swallowed  liiiuor  amnii  an  active  rv/c  in  the  formation  of 
the  meconium  is  opj)osed  bv  the  presence  of  this  substance  in  malformed 
fetuses  in  which  the  ])ossibility  of  entrance  of  the  amniotic  fluid  into  the  inus- 
tines  was  jirechulcd. 

Jjcfore  the  secretion  of  bile  meconium  is  not  present,  llennijr  obsi  :\(.,1 
liifht  vellowish-green  meconium  in  a  fetus  at  the  ben-innino^  of  the  Iniinl, 
month.  The  l)e<iinning  of  the  fifth  month  usually  marks  the  period  linin 
which  the  meconium  is  constantly  present.  This  substance,  in  addition  tn  the 
bile,  consists  of  the  unabsorbed  portions  of  the  intestinal  nuicus  and  juices. 
the  secretions  of  the  glands  of  lirumicr  and  of  the  ]>ancreas,  and  of  tiie  >\v;il- 
lowcd  amniotic  li(|ui(l,  together  with  such  remains  as  leucocytes,  intestinal  cpi- 
thelium,  lamigo,  epidermal  cells,  and  fat  from  the  vcrnix  caseosa  carried  jnt,, 
the  gut-tract  along  with  the  li(]Uor  anniii. 

The  chemical  composition  of  meectniuni,  as  ascertained  by  Zweifel,  indiulo-: 
from  20  to  27  per  cent,  ol"  solids,  of  which  about  1  per  cent,  is  inorganii',  tho 
remainder  organic;  the  amount  of  fat  and  fat-acids  and  of  cholesterin  is  the 
same — about  .75  per  cent.  The  inorganic  constituents  include  the  ])hospllat^^ 
and  sul|)hates  of  magnesium  and  calcium,  Mxlium  chlorid,  and  oxid  ol'  iron, 
The  i)rineipal  organic  substances  are  the  more  or  less  changed  bile-salts,  tin 
unaltered  bile-pigments,   bilirubin  and   biliverdin,  and  mucin. 

.').  Multiple  Conceptions. 

The  fecundation  of  more  than  a  single  ovum,  or,  as  often  less  accunitdv 
termed,  "  nndtiple  ])regnancy,"  is  by  no  means  an  infrequent  occurreiicc,  ;i> 
the  munerous  births  of  two  or  more  children  testify.  Afnltiple  conci  ptioib 
may  result  in  the  birth  of  twins,  triplets,  and,  as  great  rarities,  (pia(lni|il(t.«; 
a  nund)er  of  well-authenticated  instances  of  five  children  at  one  time  niv 
recorded  ;  and  even  an  apparently  trustworthy  case  of  the  birth  of  six,  i;,i|i 
bovs  and  two  girls,  has  been  reported  by  Vassalli.  The  reputed  biiilis  in 
excess  of  this  nundjcr  arc  apocryphal. 

The  most  extensive  series  examined  with  a  view  of  determining  tlir  iv|;i. 
five  frc(|ueiicy  of   multiple  conceptions   is    that    studied    by  (}.  Vcit.  wiiici, 
included  the  records  of  thirteen  million  births  in  I'rnssia.      According  tn  tlif-i 
statistics,  twins  occur  imee  in   (SS   births;  triplets,  once   in   7910;  ami  (|iiail- 
ru])lets,  once  in   .'571. 12().      About   a   dozen   autlicntic  cases  of  liv(~  at  a  liini: 
arc   recorded   in   medical    literature  ( Kaltenbach).      The  statistics  of  (lilllivii; 
countries  seemingly  point  to  considerable  variations  in  the  fre(iuency  (if  twin-. 
thus,  in  Bohemia  twins  occur  once  in   about  GO  births,  while  in    I'^-aiKv  ilnv 
appear  only  once  in  every  lOd.      Keccnt  statistics  supplied   by  the   linaid  >: 
Health  of  \<'W  York  and  of  I'iiiladelphia  ])Iace  the  frc(pieney  of  twin  liiiili- 
in  these  cities  at  1  in  every  \'2*^  i)irths.      In  acc(>pting  such  conclusions,  linw- 
ever,  ])ossible  errors  arising  from  ditlerences  in  the  character  and  coniplctoiii- 
of  the  statistics  compared  niu-t  not  be  overlooked. 


',  ^^^^W^*""  ■* 


.iJr.i...       ,ui 


PHYSIOLOGY   OF  PltEGXAyCY 


143 


as  well  u    in 

ct.        TIU'  \  U'W 

',  Ibrmatidii  df 
in  inaH'oi'inwl 
into  the  iiius- 

of  tlio  t'li'irili 
K'  period  lidiii 
addition  tn  tlu' 
('US  and  juicos. 
ml  of  the  >\v:il- 
3,  intostiuiil  cpi- 
iisa  carried  iiitu 

'iWeifel,  iiu'ludo- 
is  inorganii',  tlio 
■holesterin  is  tlie 
I'  the  ])hosph!ito> 
lid  oxid  of  iron, 
rod  bik'-saUs,  the 
in. 


n  loss  aeeiu'iitcly 
nt  oeeurreneo,  ;!• 
tiple  eonecptiom 
ties,  quadnii»k't>; 
at  one  time  aiv 
birth  of  six.  U\\ 
repnted  hiilli>  in 

rmininu;  tlic  ivla- 
V  (I.  Veit.  wliii'ii 
Aeeordinir  '"  du-i 
7910  ;  and  ^\\\\\\- 
„f  |iv(>  at  ;i  I'ii'ii. 
iti^ti<'s  of  ditVcivn: 
•ctiueney  of  t«i'i- 
1,.  in   FraiHv  ili.v 

by  the   r«":>i'.l  '■: 
■ney  of  twin  Im'ili- 

conclusion-,  li"«- 
■r  and  eomitletom- 


Of  loO.OOO  twin  i)regnancies  .studied  by  Veit,  in  one-third  both  children 
were  bovs  ;  in  shglitly  le.<s  than  one-third  both  were  girls  ;  and  in  the  remain- 
ing third  both  .sexes  were  represented.     Twins  are  more  frequent  in  multipane 


than  in  pnnuparic. 


Iiidividuid  and  inherited  tendencies  seem  also  to  i)e  factors 


in  tiie  oecnrrenee  of  nudtiple  conceptions,  since  plural  birtiis  .^^ometimes  renilcr 
/particular  women  or  certain  lamilies  con.-ipicuous. 

Twins  usuallvdeveloi)  from  two  distinct  ova  derived  from  the  same  or  from 
different  Graalian  ve.-icles,  which  may  be  separated  widely  or  which  may  even 
be  contril)nted  bv  dilferent  ovaries,  as  shown  by  the  i»re,«ence  and  location  of 
the  corixira  Intea.  When  derived  from  a  single  ovum,  the  existence  of  a 
double  germ  iuav  be  assmned,  with,  however,  the  possibility  borne  in  mind 
that  the  twins  mav  have  arisen  as  the  result  of  complete  fusion  of  a  single 
germ,  as  emphasized  bv  Ahlfeld  in  his  investigation  of  the  production  of 
double  monsters.  Twins  originating  in  this  manner  are  termed  "  homolo- 
ffous"  and  are  cliaractcrized  by  remarkable  physical  and  mental  similarity. 
Of  600  eases  of  twins,  Ahlfeld  foiuid  but  .sixty-six  ])roceeding  from  a  single 
^(T,  Twins  derived  from  a  single  oviun  are  always  of  the  ."iame  sex  ;  tho.se 
from  two  ova  may  hi'  of  different  or  of  the  same  sex. 

The  arrangenii'nt  of  the  fetal  membranes  of  twins  depends  upon  the  mode 
of  their  ut'i-;i'i.  The  decidua  vera  is  always  simple ;  the  decidua  rcHexa,  on 
the  contrajv.  !.-  double  when  the  ova  become  attached  to  widely  .separated  parts 
of  the  uterine  wall.  The  clioi"on,  being  i)riinarily  derived  from  the  zona 
pelhicida,  is  single  when  the  twins  originate  from  two  germs  contained  within 
a  .single  ovum,  but  double  when  they  arise  from  .separate  (}g^^^.  The  amnion 
is  primarily  always  single,  since  this  membrane  is  produced  as  an  outgrowth 
and  extension  of  the  end)ryo  it.self.  In  those  eases  where  twins  occupv  a 
common  amniotic  .sic,  a  .secondary  fusion  of  the  two  originally  di.stinct  .sacs 
has  occmred  by  the  breaking  down  and  absorption  of  the  .septum  which  for  a 
time  .separated  them. 

The  placenta  is  at  first  double,  since  each  fetus  forms  its  own  allantois  and 
resulting  placental  area.  When  the  twins  origiiuite  from  different  ova  the 
placenta  may  remain  permanently  distinct,  but  even  in  such  ca.ses  fusion  of  the 
placental  areas  eventually  takes  ])lace.  The  ])l:icental  vessels  of  single-ei>-gi'(l 
twins  almost  invariably  anastomose,  so  that  the  placental  become  more  or  less 
completely  fu.sed,  the  conunon  nutritive  area  then  consisting  of  three  parts,  an 
Intermediate,  indiffl'rent  area  being  enjoyed  in  conunon,  in  addition  to  the  par- 
ticular i)art  which  mini.sters  es|)eeially  to  each  fetus  (Ilyrtl).  The  anastomosis 
of  the  placental  vessels  may  result  in  the  mo.st  profound  impressions  in  those 
case"-  where  marked  diirerences  exist  in  the  developmeiU  and  vigor  of  the  two 
fetuses,  since  the  circulation  of  the  weaker  fetus  may  be  unfavorably  inffu- 
enced,  even  to  the  extent  of  reversal  (Ahlfeld),  by  the  overpowering  force  of 
%t  of  its  stronger  brother.  Disastrous  atrophy  and  the  production  of  an 
aoardia  are  among  the  results  attributable  to  such  conditions. 

When  one  fi'tus  succundxs,  the  press,,,.,,  exerted  during  the  growth  of  the 
living  child  gradually  r^  luces  the  mass  of  the  dead  product  of  conceptii.n,  until 


.  /i 


■t     i"iiBpii 


144 


AMKlilCAy    TEXT-liOOK    OF    OliSTETItlCS. 


fllMi! 


;:j 


fiiiallv  it  is  ropro.seiitcd  by  tlio  groatly  flattened  ami  atteiiiiattd  remains  inijiii>- 
oned  against  the  uterine  walls,  then  eonstitnting  the  "  letus  papyraeeus  "  u\  tJK.. 
teratologist.  CVtnspieuoiis,  and  sonietiincs  remarkable,  disparity  in  the  pcrllr- 
tioii  of  growth  and  development  may  exist  in  twins  at  birth,  the  more  t'a\,ircd 
fetus  sometimes  exeeeding  the  smaller  threefold  in  weight,  the  difference  depend- 
ing  upon  the  nutritive  advantages  enjoyed  by  the  one  at  the  expense  of  \{>  Ic,. 
fortunate  fellow.  In  eonsequence  of  this  disparity  it  sometimes,  though  vciv 
rarelv,  happens  tiiat  the  fully-matured  fetus  is  expelled  at  term,  while  the  -till 
imperfeetiv  developed  fetus  is  retained  for  a  time  within  the  uterus  until  \u 
devck>pment  has  p?'ogressed  farther  toward  completion,  when  it  in  turn  is  Imm, 
Two  remarkable  ea^es  in  which  double  uteri  were  present  have  been  recdidcil 
bv  Jiarker  and  (Jeuerali,.  where  intervals  of  forty-three  and  thirty  days  rc-pcc 
tivelv  intervened  between  the  births  of  the  two  fetuses.  It  is  the  occunciic, 
of  such  cases  which  is  erroneously  regarded  as  a  fact  in  support  of  the  jkiv. 
sibility  of  super  fetation. 

Triplets  may  originate,  it  is  evident,  from  a  single  ovum  or  from  two  dr 
three  distinct  eggs,  a  fmpiciit  arrangement  ijcing  that  one  child  is  dirivd 
from  a  distinct  ovum  and  tw(.>  from  a  single  ovum.  U|.on  the  nianiK  r  nf 
their  origin  depend  the  arrangement  and  relations  of  the  placenta  and  incm- 
branes,  (Quadruplets  may  exist  as  double  twins,  or  they  may  residt  Innna 
combination  of  a  single  birth  with  triplets. 

Plural  conceptions,  on  the  one  hand,  may  result  from  a  .single  coitiH, 
\vhcrcl)v  are  impregnated  ova  which  have  simultaneously  been  discharged  tVuin 
the  sexual  glaml,  ])repared  for  the  reception  of  the  male  elements;  on  the 
other  lianil,  rc|)eMted  impregnatiou<  may  occur  after  ditlerent,  though  cIuhIv 
following,  sexual  acts,  tliesc  resulting  in  the  fecinidation  of  dill'crent  ova  wiiidi 
have  been  lilierated  at  -lightly  separated  'uomcnts,  but  which  belong  to  the 
same  ovuhition.  This  possibility  has  received  recognition  in  the  term  .\////(/'- 
j'{Viin(J<iti(in  or  Kttjtcriiiijx'cf/ndtioii,  by  which  is  understood  the  fecundatidn  nf 
two  ova,  lu'longiug  to  the  same  j)eriod,  by  ditlerent  sexual  acts.  Conspiciiini. 
examples  of  such  occnrrcuccs  arc  afforded  by  instances  where  a  negress  oiws 
birth  to  a  white  and  a  lihuk  ciiild. 

While  the  oecnrrenee  of  superimpregnation  is  nndisputed,  KiijK'rfcfdtidii.nr 
the  possibility  of  ova  which  originate  from  different  ovulation  periods,  and  tliciv- 
f(»re  lii)eratc(l  at  ((lusideral)le  intervals,  being  impregnated  by  sexual  acts  wiilclv 
separated,  is  nut  admissible.  While  instances  of  the  delayed  birth  of  a  .-('('(iini 
child  arc  adduced  in  sii|tp<irt  nf  th<'  recognition  of  the  possibility  of  sup"!'fct;i- 
tion.  the  obvious  physical  impossibilities  of  the  as-nmed  occurrence  an  iiniiii- 
swerable  objcctinns  to  the  vali<lity  of  such  interpretation.  When  the  rii|iiil 
and  important  changes  in  both  the  ovinn  and  its  environment  that  f'nllnw 
fecundation  are  recalled,  the  impossibility  of  spermatozoa  reaching  ami  iiii- 
preguating  an  ailditional  ovinn  on  the  one  haml,  and  of  flic  (tviuii,  ivm 
although  ft'ciuidated,  descending  the  F.-dlopian  tui»c  t"  the  uterus,  n\\  ihe 
other  hand,  is  manifest.  The  cases  cited  in  support  of  superfetati((n  arc  all 
explicaidc  from  the  well-kiK.wn  fiicts  attending  the  nueipial  growth  and  dcvd- 


luains  impris- 
aocus"  (U  llw; 
in  tlie  pcit'w- 
morc  tU\  oivd 
Tonco  lU'ji'  11(1- 
eiiso  of  it>  lc>s 
■;,  thoiijili   .crv 
while  tlif  -till 
torus  until  is 
in  turn  is  I'uni, 
■  bt'i'U  rooordcil 
ty  days  rc~|Kr- 

thc  OCCUl'K'lHV 

ort  of  the  |l(l^- 

or  from  twd  uv 
hihl  is  (liiivwl 
the  manner  (if 
LMita  ami  iiuiii- 
V  resuh   in  111!  ;i 

a  single  enitiis 

ilischariiX'd  t'lMiii 

enients ;  oii  tlif 

,  thoupli  il(i>(ly 

erent  ova  wliidi 

I  beloujj;  tn  ilic 

the  term  ^"//(i- 

fce\uulati(Mi  ni 

;.      C'onspielKill- 

a  neji-ress  givis 

siipcrjctdlinih  111' 
'riotls,  and  lluTi- 
'xual  acts  widely 
)irtli  of  a  .-('('(mil 
itv  of  suivrfcta- 
•rcnee  an   iiikui- 
When   tlie  r:i|iiil 
(>nt  that  l(illii«- 
;ichin}ij  iuul  ill'- 
tlic  ovum,  evtii 
nterus,  »\\  tin' 
■rfctation  iHT;ill 
•owth  anil  ilevil- 


PIIYSIOLOGY   OF  PREGXANCY. 


145 


opnient  of  twin  eoneeptiuns,  where  this  disparity  results  in  the  delayed  deliv- 
erv  of  tlie  less  favored  fetus. 

"  rinial  births  frequently  occur  before  term,  twins  being  born  a  few  weeks 
before  the  end  of  gestation,  (juadruplets  and  quintuplets  in  the  earlier  months 
of  pregnancy. 

4.  Changes  in  the  Maternal  Organism  Induced  by  Pregnancy. 
1.  Local  Changes.— 'riie  pre.senee  of  tlie  fecundated  ovum  inaugurates  a 
season  of  inereased  nutritive  energy,  which  not  only  effects  changes  in  those 
organs  in  inimediate  relations  with  the  developing  fetus,  but  also  induces 
chaniies  involving  the  entire  organism  of  the  mother  during  the  continuance 
of  pro'-'nanev.  The  clianges  thus  indu(;ed  in  the  general  system  being  discussed 
in  a  separate  section  (p.  153),  consideration  in  the  present  place  will  be  directed 
to  tbcj.-e  ehaiiires  manifested  l)y  the  sexual  organs  and  the  parts  intimately  con- 
nected with  the  processes  of  gestation  and  parturition. 

The  iifrnifi,  as  may  be  expected  from  its  especial  relation  to  the  developing 
fetu,-  earlv  manil'ests  the  profound  changes  which  it  undergoes;  indeed,  the 
preparatorv  alterations  affecting  its  nmcous  lining  and  va.seularity  preceding 
each  menstrual  epoch  must  be  regarded  as  the  beginning  of  the  cycle  of 
chan<i-es  that  ends  only  with  the  return  of  the  organ  to  its  normal  condition 
after  the  expulsion  of  the  )>ro(hu't  of  conception  and  the  protecting  structures. 
The  hvperiniphy  of  the  nmcous  membrane  of  the  uterus  and  the  greatly 
i'ncrea.sed  va.scidar  supply  which  take  place  coincidently  with  the  liberation  of 
the  ripe  ovum  from  the  ovary,  under  usual  conditions,  are  succeeded  by  the 
destructive  changes  giving  rise  to  the  phenomena  of  men.struation.  Should 
impregnation,  on  the  contrary,  occur,  the  liypertrophic  proce,s.scs  are  continued 
with  inereased  vigor,  and  result  in  the  alterations  already  described  in  con- 
nection with  the  formation  of  the  decidua  (p,  86). 

The  most  conspicuous  consequence  of  the  changes  in  the  uterus  is  the  not- 
able increase  in  the  size  and  weight  of  this  organ.  From  the  insignilicaut 
dimensions  of  the  small,  rigid  virgin  uterus,  which  include  a  length  of  7  cen- 
timeters {2'-l  inches),  a  breadth  of  4.5  centimeters  (1|^  inches),  and  a  thickness 
of  2.5  centiineters  (1  inch),  there  is  developed  a  huge  flaccid  sac  which  meas- 
ures at  the  elo.se  of  gestation  from  37  to  38  centimeters  (15|^  inches)  in  length, 
26  cemimeters  (lO^^  inches)  in  breadth,  and  24.4  centimeters  (0|  inches)  in 
thickness,  with  a  circinnti'rence  at  the  level  of  tiie  oviducts  of  from  70  to  73 
centimeters  (2!)  inches). 

The  weiti'ht  of  the  virgin  uterus  is  about  40  grams  n|  oumx's) ;  that  of 
Ibe  uterus  at  term,  about  1000  grams  (2  pounds),  an  increase  of  twenty-live 
llines  taking  place.  The  ca|)aeity  of  the  uterus  at  the  clo.se  of  gestation  is 
between  4000  and  5000  cubic  centimeters  (from  S  to  10  pints),  or  over  five 
hundnd  times  that  of  the  virgin  org.iu. 

The  increase  in  the  bulk  of  the  uterus  occurring  during  the  earliest  mouths 
ff  pregnancy  is  attributable  to  the  general  hypertrojihy  atfccting  its  walls,  and 
net  din'ctly  to  the  developing  ovuuu  since  only  aticr  the  latter  completely  Mils 

10 


>*  H!, 


■ifp,     i 

"ill--     .  ' 

il 


I 


hi; 


i 


140 


AMKIUCAX   TEXT-BOOK   OF    OliSTETRICS. 


the  utcrino  cavity,  at  tlio  exj)irati()n  ol"  the  fifth  month,  is  the  aii<;monto(l  ,  izo 
of  tho  uterus  pHxhiccd  l)v  tiic  nicchanical  distoutiou  caused  by  the  ra]>iHv 
p'owinii'  fetus.  The  enhu-gement  of  the  uterus,  moreover,  is  not  dirctlv 
dependent  u])()u  the  ])reseiiee  of  the  oviuu,  hut  is  (hie  to  actual  increase  oi'  tis- 
sue, as  shown  l)y  the  iiict  that  the  liypertrojjhy  of  the  organ  ju-ogresses  ujitu 
the  fourth  month  in  extra-uterine  pregnancies,  the  same  as  if  the  ovum  wopo 
present  within  the  uterine  cavity. 

The  livpertropliy  of  tlie  uterus  at  first  affects  cfpially  all  parts  of  the  vi.cns 
but  later  the  fundus  and  the  body  grow  more  rajiidly  than  the  cervix.  Tlio 
changes  which  atfect  the  uterine  walls  consist  of  thickening  of  the  nuu'oiis 
membrane,  increa-e  of  the  nuiscular  tissue,  augmentation  of  the  connci  tivi 
tissue,  and  enlargemej-.t  of  the  blood-vessels,  the  lyiuphatics,  and  the  m  ivcs, 
As  a  result  of  these  alterations  the  walls  for  a  time  reach  a  thickness  ol'  1.5 
centimeters  {^  inch):  but  this  excessive  growth  is  followed  by  a  niiirkcd 
reduction  resulting  from  the  distention  iucident  to  the  later  mouths  of  pivo. 
nancy,  Avheu  the  extended  uterine  walls  measure  but  5  millimeters  (y'ir  inch) 
in  thickness. 

The  increase  of  the  muscular  trmic  is  etTected  not  only  by  excessive  growtli 
of  the  already  existing  involuntary  muscle-fibres,  which  increase  from  ten  tn 
eleven  times  in  length  and  from  three  to  five  times  in  breadth,  Imt  also  hv  tin 
formation  of  new  muscular  elements  which  likewise  soon  acquire  the  (IIiikmi- 
sions  of  .0  millimeter  in  length  by  .02  millimeter  in  breadth. 

The  himinaof  the  uterine  blood-vessels  are  materially  increased,  the  artcric^ 
becoming  wider  and  longer — without,  however,  entirely  losing  their  tortiKi-itv 
— and  the  veins  dilating  into  large  venous  chamiels,  the  .s'//(((.s  nfcrivi,  wliidi 
penetrate  lietween  the  nuiscular  fasciculi  and  v,-hich  are  particularly  well  <l(vol- 
oped  within  the  placental  area.  The  walls  of  the  venous  canals  are  intiiiiatciv 
united  with  the  surrounding  and  likewise  hypertroj)hied  connective  tissue,  in 
consequence  of  which  arrangeni<'ut  the  vails  of  these  vessels  do  not  cnllaiiv 


when  mutilated,   but  reinaiu   more  or  le 


'ss  traDinii 


Tl 


le  lymphatics  of  tl 


mucosa  and  the  muscular  tunic  considerably  enlarge.     The  nerves  disl 
to  the  uterus  also  share  in  the  increased  growth,  especially  the  </<i)i(/li 
c(tlc,  which   more  than  doiiiiles  its  usual   size. 

The  form  of  the  ureriis  undergoes  a  marked  series  of  changes  durinir 
nancy.      During  the  first  three  months  the  ])yrif'orm  shape  is  retained  ; 


nlilltri 


oil  ('I'm- 


pi'( 


-II I M- 

(|uently  the  organ  becomes  more  expanded  in  its  lower  segment,  and  livtlu 
fifth  month  ])r(sents  a  form  iiitirnu'diate  Ik  tweeii  the -spherical  ai.d  tlir  |ivn- 
form,  the  longest  diameter  iu'Ing  vertical,  and  the  an.ero-])osferior  diiiicii-i'i 
being  greatest  just  below  the  middl(>  of  the  body  (Webster).  Late  in  ))r(i'- 
nancy  the  pyriform  or  egg  shape  once  more  ])redoniinates,  owing  to  the  (loiih- 
lik(!  distention  of  \hv  fundus  and  the  broadening  of  the  lower  segment. 
During  tiie  early  niontii-  all  part<  of  the  uterus  incri'ase  with  ecpial  rapidily: 


after  the  fiftli  month,  howev 


<'r,  the  cervix  |)articip.".ie 


but 


slightly  ill  ( n!ii|ii 


son  with  the  rate  of  growth  manifested  in  the  upiier  part  of  the  organ.    Wliil' 
hypertrophy  of  t!ie  cervix  is  admitted  by  all,  the  (>xteut  to  which   this  portim: 


4 


PIIYSIOLOaY    OF  PltEa.XANCY 


147 


rmontcd  ;izc 

the  rapnlly 

not  tlirc'tly 
loroiiiro  ol'  tis- 
((jrossos  11)1  t(i 
ic  ovum  were 

t)ftbo  vi-in*. 

cervix.  '\\w 
){■  tlio  mu.'.)u> 
the  eoniK'i  tivr 
ul  the  luivcs, 
lieknoss  ol'  1.5 

bv  a  in;irkc(l 
lonths  ol'  pivi;- 
letcrs  {-^^;  iiMli) 

j.(.p<5i;ivo  e;ri>\vtii 

aSO  IVoiU    till    tn 

Imt  also  liy  the 
uire  tho  (Vhiumi- 

aseil.the  avtoric^ 
I  thciv  tortuosity 
i(,s  ntrr'nii,  wlucli 

hirly  well  ilcvi'l- 
are  iiiti  mutely 

nc'ctive  tissue  in 

do    IK^t    ('tillu|W' 

tnphatics  of  tlic 
rvcs  (lislriluUfil 
(/(nnjlioii  I'lrri- 

,(.es  (luriii'i  JMV'.;- 
retained  ;  suIk- 

nent,  and  Uvtli. 

a'l  a..d  til.'  pyii- 

sterior  diiiu'ibi"ii 
Late  ill  iivi":- 

vintr  to  tli<'  iluiii'- 

v  sejrment. 

th  e(Hi:d  raiiiility: 

iirlitly  in  rnini»;\i"- 
he  or^an.    ^^l"'' 

,\l,ieh  thi-  l"iiW' 


of  the  uterus  euiitrihiites  to  the  formation  of  the  excessive  uterine  sac  present 
iit  tlie  close  of  ])regiiancy  is  a  <iuestion  re.irardinj,'  which  authorities  j^reatly 
differ.  It  may  be  stated  at  once  that  the  older  view,  that  the  cervical  canal 
gradually  unfolds  itself  into  the  uterine  cavity  as  gestation  advances,  is  no 
lon.n'r  tenable,  since  the  investigations  of  :\Iiiller  so  clearly  showed  that  the 
cervical  canal  is  but  little  affected,  liegarding  the  question,  however,  as  to 
what  extent  the  ci'i'vix  ])articipates  in  the  production  of  the  uterine  sac— 
whether  it  retains  its  integrity  throughout  the  entire  canal  or  contributes  a  part 
of  Its  leuutli  to  theeularged  muscular  bag— the  solution  is  less  readily  at  hand. 
The  ditli  rcuccs  of  opinion  concerning  these  points  have  arisen  more  from 
diflfcreiices  in  the  iiiterpretatiim  of  certain  anatomical  details  than  in  their 
variation.  It  is  of  interest,  therefore,  to  note  the  structural  peculiarities  as 
repeat.'dly  observed  in  favorable  preparations  of  the  uterus  at  the  close  of 
presrnancy  or  at  the  i)eginning  of  labor.  The  classical  section  secured  by 
Bramic  oVa  woman  who  died  during  the  first  stage  of  labor  (Fig.  134)  shows, 


i/A 


.Silir.ti-i/i-l-'s  COIlt'ttlll:'!! 


/!,'ii:i,hiiy  ci  lii.'titi-J 


Antcriiir  T'li^'iiiiit  mi 


attachment . 


and  /oitu'/  itterint'  srt^- 
jtiriits  {Sr/tyordt'r  s Ciftt- 
tniction-rin^). 


r..uimhxyy  of  dilated 
txtt'rnal  os. 


Fin.  l:U.— Socliiiii  nf  Uic  imitiiriciit  canal  at  end  of  the  stas;c  of  ililatatimi,  from  a  woman  who  dieil 

(lurini:  lalior  iliraiuuM. 

in  addition  to  the  widely  dilated  os  externum,  whose  still-defined  })osition 
indicates  the  juncture  of  the  uterine  and  vaginal  ))ortions  of  the  parturi- 
ent canal,  two  annular  markings  of  much  interest.  The  uppermost  of  these 
markings  is  apjvirent  as  a  distinct  ridge  completely  encircling  the  uterine 
sac  and  s(>parating  the  thicker  and  more  voluminous  upper  segment  from  the 
more  dependent  lower  ]iart.  This  projection  was  described  by  Bandl  as  the 
dilated  true  os  internum,  and  as  defining,  consequently,  the  upper  limit  of  the 
cervical  canal ;  by  Schrouder  the  same  structure  was  r(>gai'de(l  as  a  coitfracfion- 
rivg  which  marks  the  juncture  of  the  upper  contracted  and  the  lower  dilated 
vierinc   siymcntx.      Some   distance    lower   a    second     ridge,    slightly    marked 


148 


AMi:iiICAS    TEXT- BOOK    OF    OBSTETJilCS. 


I    i 


II 


^^1     \ 


•',  '\ 


anteriorly,  but  more  foiispicuons  on  the  posterior  wall,  eonstitiitcs  IMiilln's 
ring,  wiiieli  JJancU  regards  as  indicating  the  upper  bonier  of  that  j)art  of  the 
cervical  canal  which  is  uiiatleeted  until  the  dilatation  of  labor  takes  plaop, 
Sehroeder,  on  the  contrary,  views  this  ridge  as  the  true  os  internum,  and  tlic 
zone  included  between  his  contraction-ring  above  and  the  one  in  qucMidn 
below  as  the  inferior  segment  of  the  uterus. 

From  the  foregoing  it  is  evident  that  the  significance  of  the  zone  inclndcd 
bctwci'U  these  two  rings  is  the  principal  (piestioii  at  issue,  some  authorities 
regarding  it  as  a  j)art  of  the  true  uterine  sac,  while  others  consider  it  to  n  piv- 
scnt  the  upper  jiart  of  the  cervical  canal,  that  unfolds  before  the  terminntidn 
ot'  gestation  and  thereby  contributes  to  tlie  extension  of  the  uterine  sac.  Ac- 
cording to  the  tirst  view,  the  cervical  canal  retains  its  integrity  tlirougliout 
pregnancy  ;  according  to  the  second,  the  canal  })articipatcs  to  a  limited  d(ir|.,.^, 
in  the  tbrmation  of  the  fetal  receptacle  by  dilatation  of  its  upper  portion 
toward  the  close  of  gestation.  While  both  views  claim  distinguished  iiMiiies 
in  their  support,  the  weight  of  evidence  seems  to  lead  to  the  acceptance  of  tlio 
doctrine  attributing  a  limited  jjarticipation  of  the  cervix  in  the  formatiuii  of 
tiie  uterine  sac  of  pregnancy. 

The  cervix  of  the  uterus  of  the  sexually  mature  virgin  is  about  e(|ii;il  in 
length  to  the  body  of  the  organ,  and  only  in  women  who  have  borne  childivn 
is  the  neck  relatively  shorter  (Kussmaul).     During  the  first  three  months  (,f 
pregnancy  the  cervix  partakes  equally  in  the  general  hypertrophy  afTectiiiu;  tlie 
uterus  (see  Fig.  137),  and  reaches  a  length  of  6  centimeters  (2|  inches)  or  iiioic, 
While  it  is  only  from  the  seventh  month  that  the  os  internum  exhibits  a 
tendency  to  exi)and  into  the  adjacent  uterine  cavity,  the  forces  leading  to  this 
unfolding  i)egin  their  inHiience  very  much  earlier — in  fact,  as  soon  as  tlii< 
portion  of  the  uterus  has  readied   its  maximum  hypertroj)hy,  or  from  ai)iiiit 
the  fourth   month  t)f  gestatit)n.      In  addition   to  the  effects  of  the  presence  of 
the  fetus,   the  traction   exerted    by   the   muscular  bands — retractor  fibres  nt' 
liayer — which  pass  from  the  outer  layers  of  the  uterus  into  the  round  and  the 
sacro-uterine  ligaments  is  an  important  fai'tor  in  causing  the  gradual  uiitliM- 
ing  of  the  cervical  canal.     The  dilated,  funnel-shaped  cavity  contributed  In- 
the  cervix  for  a  long  time  retains  its  fiattened  plicse  and  is  covered  by  ciliated 
columnar   epithelium  ;    its     nuicosa    finally    undergoes    conversion     '\\\U\  tlie 
decidiia  by  changes   identical  with  those  taking  place  in  other  parts  of  the 
uterine  mucous  membrane.     As  a  residt  of  these  changes  the  cervical  eiin;il 
shortens,  and  at  the  close  of  gestation  measures  from  ?t  to  4  centimeters  (l||n 
H  inches).     The  nnfblding  of  the  cervical  canal  takes  place  earlier  in  primi- 
jjarse,  owing  to  the  greater  resistance  t)f  the  comparatively  rigid  nuiscularti- 
sue  of  the  body  of  the  uterus,  until  now  unaffected  by  th:>  changes  of  prcL'- 
nancy.     These  changes  residt  in  a  general  softening  and  elasticitv  of  the  IhhIv 
of  the  uterus  from  the  begimiing  of  gestation,  the  cervix  retaining  its  iisiial 
firmness  during  the  earlier  months  almost  unimpaired.     Toward  the  closoul 
pregnancy  the  vaginal  portion  of  the  cervix  projects  less  and  less,  the  scein'Mi; 
shortening  being  probably  due,  in  part  at  least,  to  the  swelling  and  greater 


i^T* — 


I'llYSIOLOaV   OF  rilFJiXAXCY 


149 


ites  Miiller's 
t  part  of  the 
takes  place. 
luin,  aiul  the 
>  in  qiuvtidii 

zone  included 
ae  authorities 
or  it  to  repre- 
e  torminatidii 
i-ine  sac.     Ae- 
tv  throujiliout 
limited  decree 
upper  portion 
^uisheil  niiines 
■eptanee  of  the 
I  Ibi'uiatioii  of 

about  o([nul  in 
borne  ehihlreii 
bree  months  of 
iby  afti'ftiii'j;  tlic 
inebes)  or  more. 
i-num  exhiliitsu 
5  U'aclino;  to  tliis 
as  soon  as  tlii< 
,  or  from  alioiit 
tbc  presence  of 
raetor  fil)rcs  of 
0  round  aiitl  the 
jjnidual  uiifnU- 
contributi'd  liy 
ered  by  cifiatfil 
orsion     int"  i'"' 
icr  parts  of  tlio 
If  cervical  canal 
nti meters  (lit" 
earlier  in  \\nm- 
fid  muscnhiv  ti- 
■bano;es  of  \mp 
citv  of  the  hotly 
■tainin^^  its  usual 
•ard  the  closei.t 
less,  tbc  scoiio'i': 
liu'T  and  '^'renter 


proniinencc  of  the  snrronnding  walls  of  the  vagina  as  well  as  to  traction 
exerted  l)v  asecn<lin,ir  and  diverginjj:  nnisele-fibres. 

'I'he  ciian<ie  of  ixtsition  of  the  uterus  is  partieidarly  associated  witii  the 
rapid  ^rowtir  of  the  body,  hut  during  the  early  months  of  gestation  this 
erosvtirrcsidts  in  aiigmciited  autero-jtosterior  and  lateral  diameters  rather  tiian 
in  iircat  increase  of  the  longitudinal  axis  of  the  organ.  In  consequence  of  this 
increase  tn-etiicr  with  tiie  increased  anteflexion  resulting  from  the  additional 
wciglit  of  the  liypertroi)hied  tissue,  the  fundus  does  not  rise  above  the  sympiiy- 
sis  until  the  fourth  niontii.  The  fimdus  lies  usually  to  the  right  of  tlie  median 
line,  and  often  is  so  turned  on  its  long  axis  that  the  left  side  is  directed  forward. 
At  tlic  fifth  month  the  uterus  fills  the  hypogastrium,  from  which  time  on  the 
rise  in  the  jxisition  of  the  fimdus  is  so  regular  in  its  progression  that  under 
normal  conditions  this  detail  furnishes  valual)le  assistance  in  the  estimation 
of  tlie  stage  of  i)regnancy.  During  the  last  two  weeks  of  gestation  the  uterus 
sinks  within  tlie  pelvis,  the  fundus  taking  a  jiosition  somewhnt  lower  than 
before,  resting  downward  and  forward  from  7  to  8  centimeters  ('2f  to  31- 
inches)  below  tlic  ensiform  cartilage.  The  observations  of  Webster  led  this 
investif-ator  to  believe  that  the  sinking  of  the  uterus  not  infrequently  begins 
long  before  (sometimes  from  the  fifth  month)  the  last  two  weeks,  the  period 
usually  assiiinc<l. 

The  jiosivion  and  relations  of  the  full-term  uterus  alter  with  the  posture 
of  the  woman.  In  the  upright  positicm  the  fundus  bends  as  far  forward  as 
the  tension  of  the  distended  abdominal  walls  permits,  and  rests  against  the 
anterior  j)arietes.  In  the  recund^ent  position  the  uterus  lies  against  the 
lumbar  part  of  tlie  vertebral  column,  the  fundus  approaching  the  dia|)hragm 
above,  with  the  intestinal  coils  in  front  and  at  the  sides.  On  assinning  the 
lateral  ])osture  the  large,  flaccid  uterine  sac  becomes  dependent  on  the  corre- 
sponding side. 

Tiie  relations  of  the  prritoneum  and  the  uterus  become  disturbed  in  eonse- 
quence  of  the  altered  ])osition  of  the  latter  and  the  excessive  tension  caused  by 
its  enorinoiis  proportions.  The  layers  of  the  broad  ligaments  become  gradu- 
ally separated  and  tiie  entire  structures  shortened,  in  eonsecpience  of  which  the 
Falhipian  tubes  and  the  ovaries  are  drawn  toward  the  uterus,  against  which 
they  lie  at  the  close  of  gestation. 

The  changes  in  the  disposition  of  the  pelvic  peritoneum  during  pregnancy 
have  been  by  no  means  detinitely  determined,  and  opinions  dilfer  as  to  the 
forces  leading  to  such  alterations  as  well  as  to  the  extent  of  displacement. 
Regarding  the  lateral  arrangement,  it  is  evident  that  the  increase  in  the  trans- 
verse and  vertical  diameters  of  the  uterus  must  result  in  the  elevation  of  the 
peritoneum  on  each  side  of  the  pelvis  to  a  considerable  degree,  as  conclusively 
demonstrat(>d  by  the  observations  of  Barbour  and  Polk.  Tiie  arrangement  in 
front  and  behind,  however,  is  not  so  clear,  and  the  statements  of  authorities 
are  conflicting.  Polk  maintains  that  the  lowest  situation  of  the  peritoneum 
in  front  and  behind  the  uterus,  with  the  ex  "ciition  of  Douglas's  poneli,  in  the 
non-pregnant  condition   is   indicated  liy  a  line  passing  from  the  centre  of  the 


'J     ?■ 


I     ,  ! 


,& 


■y^ 


'■''prM,-.; 


loO 


AMKIilCAX    TEXT-IiOOk'   OF    OIiSTi:TliICS. 


k 


I 


\M 


svniplivsis  to  the  jiiiu'tiirc  i)t'  tlic  tliird  anil  lluirtli  sacral  viTtcbiu*.  At  iho 
tenniiiatioii  of  pregnancy,  l)iit  lMli>rc  the  usual  sinking  of  the  uterus  wiiliin 
the  pelvis  has  occurred.  tli<'  lowest  limit  of  the  peritoneum,  aceonling  to  the  .-aino 
observer,  has  ascended  and  is  now  marked  by  a  line  passing  from  the  centie 
of  the  symphysis  to  the  sacral  promontory. 

These  conclnsioiis  arc  not  eontii'med  i>y  examinations  of  frozen  sections 
n)ade  bv  Webster,  since  this  author  finds  the  inferior  limit  of  the  peritoiicul 
pouches  during  picgnancy  as  low  as  in  nidlipara'.  The  changes  in  the  ante- 
rior relations  of  the  peritoneum  of  the  vesico-uterine  fossa,  whereby  the  piri- 
toncum  becomes  -tripped  from  the  bladder,  are  usually  regarded  as  due  ti,  ili(. 
elevation  of  the  uterus  and  to  the  coiise(|ncnt  mechanical  effect,  which  togi  ihep 
are  also  supposed  to  exert  an  influence  by  which  the  floor  of  the  poucli  nf 
Pouglas  is  raised.  Wi'bstcr  attributes  the  stripping  of  the  peritoneum  I'ldin 
the  bladder,  on  the  contrary,  to  the  drag  caused  by  the  gradual  sinking  of  tjic 
pelvic  floor,  since  the  delicate  subserous  tissue  gives  way  under  the  tra<li(iii, 
and  the  peritoneum  eousiMpiently  does  not  follow  the  posterior  wall  of  tin 
bladder  in  its  descent.  The  extent  to  which  the  stripping  of  the  serous  cover- 
ing fakes  ])lace  depends  largely  upon  the  caj)acity  of  the  peritoneal  folds  <  xi>t- 
ing  in  the  uon-prcgnaut  condition,  as  when  these  are  ample  less  displaccniem 
follows  than  when  the  traction  camiot  be  met  with  supplementary  fi>siie. 
According  to  Webster,  the  central  portion  of  the  pouch  of  Douglas  at  no  time 
during  pregnauey  becomes  elevated  ;  this  author  further  points  out  that  the 
sinking  of  the  uterus  may  be  progressive  from  the  middle  of  pregnaiuv, 
resulting  in  the  marked  downward  displacement  of  the  organ  sonietiiiies 
observed  before  the  end  of  gestation. 

The  nujiiui  also  exhibits  changes  resulting  from  the  exaggerated  uutritien 
of  i)reu:iiancv.  These  changes  include  irreativ  increased  vascidaritv,  thickeiiiiiir 
and  softening  of  its  niucous  membrane,  whose  folds  become  less  rigid  and  (.'(iii- 
spicuous.  and  hypertrophy  of  the  uuiscidar  tunic  with  great  dilatation  of  tin' 
blood-vessels.  In  couse(|ui'Uce  of  the  large  (piautity  of  blood  contained  within 
the  less  compact  tissues,  the  vaginal  surface  presents  a  bluish  tint  in  contrii-t 
with  the  bright  red  of  its  usual  condition.  This  change  of  color  is  rcganleil 
bv  some  as  a  valuable  objective  sign  of  pregnancy. 

llic  e.vfcriKi/  (/iiilldln  likewise  participate  in  the  increased  hyperemia  uf  the 
generative  tract,  the  unusual  development  of  the  blood-vessels  and  the  lyiiijili- 
atics  inducing  a  condition  charactcri/cd  by  softening  and  greater  infiltratiim  et' 
the  tissues,  hence  the  vulva  ap|)ears  particidarly  prominent.  The  exetssive 
vascularity  of  the  parts  finds  expression  in  the  dusky  hue  and  the  unusual 
activity  of  the  sebaccnus  follicles  and  the  sweat-glands  of  the  labia. 

T/ic  (trllcii/(ifli)iis  of  (he  pclrin  exhibit  to  a  limite<l  degree  changes  due  to 
])regiiancy.  These  changes  .'U'(>  manifested  by  an  unusual  softening  and  v;wii- 
larity  of  the  iuterarticular  cartilage,  particidarly  that  of  the  symphysis,  in 
consequence  of  which  there  takes  j)lace  a  certain  amount  of  loosening,  attciidul 
in  some  cases  with  slight  movement.  Whatever  temporary  increase  in  tlie  pil- 
vie  boundary  may  thus  be  secured,  the  gain  at  best  is  j)robably  very  insignilieaiit, 


'■^■A* 


vx.  At  ilio 
Items  wilhiu 
i>;  to  the  i^aino 
n  the  eoiitre 

;)/.en   soctiiiiis 
he  peritiiiitiil 
i  in  the  antc- 
rehy  the  pciM- 
as  (hie  tn  the 
liich  to<:(  ilior 
tlie  poucli  (if 
itotieiini  1111111 
iinkin^  nl'  the 
•  the  t  radii  III, 
r  wall  of  till' 
^  ."ierous  I'livcr- 
ml  loUls  (■xi^t- 
s  disphicciiicm 
leiitary   tis.-iu'. 
ifhiH  at  no  time 
ts  ont  that  tin- 
ot"  pre<riiaiuy, 
trail  soiuctiiiiis 

rated  nutritidii 
rity,  tliiekciiiiis; 
riirid  and  •■nii- 
latatiun  of  tli- 
ontained  within 
tint  in  couti'ibt 
Ltlur  is  re,<:anloil 

vpereniia  of  the 
and  tlie  lymiili- 
r  infiUratiiiiHif 

The  extrssive 
nd  the  unusual 
ic  hd)ia. 
(•hanji;es  due  to 
niiiii:  and  viwii- 

symphysis,  in 
iseninj:,  attciidi'l 
rea.'^e  in  tlic  pi- 
(TV  insiii-niliranl, 


"^ 

.::i- 


riiYsioLoay  of  rRKaxAXcv. 


151 


Other  ehaiiiie-  atl'ecting  the  pch'lc  floor  and  the  parts  closely  connected 
thorewitli,  snclfas  the  ha.^e  of  the  bladder  and  the  urethral  orifice,  result  from 
the  downward  displaeeinent  of  the  structures  closing'  in  the  outlet  of  the  pelvis. 
The  jH'lvie-tloor  projection  is  pro.<rressively  increa.^ed  from  'l.'i  centimeters  (1 
i„rii)  ill  the  nullipara  to  !).'»  centimeters  (;.\}  inches)  at  the  end  of  pregnancy; 
the  -kiii-distaiiec  t'roin  tlie  .symphysis  to  the  coccyx  is  almo.st  doul)led. 

The  foliowiKj:  table,  compiled  by  Web.ster,  ba.sed  on  the  olwervations 
of  himsdf  and  of  other  observers,  displays  some  of  the  more  imiKirtant 
variations  induced  iiy  pregnancy  within  the  parts  in  relation  to  the  pelvis: 


p.' 

vic'-lli 

ur 

Sk 

l.-ilislMlH 

I)i^ 

lilMCL' 

i>t 

I>i. 

\:\W<- 

ol 

l)i.- 

tllMC'l' 

1.1 

Th 

ickllr^ 

<;  u 

Df 

|.th  of 

lltl 

Dh 

tilllCC 

ot. 

\)\> 

tllllCl' 

ol 

Piftiiiici' 

ol 

Distiiiici' 

of 

iirnji'dioii •   ■ 

•r  from  cnccvx  losyini'liyl!* 

iirilhnU  oriiicc  liclow  liriiii     .  ^ 

invllinilorilHvlii'lowsyiiiiplivMM      .   .          . 
juiKiiiiM  111  liliiilil'T  mill  iiri'llini  lirlow  brim 
f  Ilsxuc  liclwciii  i>ubi'S  mill  viif,'iiiii 

,.,•,,  vi-inil  I'l'Uili  I'i'l""'  l'"">         •,  •    ■    •    • 

,,<  rxtii'iiuiii  l"l"v\- brim  posteriorly  .... 

oscxti'rniiiu  li'low  brim  iiiitrriorly  .... 

o<  iiitrrimm  b>'low  brim  posteriorly  .... 

osiuterimm  belinv  luimuiiteriurly  .... 


NcL-     '    Fifth      Ekhith      Ninth 
LiPAKA.     Month.     Month.  ,  Month. 


Cm. 

Cm. 

Cm. 

Cm. 

i") 

4.1 

.").(l 

«.,5 

!;)..-> 

14.0 

10..S 

•£xb 

fi.i 

0.7 

0.7 

■J..^ 

0.0 

U'.f) 

•A:l 

■A:l 

i\.\ 

7.6 

o.:i 

7.0 

i.ii 

'.'.8 

;i.r. 

4.4 

:^.i 

r..'> 

0.7 

0.0 

0.3 

11.1 

8.7 

.H.O 

0.:! 

11.1 

8.7 

IJ.J 

:..7 

7.1) 

7.0 

0.0 

0.7 

7.9 

7.0 

0.7 

The  (ilxlniiiiiKil  lail/ff  manifest  the  enormous  distention  to  which  they  arc 
subiceted  bv  tiie  formation  of  more  or  le,<s  conspicuous  lines — the  struv  f/ravi- 
dantm — whicii  are  found  in  over  90  per  cent,  of  pregnant  women.  These 
lines  ai)pear  as  reddisii  or  lihiisli,  sometimes  lighter,  streaks,  which  are  most 
numeroiis  and  well  marked  during  the  la.'st  months  of  pregnancy  over  the 
lower  part  of  the  abdomen,  particularly  at  the  sides.  They  extend  as  curved 
or  simioiis  liiii's,  and  they  persist  for  some  considerable  time  after  the  termina- 
tion of  gestation,  gradually  becoming  whiter  and  more  cicatricial  in  appearance. 
Thc.-;e  .striio  are  due  to  displacements  and  partial  ruiiture  and  atrophy  of  the 
connoetive  tissue  of  the  (lce|)  layer  of  the  greatly  di.stended  cutis.  They  are 
not  peculiar  to  pregnancy,  but  may  a])pear  even  in  men  whenever  the  skin  is 
sulijccted  to  unusual  stretching,  as  from  tumor.s,  ascites,  and  other  causes ; 
furthermore,  they  are  not  limited  to  the  abdomen,  but  in  pregnancy  are  seen 
on  the  nates,  the  thighs,  and  the  breasts. 

The  linea  alba  also  not  infrequently  becomes  broader,  and  in  mnltipane  the 
recti  muscles  are  .sometimes  .-^o  widely  separated  that  the  mass  of  the  uterus 
appears  between  as  a  median  projection. 

The  umhU'wm  is  aft'eeted  by  the  increasing  bulk  of  the  abdominal  contents, 
and  by  the  fifth  month  begins  .o  exhibit  a  diminution  in  its  depths;  bv  the 
seventh  month  its  dejiressioii  I  .^  become  obliterated,  and  during  the  remaining 
weeks  it  becomes  gradually  everted  until  the  umbilicus  forms  a  rounded 
elevation. 

Tlw  v)(nn)i)(trii  f/lands,  coineidently  with  the  changes  affecting  the  genera- 
tive organs,  undergo  important  alterations  during  the  preparation  for  their 
assunijition  of  the  stage  of  functional  activity.     These  changes  early  induce 


■  i 


^, 


V] 


/5 


/ 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


1.0 


145 


I.I 


12.0 


■  2.2 

iu  „^    liii 


■  40 


11.25  1111.4 


HiotDgraphic 

Sciences 

Corporation 


21  WEST  MAIN  STREET 

Wlki^ViR  t«Y    MSSO 

(716)S/2-4503 


m 


n 


\ 


iV 


\\ 


^ 


6^ 


i^.^ 


,.^^ 


6^ 


152 


AMKIffCAiY   TKXT-BOOK   OF   OliSTETRIVS. 


I        :   1 


'i. 


"I 

1  r 


greater  general  voliimc  in  the  hreasts,  <lei)en(ling  upon  an  increase  both  of 
the  interlobular  connective  tissue  and  fat  and  of  the  true  secreting  tissue  of 
the  glands.  The  enlargement  of  the  breasts  begins  as  early  as  the  second 
month,  but  it  does  not  become  conspicuous  until  toward  the  middle  of  preg- 


Fio.  IST).— VlrKin  nipi)le  and  areola:  1,  iiippk';  'J,  iin'ola  ;  ;i,  tubercles  of  MorKiij,''" ;   '.  crevlec  at  base 

of  iiip|)le. 

nancy.  On  touch  the  periphery  of  the  organ  presents  uneven  and  knotty 
masses  consisting  of  the  enlargal  acini  and  lobules  of  the  rapid-growing 
glandular  tissue  inibedde<l  within  the  areolar  and  adipose  tissue.  The  ulti- 
mate compartments  of  the  secreting  structure  become  earliest  enlarged  ;  conse- 


Via.  136.— Nipple  and  breast  of  proKnancy :  1,  nipple  with  openinRS  of  milk-duets;  2,  primary  areola; 
3,  glands  of  Montgomery  ;  T),  secondary  areola ;  (i,  venous  circle  of  llaller. 

quently  the  increase  is  first  noticeable  at  the  jjcriphery,  afterward  extending 
along  the  course  of  the  larger  ducts  toward  the  centre  of  the  organ.  The  dis- 
tention of  the  skin  due  to  the  augmentetl  volume  of  the  glands  is  especially 
marked  over  the  periphery,  in  which  location  rcnldish,  bluish,  or  whitish  striae, 


I 


PHYSIOLOGV   OF  PREGNANCY 


153 


nw, 


similar  to  those  seen  iijm)ii  the  distendetl  ubdoiuinal  walls,  ;!j>})ear  c  manifes- 
tations of  tlie  nnusnal  tension  of  the  integument.  The  veins  are  also  enlarged, 
juid  show  through  the  tightly  drawn  skin  as  a  network  of  blue  lines. 

The  nipple  shares  in  the  general  hyj)ertrophy  of  the  organ,  Wcoming 
enlarged,  more  readily  erwtile,  and  sensitive.  The  surrounding  rosy  areola 
of  the  virgin  (Fig.  135)  is  gradually  replaced  by  a  more  deeply  colored  area, 
whose  tint  by  the  middle  of  pregnancy  varies  from  the  slight  brownish  discol- 
oration seen  in  women  of  light  complexion  to  the  dark  brown  or  almost  black 
.'olor  seen  in  bnniettes  (see  PI.  17).  The  areola  by  the  eighth  or  the  ninth 
week  Ix^omes  softer  and  more  elevated  than  usual,  and  its  sebaceous  glanils, 
from  one  to  two  dozen  in  number,  greatly  enlarge,  those  at  the  periphery 
i)econ>ing  particidarly  conspicuous.  These  enlarged  sebaceous  follicles  consti- 
tute the  glands  of  Montgomery  (Fig.  136).  The  mammary  areola  varies  from 
'J. 5  to  4  centimeters  (1  to  1^  inclies)  in  diameter,  although  these  dimensions 
iiiiiy  greatly  \w  exceodwl.  In  the  fifth  or  the  sixth  month  of  pregnancy  an 
additional  irregularly  pigmented  area,  the  so-called  '*  secondary  areola,"  some- 
times appears  (see  PI.  17). 

After  the  third  month  of  gestation  the  breasts  contain  a  thin  fluid,  the 
colostrum,  which  may  bo  pressetl  out  of  the  newly  formed  glandidar  tissue. 
This  fluid  consists  of  a  thin  albuminous  medium  containing  numlH>rs  of  fat- 
drops,  displaced  epithelial  cells,  and  characteristic  aggregations  known  as 
"colostrum-corpuscles." 

2.  General  Chaneres. — Pregnancy,  while  a  purely  physiological  con- 
dition, creates  great  and  important  changes  in  the  maternal  organism. 
These  changes  pertain  to  the  different  systems  and  organs  of  the  Ixxly ;  to 
some  more  than  to  others.  The  general  changes  in  the  maternal  organisni 
dcpeiul  to  a  great  extent  on  the  alterations  in  the  blood  and  in  the  functional 
modifications  of  the  nervous  system.  The  jiregnant  woman  has  to  provide 
nutriment,  to  breathe,  to  maintain  blood-circulation,  to  secrete  and  to  excrete 
tor  two  individuals — herself  and  her  fetus.  All  this  means  that  extensive 
changes  in  the  general  system  must  occur.  If  these  changes  are  carrii'd  to  a 
reasonable  extent,  health  is  maintained  and  the  system  liecoines  fortified,  as 
it  were,  for  the  coming  parturition  ;  but  when  these  changes  are  developed  to 
excess,  disorders  complic"ating  the  pregnancy  are  jiroduced. 

Changes  in  the  Circnlaton/  Sydem. — Formerly  it  was  supposed  that  preg- 
nancy was  accompanied  by  l)lo(Kl-changes  like  unto  ])lethora,  and  it  was  almost 
universally  inferred  that  the  attending  symptoms — the  headache,  the  ring- 
ing in  tl:a  ears,  the  flushed  face,  the  cardiac  palpitation,  and  the  dyspnea — 
were  the  results  of  these  alterations.  Consecpiently  it  was  a  very  common 
|)ractice  with  physicians  many  years  ago  to  bleed  pregnant  women  from  one 
to  many  times  at  intervals  during  the  latter  months  of  pregnancy.  Enormous 
((uautitics  of  blood  were  thus  extracted  by  venesection.  A  wonderful  revolu- 
tion has  taken  place  in  the  treatment  of  pregnant  women  during  the  past 
twenty-five  years,  owing  to  more  rational  ideas  of  the  real  condition  of  the 
circulatory  fluid. 


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111  pregnancy  the  composition  of  the  bloiHl,  which  is  increased  in  quantity, 
is  profbtmiUy  ahercil,  as  many  careful  analyses  prove.  The  quantity  of  blood 
present  beftn'e  pregnancy  would  Ixi  iiKuUHpiate  to  meet  the  condition  of  preg- 
nancy. Thus,  the  blo(Rl  is  increased  in  its  watery  elements  and  white  corpus- 
cles, but  is  made  deficient  in  the  element  of  albumin,  is  increased  materially 
in  the  amount  of  fibrin,  and  is  diminished  in  the  proportion  of  retl  corpuscles 
— conditions  of  anemia,  hydremia,  and  liyj)eriiiosis.  This  hyi^rinosis  is  also 
augmented  after  parturition,  because  at  this  time  large  quantities  of  effete 
materials  are  thrown  into  the  circulation. 

Instead  of  a  blood-change  called  "plethora"  being  present,  it  should  be 
recognized  as  one  of  anemia  and  hydremia  orof  ehlorof  is.  If  called  "  plethora,'' 
it  should  be  named  scroun  plethora.  Individual  variations  in  the  quantity 
and  quality  of  the  blood  are  depen<lent  on  many  conditions  of  hygiene  and 
diet ;  poor  hygiene  raluces  the  blootl  to  marked  chlorosis  and  hydremia.  The 
surrender  of  the  maternal  nutritive  material  to  a  growing  fetus  and  a  devel- 
oping uterus,  to  pelvic  tissue,  and  to  glands  means  a  great  tissue-drain  on  the 
maternal  circulatory  fluid.  As  these  changes  in  blood-quality  are  most  marked 
at  the  close  of  utero-gestation,  the  attending  phenomena  must  be  those  that 
are  most  strongly  shown.  Certain  thrombotic  affections  observed  in  preg- 
nancy and  after  delivery  are  thus  explainable.  In  place  of  the  blood-supply 
at  this  time  l)eing  improved  by  bloodletting,  it  must  clearly  be  evident  that 
venesection  is  strongly  contra- indicated,  for  it  tends  further  to  aggravate  the 
abnormal  alteration.  To  C'azeaux  are  we  indebted  for  much  of  our  present 
knowledge  of  the  blood-changes  of  pregnancy. 

Certain  viscera  of  the  circulatory  apparatus  are  also  much  modified  in  size 
and  in  function.  The  heart  becomes  physiologically  hypertrophied — a  I'act 
known  for  many  years  and  determined  by  numerous  observations.  This  liy- 
pertroi)liy  is  u  wise  provision  of  nature  to  meet  the  increasing  exigencies  of 
the  blood-supply  in  the  advancing  months  of  pregnancy.  Hypertrophy  of  the 
heart  is  constantly  present  to  a  considerable  degree,  the  whole  weight  of  this 
organ  being  one-fit th  more  in  the  pregnant  than  in  the  non-j)regnant  state. 
The  left  ventricle,  the  profiling  part  of  this  organ,  is  alone  att'ected.  This 
physiological  hypertrophy  remains  during  the  period  of  lactation  in  those  who 
suckle  their  children,  otherwise  the  organ  quickly  diminishes  in  size;  hence 
in  women  who  have  borne  many  children  the  heart  may  remain  ])ermanently 
large.  Incident  to  the  total  blood-supply  in  pregnant  women  the  maintenance 
of  tlie  cinuilation  demands  either  greater  frecjuency  in  the  heart-contractions 
or  an  increase  in  the  entire  quantity  of  blood  entering  the  left  ventricle.  The 
multiplied  vascular  elements  of  the  jK'lvic  organs  also  increase  the  labor 
thrown  on  the  heart. 

Disturbances  of  the  circulatory  organs  are  very  often  seen.  Thus, 
])alpitation,  while  purely  sympathetic  in  the  earlier  months  of  gestation, 
later  come  on  from  the  encroachment  of  the  enlarged  and  enlarging  uterus 
j)usliing  up  th(!  diaphnigm  and  embarrassing  the  heart's  action.  The 
blood-changes   of  anemia  and   of  hydremia   may  be  so  great   that   edema 


PJIYSIOfAHiV   OF  PREGXAXVY 


155 


may  be  observed  in  the   feet  aiul    may  extend  upward  to  the  thiglis  and 
the  labia  majora. 

Other  orjians  are  likewise  increased  in  size.  The  liver  and  the  spleen  are 
enlarged.  The  spleen  norniully  increases  in  size,  owing  to  an  in)i>ortant  rela- 
tion to  the  quantitative  change  in  the  circulatory  fluid.  A  fatty  degeneration 
shows  itself  in  both  the  liver  and  the  spleen  in  women  who  have  suddenly 
(lied  after  labor.  Xuinerous  small  yellow  spots  are  seen  scattered  through  the 
liver — fatty  deposits  in  the  hepatic  cells.  The  thyroid  gland  is  increased  in 
>izo.  In  women  in  whom  there  is  a  predisposition  to  this  enlargement,  preg- 
nancy may  further  stimulate  the  growth  and  bring  about  permanent  structural 
clianges.  The  eidargement,  of  this  organ  is  thought  to  sustain  some  relation 
to  changes  in  the  heart  and  the  blood-glaiu'.idar  system. 

Changes  in  liespi ration. — Pressure  of  the  enlarging  uterus,  through 
mechanical  action,  causes  changes  in  the  respiratory  organs.  An  upward 
movement  of  the  diaphragm  lessens  the  longitudinal  dimensions  of  the  thorax. 
Some  embarrassment  of  the  respiration  follows  this  decrease,  notwithstanding 
that  there  is  some  increase  in  the  breadth  of  the  lower  thorax.  In  the  last 
two  weeks  of  utero-gestatioii,  owing  to  the  limited  shortening  of  the  cervix 
iitiTi  and  to  the  settling  down  of  the  fetus  in  utero,  respiration  and  circulation 
Ixrome  easier. 

As  more  blood  must  naturally  be  jM'ovided  to  noin-ish  the  woman  and  her 
child  during  pregnancy,  this  extra  blood  nuist  not  only  be  properly  circu- 
liitid,  but  must  also  be  duly  purified.  The  elimination  of  carbonic-acid  gas 
l>y  respiration  is  therefore  increased  in  pregnancy. 

The  resj>iratory  organs  nmy  be  dcrangitl  by  cough  and  dyspnea  originating 
tVoin  nervous  sympathy  in  the  earlier  months  of  pregnancy.  In  the  later 
months  of  gestation  the  derangement  is  from  encroachment  of  the  gravid 
uterus,  interfering  with  normal  respiration.  These  phenomena  are  mostly 
(>l)sorved  when  there  is  twin  pregnancy  or  dropsy  of  tin;  amnion. 

ClKUi[/Cfi  in  the  lYKjextivc  Si/ntem  <ni>l  in  Xutrition. — The  pregnant  woman 
provides  the  nutritive  pabidum  by  which  the  growing  organs  are  sustained 
and  by  which  the  fetus  and  its  apjK'udages  are  built  up.  She  must  therefore 
digest  more  food,  form  more  blocnl,  and  increase  the  activity  of  the  secretory 
and  exi-retory  organs.  Very  few  W(»men  escape  such  troid)lcs  of  digestion  as 
nausea  and  vomiting.  In  the  earlier  months  the  appetite  is,  as  a  rule,  capri- 
eioiis.  Further  al(»ng  the  appetite  and  the  digestion  increase  in  activity, 
thereby  assisting  in  improving  the  general  nutrition. 

An  increase  of  weight  takes  place  in  normal  cases,  irrespective  of  the  grow- 
ing uterus  and  the  ovum.  The  average  gain  anu>iu)ts  to  from  ten  to  fil"teei> 
pniinds  in  the  whole  nine  months,  being  greatest  in  the  last  two  months.  This 
increase  is  not  far  from  one-thirteenth  of  the  whole  body-weight,  and  it  is 
progressive  from  the  beginning  to  the  end  of  jtregnancy,  notwithstanding  the 
n:iiisea  and  vomiting. 

The  adipose  tissue  increases  most  in  bidk,  especially  in  the  latter  half  of 
gestation.     These  deposits  are  most  noticeable  in  the  mammary  glands,  in 


'     V 


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AMERICAN   TEXT- HOOK   OE   OBSTETRICS. 


ill 


iM;l«, 


i      i' 


i^' 


!    M 


j  ! 


the  alKlominal  parietcs,  in  the  hips,  and  in  tlie  omentum.  The  wliole  figure 
becomes  fuller  and  rounder.  All  this  increase  is  but  so  much  stored-uj)  ])()ten- 
tial  energy,  to  he  utilize*!  after  delivery,  when  this  energy,  by  the  metabolism 
of  the  body,  assists  the  manimary  function. 

Rokitansky  has  spoken  of  the  lamelltp  of  osseous  material  on  the  inner  sur- 
face of  the  skull  and  the  frontal  and  parietal  bones  external  to  the  dura  mater, 
called  "puerperal  osteophytes."  Those  lamellte,  which  are  irregular  in  shape, 
consist  of  calcium  carbonate,  traces  of  phosphates,  and  organic  matter.  They 
are  not  jKJCuliar  to  pregnancy.  Robert  liarnes  thought  they  sustained  son)e 
relation  to  the  calcareous  changes  found  in  the  placenta  and  to  the  forthcoming 
milk.  The  temperature  of  the  bmly  in  pregnancy  is  not  materially  changt  1, 
although,  according  to  some  authorities,  it  is  slightly  lower  in  the  morning 
than  during  the  day. 

CImnyca  in  the  Skin,  the  Gait,  and  the  Osteons  Elements. — The  functional 
activity  of  the  sebaceous  glands,  the  sweat-glands,  and  the  hair-follicles  of 
the  skin  is  increasetl  by  pregnancy.  It  has  Iwen  ssiid  by  Robert  IJarnes  that 
the  growth  of  the  hair  is  invigorated  during  pregnancy  when  prior  to  ges- 
tation the  hair  had  been  falling  out. 

Pigmentations  are  quite  generally  observal  in  spots  over  the  body,  the 
linejB  albicantes  being  most  noticeable.  They  are  also  seen  about  the  ab<lomen, 
the  navel,  and  on  the  face.  Around  the  nipples  these  deposits  may  be  seen  in 
the  form  of  areola?,  primary  and  secondary  (see  PI.  17).  These  pigmentations 
vary  much  in  extent  and  in  intensity  in  different  subjects,  being  more  marked 
in  brunettes  than  in  blondes.  Seldom  do  these  deposits  completely  disapj)ear, 
but  they  are  always  less  after  parturition.  It  is  not  unlikely  that  they  are 
the  result  of  a  teni])orary  hypertrophy  of  the  suprarenal  cjipsules. 

There  is  also  a  change  in  the  gait  of  a  pregnant  wonian.  To  ])reserve  the 
centre  of  gravity  of  the  body  the  head  and  shoulders  must  be  thrown  back- 
ward. This  action  produces  a  change  in  the  gait  most  noticeable  in  women  of 
low  stature. 

Owing  to  the  drain  on  the  osseous  elements  of  the  blood  during  ])regnancy 
by  the  growing  fetus,  there  is  always  a  considerable  delay  in  the  union  of 
fractured  bones. 

Changes  in  the  Urine. — Owing  to  the  hydremic  condition  existing  during 
[)regnancy,  the  urine  becomes  more  abundant  and  of  a  lower  specific  gravity. 
It  is  thought  that  the  kidneys  Iwcome  enlarged,  which  is  probably  the  case. 
This  change  in  the  size  of  the  kidneys  has  somewhat  to  do  with  the  increase<l 
(juantity  of  urine,  but  more  probably  the  more  active  function  is  attributable 
to  the  increased  blo(Ml-supj)ly  and  to  the  increased  arterial  tension. 

There  are  also  (pialitative  changes  in  the  urine.  The  chlorids  have  been 
found  increased,  while  the  phosphates  and  sulphates  are  decreased,  due  to  their 
use  in  the  growth  of  the  fetus.  The  kiestein  |u*llicle  found  u|M)n  the  urine 
of  jm'gnant  women  several  hours  after  its  excretion  has  no  necessary  relation 
to  jn-egnancy,  l)ecause  it  is  found  on  the  urine  of  virgins  and  on  that  of  men. 
The  glucose  found  in  the  urine  of  many  pregnant  women  in  variable 


pifvsioLoay  of  preg nancy. 


157 


<(iiantities  has  been  referred  ti)  a  putlutlogiciil  increase  in  tlie  jrlycogenic  func- 
tion of  the  lis'cr.  Sugar  is  present  in  the  nrine  of  almost  every  woman  at 
."(ime  jwriod  of  hictation  Ix-ing  inflnenccd  inneii  hy  the  character  of  the  diet. 
Its  presence  dejMinds  on  tlie  (piantity  and  qnality  of  the  milk,  dimiui8hing  as 
I  ho  lacteal  secretion  is  snppre.ssed. 

Traces,  more  or  less  in  quantity,  of  albumin  are  found  in  the  urine. 
Authorities  differ  as  to  the  frecjuency  of  albuminuria  in  pregnancy.  Hchrowler 
siivs  that  the  urine  of  all  pregnant  women  will  contain  albumin  in  from  3  to 
")  jwr  cent. ;  other  authors  have  contended  for  a  much  larger  jwrcentage 
(tVom  20  to  30).  Unquestionably,  albumin  is  found  in  the  urine  of  a  very 
large  number  of  i)rcgnant  women.  No  regard  being  paid  to  the  numl)er  of 
iircgnancies,  nor  to  the  ])revious  con(litit)n  of  the  kidneys,  the  presence  at 
Miine  time  of  a  trace  of  albumin  will  l)e  found  in  a  very  large  nnml>er 
(if  cases.  The  writer,  who  instituted  these  examinations  in  a  large  clinical 
experience  in  hospitals,  has  found  the  frcipicncy  to  be  at  least  30  jKir  cent. 
This  frequency  must  Ik?  inquircKl  into  with  reference  to  its  etiology.  In  the 
fust  place,  quite  a  nuniber  of  pregnant  women  have  a  physiological  albumi- 
nuria. The  trace  of  albumin  is  then  small  and  of  short  duration  ;  there  are 
iKt  tube-casts,  and  no  attending  morbid  symj)toms.  Every  authority  must  coiu- 
clih'  with  Miirickc,  that  all>uminuria  is  relatively  commoner  during  labor  than 
(luring  pregnancy.  A  proh)nged  labor  is  oflener  thus  accompanied  than  is  a 
short  and  easy  labor.  Albuminuria  is  often  confined  exclusively  to  the  periml 
i.r  labor.  The  (Hrcnrrence  of  albuminuria  during  labor  is  explained  by  the 
tlieory  that  the  reflex  vaso-motor  spasm  of  the  renal  arteries,  resulting  from 
uterine  contractions,  causes  renal  anemia.  This  theory  has  the  support  of 
Tvler  Smith,  Spiegelberg,  and  others. 

Renal  albumiiuu'ia  may  appear  early  in  pregnancy,  before  there  is  any 
possible  renal  venous  stagnation  from  pressure,  being  the  result  purely  of 
reflex  irritation.  Why  should  not  this  irritation  at  times  be  transferred  from 
the  uterus  to  the  kidneys  as  well  as  to  the  stomach  ?  Such  an  explanation  must 
Imhl  good,  if  albumimiria  is  present  early  in  jjregnancy,  the  urine  having  been 
iiurnial  iM'forethat  time.  There  is  an  intimate  comiection  between  the  nervous 
ganglia  of  the  pelvis  and  the  nerve-filaments  of  tiie  kidneys. 

The  hydremic  state  of  the  bhuKl  incident  to  pregnancy  is  at  times  a  cause 
of  albumimu'ia.  An  increased  arterial  tension  which  exists  in  pregnancy  may 
he  productive  of  albuminuria.  The  urine  of  a  pregnant  woman  may  be 
alhntninous  from  causes  not  nephritic,  yet  morbid.  Thus,  it  may  be  albumin- 
ous from  blood,  from  mucus,  or  from  pus  in  the  tirine,  each  of  which  may  be 
cystic,  vaginal,  or  uterine  in  origin. 

The  prevalence  of  albuminuria  during  ))regnaney  may  be  classified  as  fol- 
lows: {(()  Crises  in  which  it  was  present  when  conception  took  place,  a  chronic 
Hright's  disease  of  some  type,  with  albumiiuiria,  having  existed  before  jH'eg- 
nancy ;  (/>)  Cases  in  which  albuminuria  from  sub-acute  or  chronic  Bright's 
disease,  the  result  of  scarlet  fever,  etc.,  ha<l  existed  years  Ix^fore,  and  from 
which  disease  a  recovery  seemingly  had  taken  place :  at  least  there  was  uo 


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I 


li. 


trace  of  albiiniiii  in  tlic  nrine  at  tlio  time  of  j'oncoption  ;  (c)  Cases  in  wliicli  tlie 
existinj;  ])re<rnan('y  or  parturition  was  attended  hy  an  allunniniiria,  it  haviiifj 
never  existed  before. 

In  tlie  first  two  divisions  of  the  above  elassifieation  prefjinaney  aggravated 
or  eansed  a  retnrn  of  tlie  albumin.  In  the  last  division  albuminuria  started 
during,  and  had  been  clearly  attributai)le  to,  the  eonJition  of  pregnancy. 

Excepting,  then,  the  cases  in  which  the  albuminuria  has  been  due  to 
physiological  or  pathological  causes,  not  nej)hriti(!,  and  not  attributable  to 
pregnancy,  the  author  is  disposed  to  think  that  the  estimate  made  by  Sell roeder 
(.']-5  per  cent.)  is  not  wide  of  the  ai^tual  facts. 

The  oldest  theory  is  that  albuminuria  and  kidney  disease  during  pregnancy 
are  due  to  mechanical  ju'essure  of  the  gravid  uterus  on  the  renal  blood-ves- 
sels, especially  on  the  veins.  All  admit  that  this  mechanical  ])ressure  pre- 
disposes to,  if  it  does  not  excite,  the  disease.  This  doctrine  has  been  ably 
advocated  by  Simpson,  Carl  Brown,  and  Cazeaux.  It  is  not  so  much  the 
renal  pressure  alone  as  it  is  the  intra-abdominal  pressure  that  so  acts.  Support 
of  this  theory  is  obtained  from  the  following  facts : 

Albuminuria  is  more  conunon  in  the  latter  half  than  in  the  fii-st  half  of 
pregnancy.  More  cases  exist  among  ]»rimij)ara^,  in  whom  there  is  great  ab- 
dominal pressure  from  the  rigid,  unyielding  aUlominal  Malls.  Albuminuria  is 
greater  in  twin  pregnancy  ;  it  is  also  common  when  there  is  a  severe  pressure 
from  large  uterine  fibroids  or  from  ovarian  cysts.  Tight  lacing  and  heavy 
skirts  aggravate  the  disease.  It  is  less  frequent  during  gestation  than  (luring 
labor,  when  pressure  is  greatest ;  it  diminishes  after  labor  or  after  the  removal 
of  the  abdominal  tumors.  Any  cause  that  brings  about  renal  venous  stasis  pre- 
disposes to  and  excites  ne])hritis.  For  instance,  valvular  defects  and  j)ul- 
monary  emphysema,  as  well  as  pregnancy,  may  develop  true  parenchymatous 
inflammation  of  the  kidneys. 

No  one  of  all  the  above  tlieories  or  facts  constitutes  a  sufficient  explanation 
for  all  cases.  Each  fact  or  theory  may  answer  for  some  cases;  two  or  more 
combined  afford  a  better  soluticm  for  most.  All  can  recognize  the  influence 
of  intra-abdominal  tension  with  pressure  on  the  vena  cava  and  its  branches, 
esi)ecially  in  priniiparous  women.  The  sinking  of  the  fetal  head  into  the  true 
pelvis  in  the  last  two  weeks  of  pregnancy,  while  it  improves  the  respiration 
and  circulation  in  general,  does  not  relieve  the  renal  venous  stasis.  WhlK- 
most  women  feel  lighter  and  freer  during  these  last  two  weeks,  owing  to  the 
settling  down  of  the  fetus  from  the  shortening  of  the  cervix,  the  intra- 
al)doniinal  and  jK'lvic  ])ressure  is  not  diminished. 

So  great  is  the  significance  of  albuminuria  during  pregnancy  that  its  ])res- 
enc(!  should  always  Imj  watched  for.  Frequent  physical,  chemical,  and  niicro- 
scopi<'al  examinations  of  the  urine  shotdd  be  made  in  the  latter  months  of 
pregnancy.  If  the  presence  of  allniniin  is  but  slight,  it  may  be  physiological, 
or,  if  pathological,  no  noticeable  symptoms  may  be  observed  ;  but  if  it  is  con- 
siderable and  pei'sistent,  and  if  it  occurs  early  in  pregnancy,  the  prognosis  is 
grave.    Albuminuria  is  then  a  condition  full  of  ill  omen,  although  it  is  always 


PHYSIOLOGY   OF  PREGNANCY, 


159 


susceptible  of  anit'lioration  by  well-iHrw'twl  treatment,  ami  in  many  eases  it 
iiiav  entirely  be  overcome. 

From  a  clinica'  standpoint  it  is  ordinarily  presnmed  that  wluii  there  is 
;ill)UMiinuria  there  is  also  nremia  to  a  corresponding  degree.  Donbtiess  it  is 
true  that  when  albumin  is  abnormally  excreted  by  the  kidneys  there  is  some 
ii'tcntion  of  urea  iu  the  blood,  from  defective  atftion  of  the  kidneys,  but 
certainly  these  two  fiuietlonal  tlisorders  do  not  hold  the  same  proportion  or 
Illation.  There  may  be  much  albuminuria  and  but  little  uremia,  and  Wcc 
(V/'.««l.  It  is  the  tlegrce  of  the  latter  disorder  that  forebodes  evil.  The 
whole  line  of  treatment  should  be  directed  toward  favoring  the  elimination 
tVoni  the  blood  of  this  poisonous  material  of  urea,  with  its  ju-oducts.  To  secure 
this  result  it  is  ineuml)ent  upon  us  to  act  as  potently  as  we  can  upon  the 
bowels  and  the  skin — compensatory  organs  of  the  kidneys — and  to  address  our 
remaining  treatment  to  controlling  other  symptoms  that  may  arise. 

Changes  in  the  Nefvoun  Hi/ntem. — The  nervous  system  becomes  more  impres- 
sionable in  pregnancy.  The  emotional  susceptibility  is  markedly  increased 
and  the  whole  character  is  altered.  A  woman  may  become  fretful,  peevish,  irri- 
t:il)le,  and  at  times  unreasonable.  The  most  amiable  woman  may  thus  be  dis- 
posed when  pregnant.  She  is  often  depressed  in  spirits  at  first,  when  her 
general  nutrition  is  impaired  from  an  imperfect  appetite  or  a  faulty  digestion. 
Mania  may  be  excited  later  on — easily  in  those  who  are  thus  predisposed  by 
inlu^ritance  or  by  actual  melancholia.  These  conditions  are  among  the  most 
troublesome  of  the  various  comj.lieations  of  pregnancy.  To  witness  a  woman 
ill  the  process  of  child-bearing  impaired  in  her  mental  functions  is  indeed  sad. 
Tliere  are  cases,  however,  in  which  a  sense  of  well-being  takes  the  place  of 
one  of  more  or  less  physical  debility.  A  conclition  of  want  of  mental  and 
physical  activity  before  pregnancy  at  times  becomes  changed  to  one  of  buoy- 
ancy and  exhilaration.  Physically  such  women  are  stronger,  and  mentally 
tliey  are  more  active  and  energetic.  Xo  fSictor  enters  so  much  into  the 
eiiiisation  of  this  mental  cheer  and  despondency  as  the  psychical — the  degree 
of  the  desire  for  an  offspring. 


■ 

11 


II.  DIACIXOSIB  OF  PREGNANCY. 


1.  Symptoms  and  Signs  of  Pregnancy. 
1.  The  Nausea  and  Vomiting  of  Pregnancy,  called  the  "Morning- 
Sickness." — This  symptom  consists  of  nausea,  accompanied  often  with  vomit- 
ing »»r  the  retching  of  a  glairy  fluid,  showing  itself  early  in  the  morning,  gen- 
cially  before,  at  times  only  after,  breakfast.  The  assiunption  of  the  erect 
posture  seemingly  excites  the  disorder.  Sometimes  it  begins  very  early,  within 
a  few  days  after  conception,  but  usually  not  until  the  fourth  or  the  fifth  Aveek 
of  pregnancy.  Seldom  does  it  pei-sist  throughout  pregnancv,  but  generally 
coases   spontaneously  within   the   fourth    month,  although    it    may  continue 


b 


:     l 


If 


i 


i^ 


1(50 


AMKIilCAX   TKXT-JiOOK   OF   OliSTETItlCS. 


tliruuglioiit  tlu;  whole  plthmI.  In  many  or  in  most  cases  it  is  comparatively 
mild,  and  does  not  seriously  imj)air  the  health,  its  presence  being  regarded  as 
a  lavorahle  omen  ;  i)Ut  as  there  is  every  degree  of  seriousness  in  its  nature,  it 
is  at  times  so  severe  and  so  long  continued  that  not  only  are  parts  of"  meals 
vomited,  but  all  foods,  of  whatever  kind,  variety,  or  (juantity,  are  also  rtjected. 
Not  only  may  the  ingestion  of  food  excite  v  tmiting,  but  the  siglit  or  the  smell 
of  food  may  also  give  rise  to  this  characteristic  nausea. 

Morning  sickness  is  a  sympathetic  disonler  reflected  from  the  uterus.  It 
is  aggravated  i)y  unpalatable  food,  by  sexual  excitement,  and  by  emotional 
disturbances.  It  is  most  marked  in  first  pregnancies,  and  in  women  of  highly 
nervous  organization — a  fiict  ever  to  l)e  considered  in  the  management  of 
this  affection.  It  is  a  suspicious  or  presumj»tive  evidence  taken  by  itself,  but 
when  associated  with  certain  other  symptoms  and  signs  it  l)ecomes  a  more  prob- 
able symptom  of  pregnancy.  Not  necessarily  in  the  regular  order  of  time,  but 
quite  generally  asscK-iated  with  this  morning  sickness,  there  are  certain  morbid 
longings  for  food  ;  for  instance,  foods  and  drink  and  certain  vegetable  acids 
formerly  disliked  are  now  desired  ;  the  most  unpalatable  substances,  such  as 
chalk,  clay,  and  slate-|)encils,  may  be  craved ;  or  there  may  be  a  distaste  for 
the  usual  articles  of  diet.  Other  stomach  disorders,  such  as  acidity,  flatulency, 
heartburn,  and  unpleasant  eructations,  are  sometimes  noticed. 

Sdlicdfion  is  a  very  common  aivompaniment  of  the  morning  sickness  when 
the  latter  is  severe.  A  constant  dribbling  of  the  saliva  by  day  or  by  night 
occurs  in  the  earlier  months  of  pregnancy,  and  its  severity  and  duration 
remain  for  an  uncertain  |»erio(l.  It  has  Im'cu  observed  to  continue  for  months 
after  the  abatement  of  the  nausea  and  vomiting. 

Tontlnii'hc, — Under  the  above  heading  may  also  1k'  included  tootha(;he, 
which  at  times  is  a  purely  functional  disorder  ;  n»ore  often  it  is  a  symptom 
of  actual  caries,  arising  from  alteration  of  the  buccal  secretion,  dissolving  the 
lime-salt-  of  the  enamel  of  the  teeth  ;  t»r  it  may  be  the  result  of  a  morbid 
determination  of  the  ossific  elements  of  the  teeth  of  the  mother  to  the  bones 
of  the  growing  fetus. 

2.  Menstrual  Suppression. — The  second  symptom  more  or  less  ex|)ress- 
ive  of  the  existence  of  pregnancy  is  the  suppression  of  the  menses.  The 
fniKrtion  of  menstruation  is  almost  always  suspended  throughout  the  whole 
period  of  pregnancy.  80  reliable  is  this  symptom  that  the  <letermination  of 
the  end  of  gestation,  or  the  time  for  the  expected  parturition,  is  best  obtained  by 
adding  from  two  hun(lre<l  and  seventy-eight  to  two  hundred  and  eighty  days 
to  the  date  of  aj>pearance  of  the  last  menstrual  flow.  Hut  not  invariably  is 
nienstruation  suspended  following  an  inipregnation.  The  most  frequent  ex- 
ception to  the  general  rule  is  found  when  menstruation  returns  (mceonly  ;  then 
it  is  usually  for  a  somewhat  shorter  time  and  in  diminished  quantity.  The 
occurrence  of  a  menstrual  flow  in  diminished  quantity  and  for  a  shorter  time 
in  a  married  M-oman  who  has  had  her  menstrual  periods  regular  as  to  time, 
quantity,  and  duration  is  very  significjuit  of  a  possible  pregnancy,  and  the 
conception  must  have  occurred  several  days  before  this  function  last  appeared. 


DIAUXOSLS   OF  PREGyAWY 


161 


us.     It 
lotioiml 
■  highly 
iicut  of 
soH;  hilt 
re  i»roh- 
ime,  hilt 
1  iiiorhid 
ble  uc'ul-^ 
,  Slid  I  as 
^tuste  Ihr 
atulency, 

less  whon 

by  nigl't 

(Ui  nit  ion 

»r  mouths 

:oothtv<:he, 

syiiiptoni 

Llvhig  tho 

|ji  niorhul 

he  hones 


AL'iiiii,  hy  way  of  cxecj»tion  to  the  rule,  there  are  recorded  notable  instances  in 
which  the  peritnl  of  prej^naney  was  attended  by  a  rejijular  incnstruation.  The 
writer  recalls  in  his  experience  the  case  of  u  woman,  now  living  and  in  health, 
wiu>  never  menstruated  Ix-'fore  marriage,  nor  during  her  married  life  of  several 
years  unless  she  l)ecanie  pregnant.  She  had  no  menstruation  the  first  two  yeare 
ot'  her  married  life  until  pregnant,  and  there  was  no  return  of  the  menstrual 
ilow  until  she  was  again  pregnant;  in  other  w(»rds,  menstruatictn  in  this  case 
wiis  never  present  except  during  pregnancy,  when  it  was  normal  in  all  regards," 
having  thus  appeared  in  three  distinct  pregnancies.  Possibly  the  periodic 
lii'inorrhage  in  this  case  was  of  cerviral  origin,  but  no  ])athologicid  lesion  of 
tiie  uterus  ctndd  ha  detected.  Menstruation  ot!curring  during  the  first  three 
iiinnths  of  pregnancy  may  come  from  the  decidual  cavity  of  the  uterus,  not 
vet  closed,  before  the  decidua  vera  and  the  decidua  reflexa  have  become 
ai:<rlutinate<l ;  then  there  must  have  been  a  certain  amount  of  chrouic  decidual 
(lulometritis — a  morbid  state,  of  course. 

As  many  causes  purely  pathological — general  and  local,  physical  and 
psvchical — induce  menstrual  suppression,  the  exact  significance  or  the  relative 
value  of  this  symptom,  as  an  evidence  of  the  existence  of  pregnancy  deserves 
most  careful  consideration.  For  instance,  menstrual  supjiression  following 
months  and  years  of  menstruation,  normal  in  all  regards,  is  a  very  strong  siis- 
l»icion  of  pregnancy.  Its  value  as  evidence  becomes  less  when  it  is  stopped 
ill  a  woman  whose  previous  periods  have  been  irregular  from  any  cause.  This 
symptom  of  ntenstrual  suj)pression  cannot,  of  course,  be  present  from  preg- 
nancy when  the  menses  are  physiologically  absent  from  lactation,  or  when  the 
lirctriKUuy  iKVurs  l)efore  the  first  menstrual  apiwarance,  prior  to  puberty  or 
after  the  menopause.  So  much  faith  has  the  popular  mind  in  the  presence  of 
tiiis  symptom  of  menstrual  suppression  as  indicative  of  pregnancy  that  no 
small  degree  of  anxiety  in  looking  forward  to  a  pregnancy  is  often  manifested 
by  women.  There  is  what  is  calletl  "  jisychical  amenorrhea,"  in  which  case 
menstruation  is  suspended  or  is  delayed  from  purely  psychiad  causes.  While 
it  ailects  newly-married  women  who  may  l)e  anxious  to  avoid  pregnancy,  it 
coiu'erns  mostly  unmarried  women  who  have  exposed  themselves  to  the  pos- 
sibility of  impregnation.  The  fear  of  a  possible  pregnancy  is  doubtless  suf- 
ficient to  prevent  a  normal  return  of  this  function. 

All  the  exceptions  above  mentioned  should  ever  be  held  in  mind  in  esti- 
mating the  actual  worth  of  the  symptom  of  menstrual  suppression. 

;5.  Mammary  Changes. — During  pregnancy  the  mammary  glands  are  in 
immediate  sympathy  with  the  growing  reproductive  organs  of  the  i)elvis,  con- 
st'(|uently  a  genuine  physiological  hypertrophy  commences  in  these  organs 
i'mm  the  beginning  of  gestation.  Their  glandular  structures  become  larger, 
fuller,  and  firmer;  a  sensation  of  weight  or  of  pricking  in  them  is  felt  by  the 
|»atient;  the  veins,  blue  in  color,  become  enlarged  and  more  visible.  Light- 
colored,  silvery  lines  are  seen  radiating  over  the  prr)jecting  organs  in  the  last 
iiKinths  of  pregnancy.  The  nipples  also  become  enlarged,  nutre  elongated,  prom- 
inent, and  somewhat  erect  (l*Is.  17, 18).  Surrounding  the  nipple  is  noticed  the 
11 


I 


i:i\n  '  '  "?' 


Illi 


/ 


ir) 

1 

h 


m\ 


ir,2 


j.i//;a7<j.v  TiLXT-nooK  or  onsTF/nncs. 


uri'ola,  which  Ih-coiiics  darUi'i'  in  color,  and  which  is  most  pronounced  in  bru- 
nettes (I'l.  17).  Two  or  more  cnhirgcd  moist  i'olliclcs,  varyini;  in  size  and  con- 
taining sebaceous  material,  are  seen  proje*  tiiig  from  the  surface  of  the  areola. 
In  tiie  lifth  or  the  sixth  moutli  tiiere  appears  a  secoiidarv  arecthi  (IMs.  17,  18)  con- 
sisting of  scattered  minid  spots,  appearing  as  if  tlie  color  had  l)een  dischar<"'d 
as  a  shower  ol"  <lrops  (Montgomery).  Thus  every  structure  entering  into 
the  composition  of  the  mannnary  glands  is  physiologically  hypertrophied. 
These  changes  begin  as  early  as  the  seccuid  month,  an<l  become  more  pro- 
ncMinced  as  pregnancy  |)roeeeds.  The  two  mammary  glands  are  equally 
enlarged  and  progres.-ively  (h'veloped.  The  secretion  of  colostrum  in  the 
glands  eidianees  the  value  of  these  mannnary  changes  indicative  of  pregnancy, 
especially  if  noticed  in  women  who  have  never  before  been  ])regnant.  Milk  is 
now  and  then  seen  to  ooze  from  the  nipples  of  some  women  before  deliverv 
(I'l  17);  in  most  women  a  drop  (»r  more  of  colostriun  may  be  s<jueezed  from 
the  nipples  after  the  third  month.  Instead  of  the  lacteal  secretion  being  pro- 
moted, its  suppression  in  niu'sing  women  is  very  suspicious  of  another  preg- 
nancy. Milk  is  secreted  at  times,  though  rarely,  when  there  is  no  ])regiiancy. 
Pelvic  diseases,  such  as  chronic  metritis,  rapid-growing  fibroids,  ovarian  cyst«i»- 
niata,  and  false  pregnancy,  at  times  induce  milk-secretion.  Cases  are  reconled 
of  the  j)resenee  of  milk  in  the  mannnary  glands  of  males.  These  character- 
istic physiological  changes,  in  their  uniformity  and  progressiveness,  mark  the 
distinguishing  ditferences  l)etween  the  mammary  changes  of  pregnancy  an<l 
those  alterations  noticed  in  size  and  shape  of  the  glands  from  symj)athy  Mitli 
certain  pelvic  diseases — ovarian  and  uterine. 

These  mammary  changes  in  structure,  color,  and  func^tion  are  of  little  diag- 
nostic value  when  considered  alone,  but  when  taken  in  conjiniction  with  other 
symptoms  they  are  highly  probable  evidi'uces,  especially  in  first  pregnancies. 
Owing  to  the  fact  that  tiie  darkening  of  the  areola  in  nndtipai'ie,  and  tli( 
ei*'«tility  of  the  nipple  remain  more  or  less  prominent,  while  colostrum  may 
st»»»ietimos  be  j)reseiit  for  years  after  the  cessation  of  lactation,  it  can  be  ap- 
preciated how  these  signs  lose  their  diagnostic  value  in  v)ineu  who  have  borne 
children. 

4.  Functional  Disturbances  of  the  Bladder. — Fiuictional  disturbances 
ot'  the  bladder  are  ([iiite  often  noticeable  ear'y  in  pregnancy.  As  the  bladder 
is  s(»me\\liat  dragii'cd  upon  by  the  physiological  prolapsus  of  the  uterus  in  tlic 
first  month  (a  |)ositioM  rather  increased  in  the  second  month),  inid  as  it  is  pressed 
ii)Htn  din'iug  the  third  month  by  the  increasing  normal  anteversion,  it  can  lie 
understood  why  fuMctional  disorders  of  this  organ  may  result.  The  bladder- 
capacity  is  diminished,  and  in  consequence  there  is  an  increased  fre(piency  ot 
urination.  The  vesical  symptoms  tend  to  diminish  in  the  fourth  montli. 
because  of  the  ascent  of  the  uterus  from  the  pelvic  to  the  abdominal  cavity. 
if  iH'troversiou  of  the  uterus  existed  prior  to  pregnancy,  this  backward  mal- 
position is  increased,  while  the  uterus  is  j)elvic  in  position.  IJecau.sc  of  the 
increasing  size  of  the  organ,  with  its  growing  contents,  there  follows,  at  times. 
fViim   ri^troversion,  serious  urinary  retention.       Incontinence  of  urine  more 


I'Ki:<i  NANCY. 


I'l.ATK   17. 


I'rimiiry  iireolii,  olnvaf  cd  iiiul  cdeniiitouH 

'i  1'  \i,  Willi  |..lhi  I.-  liii  11  l.|uhili-i 


Vi'imni'y  iiruulu,  piKUieiUed  d'A  ,  I'ut  ilai, 

Willi    Klllllll    lll|l|i|l'    (III    II    llllllK-ltl'l. 


-i./| 
S 


MmitKui  LT.v'Hfolliclesil'i.  iiu>;iiN  .li\ilii|i(il. 


Veins  i"iii>iiii:  "MT  iIh'  IpIvhsI  iinil  piiiiiiirv  iiicula, 
Willi  iiii'Kiilai'  I'ipiiii'iitaliHii  liii  a  Mnihlii 


Eil'eotility  "l  nil'I'lia';  1  iniiuaiya la. 


Milk,  Willi  lailil  ^'  >oiMlai\  ali'i'la  liii  a  liliMiilli' 


Secoudiiry  iireoliv  ui  "Mia!  .«i/.i'  (in  a  iiiiin.iic). 


Becondnry  areoln. pruiniin'iitly  maiki.i  iS  .  w iiu 

wi<li'  |ii'iniar\  1 1*1  areola  lin  a  1*1  iin>'tl<'i. 


Miimiiiiiiy  -inns  nf  iiir^iiuiicy  in  llK'ir  nnU  r  it»niliiiil>  lilc  >i/.iM. 


i    I 


1 


PREGNANX'Y. 


KIrvaliiiii  III  piiiiiaiv  aiinla  (10)  in  |ii'iitiU',  <'ij|ii- 
piiM'tl  witli  all  art'ola  wliii'h  is  nut  t-lfvat^'il  (cnni* 
liusitu  iili>>t<<Ki'<>I'l>)- 


Plate  18. 


1 


Wi'll  roniKMl,  lirni  lui'a^t  ami  iiii'pli'  (in  a  liruiictte). 


Typii'iil  i^i^'hA  in  a  lnnni'lti'.  inrlmlint;  tnllicli'H  ami 
|)i'inmi'.v  anil  Ki'Cdmlai.v  ari'ula'. 


T}|ii('al  ni^nit  in  tlin  blniidi':  K,  fnllii'U'Hi  I'A,  |>i'i- 
niary  aronla. 


i.. 


I:i 


Miminiuiy  sl^ns  at  progniini'y. 


'if 


i  \^  m. 


DIAGNOSIS    OF  PREGNANCY. 


163 


rarely  occure  during  pregnancy,  from  coughing  or  from  sneezing,  when  the 
bladder  is  somewhat  distended. 

Kiesteine,  sometimes  present  in  pregnant  women,  is  a  proteine  substance, 
consisting  of  triple  phosphates,  fungi,  and  infusoria,  that  forms  like  a 
flocculent  cloud  on  the  urine  kept  standing  for  a  few  days  at  a  tem- 
perature of  70°  F.  It  occurs  in  the  urine  from  the  eighth  to  the  thirty- 
second  week  of  pregnancy,  then  disai)pears.  It  has  practically  no  diag- 
nostic value,  as  it  is  found  in  the  urine  of  non-pregnant  women,  and  at 
times  in  that  of  men. 

5.  Intrapelvic  Sigrns. — Certain  changes  in  structr.re  take  j>lace  in  the 
uterus  in  the  earlier  mouths  of  pregnancy,  when  the  organ  is  confined  within 
ilie  true  pelvis,  before  it  ascends  within  the  abdominal  cavity ;  tliese  changes, 
carefully  studied  and  detectal  by  vaginal  touch  and  by  bimanual  exami- 
nation, possess  a  significance  far  greater  than  any  of  the  aforementioned  symp- 
toms. Associated  with  some  of  the  other  symptoms,  these  changes  become 
extremely  probable  evidences : 

{(i)  Softening  and  Enlargement  of  the  Cervix  Uten. — These  changes,  com- 
])ared  with  the  physical  conditions  of  the  same  parts  in  the  virgin  or  the 
never-pregnant  woman,  will  be  observed  to  be  quite  characteristic — less  so 
in  women  who  have  borne  children.  The  cervix  uteri  softens  and  enlarges 
in  all  directions.  The  lips  of  the  os  uteri  become  patulous  and  puffy,  a 
condition  most  noticeable  in  primiparse.  The  softening  of  the  infravagi- 
nal  cervix,  beginning  below,  extends  upward.  The  cervical  secretion  of 
nuu'us,  the  so-called  "cervical  plug,"  is  increased. 

The  diminished  resistance  to  touch  and  the  increasing  width  of  the  tissues 
i^oemingly  shorten  the  cervix.  These  changes,  while  beginning  in  the  first 
month,  are  not  recognizable  until  the  second  month  ;  from  this  time  they  are 
progressive. 

Erroneous  views  as  to  changes  in  the  cervix  uteri  during  pregnancy  existed 
ill  years  past.  It  was  believed  that  the  cervical  canal  was  greatly  shortened 
to  form  ])art  of  the  corporeal  cavity,  and  that  toward  the  last  of  pregnancy  no 
cervical  cavity  existed,  it  having  lost  one-half  its  length  by  the  sixth  month, 
and  so  on,  until  it  was  obliterated  in 
the  eighth  and  ninth  months.  These 
views,  long  entertained,  were  in  1826 
called  in  qiiestion  by  Stolz,  whose  views 
most  moilern  obstetricians  now  u))hold. 
Post-mortem  examinations  made  of 
women  in  advanced  pregnancy  —  the 
best  proofs — have  established  the  fact 
that  the  cvrvix  maintains  its  length  of 
'J. 5  centimeters  (1  inch)  or  more  to  the 
last  days  of  j)regnancy  (Fig.  137). 
Digital  exploration  through  the  patulous  cervix  substantiates  this  fact.  iJut 
during  the  fortnight  preceding  j)arturition  a  genuine  broadening  of  the  cer- 


Kui.  137.— (Vrvix  nt  end  iif  pn'Riiaiioy  (Winter). 


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164 


AM/:/i/('AX    TEXr-BOOK    OF    OBSTETRTCS. 


vix  takes  plaw,  when  the  cervical  canal  is  merged  into  the  upper  uterine 
cjivity — a  result,  no  doubt,  of  the  incipient  uterine  contractions  i)reparatory 
to  labor,  as  pointed  ont  by  Matthews  Duncan. 

The  broadening  ot"  the  cervix  in  the  last  stage  of  pregnancy,  prior  to 
eight  and  one-half  months,  then,  is,  seemingly,  not  real  until  the  last  fort- 
night. More  or  less  of  these  changes  remain  even  after  parturition ;  in  other 
words,  tho  cervix  does  not  completely  resume  its  pristine  virgin  firmness  and 
smoothness  of  siu'face  or  its  original  size. 

While  these  changes  are  noticeable  from  pathological  as  well  as  from 
physiological  causes,  their  value  in  the  diagnosis  of  pregnancy  is  only  to  be 
relied  upon,  when  associated  with  other  signs  and  when  taken  in  conjunction 
with  certain  other  symptoms. 

{h)  The  Violet  Color  of  the  Vulvar  and  Vaginal  Mucouh  Membrane. — 
Dr.  Jacquemin  of  Paris  first  discovered  this  sign,  and  Dr.  Chadwick  of  Boston 
has  fully  dwelt  upon  its  diagnostic  significance.  Insj)ection  reveals  its  pres- 
ence. It  is  of  importance  in  the  earlier  months  of  pregnancy,  when  there  is 
seen  the  then  pale  violet  color,  becoming  nu)re  bluish  as  pregnancy  advanc(;s. 
But  this  sign  is  not  of  positive  value.  While  arising  from  a  venous  stag- 
nation in  tiie  vaginal  vessels,  it  may  come  also  from  vaginal  or  uterine  con- 
gestion due  to  disease.  This  sign  is  valuable  often  as  early  as  the  second 
month,  and  in  the  latter  half  of  pregnancy  it  is  highly  diagnostic ;  then  its 
recognition  possesses  great  value. 

((•)  Jlef/ar^s  .w/»,  which  has  been  given  to  the  profession  within  the  last 
decade,  possesses  a  great  advantage.  In  all  doubtful  contlitions  of  early  preg- 
nancy this  sign  ought  to  be  searched 
for.  It  is  to  be  detected  by  vaginal 
touch  and  by  bimanual  exann'nation. 
Its  presence  implies  a  change  in  the 
consistency  of  the  lower  uterine  seg- 
ment. The  greatest  changes  in  the 
uterus  must  and  do  take  place  in  the 
body  of  this  organ — the  l)ed,as  it  were, 
for  the  growing  oviun.  The  neck  of  the 
womb  is  less  supplied  with  blood,  and 
it  receives  comparatively  little  of  the 
stimulus  of  pregnancy.  The  develop- 
ment of  the  cervix  is  largely  comj)leted 
by  the  fourth  month.  During  the 
first  six  or  eight  weeks  of  gestation 
Fi(i.  isx.-i'roKnnnt  litems  cif  early  part  of  the  body  of  the  utcrus  enlarges,  espe- 

tliinl  iiidiitli  il)ni\iii's  Croziii  secliDiii,  with  iimb-      .    ,,      .       .  ... 

ui)ieiM,stii...rte.nrein,vei-si.m:  I.,  i., .kei.iua  vera.  <'ially  HI  its  autero-jjosterior  diameter. 

Bimanual,  recto-vaginal,  or  abdomino- 
vaginal touch  will  detect  some  enlargement  in  all  directions — anterior,  pos- 
terior, and  lateral.  The  lower  uterine  segment  becomes  soft,  compressible, 
and  pulsating;  above  there  is  the  j)rojecting  or  bulging  uterine  wall,  hard  and 


i 


DIAGNOSIS    OF  PREGNAXCY. 


165 


resisting;  diiriii};  uterine  contmction,  l)<)<rf;y  or  soft  (Inrin;;  relaxation.  The  ac- 
eonipanyin}^  illustrations  (Figs.  138-140)  best  elneidates  these  facts.  The  uterus 
in  shape  has  t)een  likened  to  that  of  a  deniijohn,  to  an  old-fashioned  fat-bellied 
jug,  or  to  a  sphere  (corpus)  resting  upon  a  cylinder  (cervix).  These  alter- 
iitions  in  consistency,  while  noticed  on  the  jwsterior  wall  by  rectal  touch,  are 
best  detected  along  the  anterior  uterine  wall,  by  the  finger  in  the  vagina  with 


Ri-sl'i.'Hf 


Flo.  139.— Uimaiiiial  sikiis  of  the  sixth  to  eighth  week,  sliowiiig  dingrnnimHticnlly  the  iilterntlons  in 
consistency  of  cervix  and  corjnis  uteri:  A  represents  the  vaulting  or  overluuiglng  of  the  body  and  its 
rlastic  feel,  witli  the  compressibility  of  the  lower  uterine  segniont  and  the  iinyielding  cervix;  B  shows 
tlie  conditions  during  uterine  contraction,  when  the  body  is  hard  and  globular. 

the  outer  hand  on  the  abdomen  seizing  the  uterus.  The  .structures  of  the 
ciirporeal  wall  may  become  soft  and  yielding,  and  may  show  a  contrast  with  the 
cervix  below.  It  is  true  that  the  sign  of  bof/f/incas  of  the  body  is  not  always 
present,  and  that  its  presence  is  simulated  somewhat  by  morbid  states,  but  the 
])eculiar  compressibility  of  the  lower  segment,  together  witii  the  bogginess  of  the 
body  and  the  ciianges  in  shape  of  the  womb,  is  not  simulated  by  anything  else. 
(d)  Changed  Position  of  the  Uterun. — We  must  not  fail  to  bear  in  mind 
the  modification  in  the  jjositions  of  the  uterus  that  pregnancy  usually  produces. 


f/rroiy. ,) 


Kkj.  UO.— Frozen  section  of  uterus  at  two  and  a  half  months  (I'liiardi.  sliowing  relaxed  and  thin 
walls,  thickened  decidua  ;  with  the  clinical  Ihidings  of  Figure  l;l'J  it  will  be  seen  how  the  bimanual 
signs  originated. 

Ill  the  first  and  second  months  the  uterus  is  somewhat  lower,  but  in  the  third 
iiKtnth  it  undergoes  an  increased  anteversion,  for  the  reason  that  the  relatively 
iiicrea.'  lug  weight  of  the  body  of  the  uterus  with  its  growing  contents  tilts  the 
upper  end  of  the  uterine  lever  downward  and  forward.  This  change  in  ])osi- 
tion  will  be  noticed  in  all  ca.ses  except  tho,se  in  which  |)regnancy  has  oc- 
curred in  a  previously  retroverted  uterus ;   the  retroversion  is  then  increased. 


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TIlis  statement  is  made,  notwithstaiidiii^  that  some  of  this  antoversion  maybe 
ap]>ai'eiit,  not  real,  the  aiitero-postcriin"  diameter  of  the  organ  being  thickened. 

Hegar's  sign,  reeognized,  as  it  may  be,  so  early  as  the  seeond  month, 
and  the  overhanging  and  softness  of  the  eorpns,  the  changed  position  of  the 
uterus,  and  the  violet  color  of  the  vagina  and  cervix  uteri,  while  not  abso- 
lutely positive  signs,  are  highly  pri>bable  evidences  when  associated  with 
some  of  the  rational  symptoms  referred  to.  They  jwssess  a  diagnostic  sig- 
niticance  ever  to  be  watched  for  and  carefidly  es'.  lUated.  They  are  a  com- 
plexus  of  physical  signs  that  gives  a  reasonable  diagnostic  certainty. 

(j.  Abdominal  Changes. — Under  this  head  are  included  all  those  cliangcs 
in  size,  shape,  and  ai)pearance  of  the  abdomen  that  may  take  i)lace. 

(a)  EHlairfemcnt,  Size,  and  Slutpc  of  the  Abdomen. — At  first,  diu'ing  the 
first  six  to  eight  weeks,  there  is  somewhat  of  a  flattening  of  the  abdominal 
snrface,  due,  doubtless  to  the  descent  of  the  uterus  into  the  pelvic  cavity,  thus 
slightly  dragging  the  bladder  downward  and  making  traction  on  the  tu-achns, 
thereby  drawing  the  umbilicus  inward.  The  navel  in  consecjuence  becomes 
dei)ressed  ;  hence  the  conunon  expression,  "  A  blank  before  a  bank."  I^ater 
in  the  fourth  month,  as  the  growing  uterns  rises  for  proper  acconnnodation 
in  the  abdominal  cavity,  a  slight  abdominal  enlargement  will  be  observed, 
and  the  umbilicus  is  no  longer  sunken.  By  the  fourth  mouth  the  fundus 
uteri  has  risen  about  5  centimeters  (2  inches)  above  the  symphysis  pubis.  The 
vertical  enlargement  jiiogresses  at  the  rate  of  fully  two  lingers'  breadth  each 
four  weeks,  reaching  the  umbilicus  at  the  end  of  the  sixth  month,  and  touch- 
ing the  ensiform  cartilage  at  the  end  of  thirty-eight  weeks,  or  eight  and  a  half 
lunar  months  (PI.  19,  Fig.  1).  The  umbilicus  for  many  weeks  prior  to  that 
time  lias  been  protruding.  During  the  last  two  weeks  of  utero-gostatiou  the 
upper  portion  of  the  abdominal  walls  protrudes  less  and  the  girth  of  the  woman 
seems  smaller  (PI.  19,  Fig,  2).  The  patient  feels  more  comfortable.  The  cer- 
vical canal  is  now  eflaced,  the  child  in  idem  has  sunken,  and  the  pelvic  liga- 
ments are  relaxed — changes  preparatory  to  the  coming  i)artm'ition.  During 
this  time  it  will  be  noticed  that  the  enlarging  pregnant  womb  is  symmetrical, 
snujoth  iu  its  contoiu",  larger  vertically  than  transversly,  and  by  proper  pal- 
pation it  will  be  felt  to  contract  spontaneously. 

(h)  Coloration. — On  inspection  of  the  abdomen  of  ])regnant  women  there 
will  be  recognized  not  only  the  condition  of  the  navel,  but  also  a  changed 
color  of  the  abdominal  surface,  and  the  presence  of  stria;,  due  to  distention  of 
the  abdomen.  The  pigmentation  may  extend  from  the  pubis  to  the  xiphoid 
cartilage — the  brown  lines.  On  the  sides  of  the  abdominal  walls  and  dowu 
the  thighs  red,  blue,  or  white  markings,  like  cicatrices,  may  be  seen. 

(c)  Fi((d  Movcmnd.'<. — Fetal  movements  are  generally  visible  after  the  sixth 
month  through  the  abdominal  parietes. 

7.  Ballottement. — Hallottemeut  is  a  passive  motion  of  tlie  fetus,  consist- 
ing of  the  peculiar  sensation  felt  by  the  examining  fingers  upon  giving  the 
fetus  a  motion  //;  ufcro.  A'aginal  ballotteme;.'^  is  usually  emj)l')yed,  although 
abdomiuid  ballottement  is  also  pract .cable  at  times,  and  may  be  noticed  for  a 


I'HK(JXAN(Y. 


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DIAGNOSIS   OF  PREGNANCY. 


167 


longer  period  of  time,  even  during  the  Ix'ginning  of  labor.  F«)r  the  ballotte- 
ment  impulse  to  be  perceptible  there  must  be  a  mobile  fetus,  not  too  large,  and 
a  sufficient  quantity  of  the  liquor  amnii  to  permit  the  entire  fetal  displace- 
ment in  idem.  The  woman  stands  or  reclines  during  its  performance.  In  the 
vaginal  ballottcnfient  the  Hnger  is  placed  within  the  vagina,  anterior  to  the 
cervix,  the  pulp  of  the  finger  being  applied  to  the  anterior  vaginie  fornix  by 
a  direct  brisk  motion.  The  fetus  is  propelled  upward  into  the  uterine  cavity, 
and,  falling  back  by  its  gravity,  an  impulse  is  imparted  to  the  finger  against 
which  it  falls. 

Ballottemeut  distinctly  noticed  is  a  pathognomonic  sign  of  pregnancy, 
there  being  no  other  condition  in  which  a  solid  body  is  found  Hoating  in  the 
uterine  cavity.  The  absence  of  this  body  does  not  preclude  the  possibility  of 
pregnancy,  lor  different  conditions  may  prevent  its  being  noticed,  such  as  ex- 
cessive or  great  dinunutiou  in  size  of  the  fetus,  hydramnios,  multiple  preg- 
nancy, some  abnormal  presentation,  or  a  faulty  insertion  of  the  placenta. 

Vaginal  ballottemeut  can  sometimes  be  practised  successfully  as  early  as 
the  latter  part  of  the  fourth  month.  It  is  more  easily  recognized  in  the  fifth 
month,  is  most  distinct  in  the  sixth,  continues  in  the  seventh,  is  doubtful  in 
the  eighth,  and  is  absent  in  the  ninth  month. 

8.  Intermittent  Contractions. — As  soon  as  the  uterus  is  developed  suf- 
ficiently to  be  felt  by  the  hand  through  the  abdominal  wall,  there  may  be 
perceptible  intermittent  uterine  contractions  which  are  constantly  going  on  at 
intervals  of  a  few  minutes  throughout  pregnancy.  Purely  independent  of 
volition,  they  may  become  valuable,  in  a  diagnostic  sense,  in  corroborating 
other  signs.  Uterine  contractions  are  not  positive  signs,  because  the  uterus 
undergoes  somewhat  similar  contractions  to  free  itself  of  clots  of  blood,  of 
polypoid  or  fibroid  tumors,  and  of  retained  secundines,  or  they  may  be  simu- 
lated by  a  distended  bladder. 

The  method  of  procedure  for  detecting  uterine  contractions  is  to  grasp  the 
fundus  uteri  for  from  five  to  twenty  minutes,  with  the  patient  recumbent  on 
her  back,  the  uterus  meanwhile  being  lifted  by  the  right  finger  per  vaf/inam, 
the  abdominal  walls  being  relaxed  by  some  flexion  of  the  lower  limbs.  The 
characteristic  hardening  will  then  Iw  felt,  the  contraction  lasting  for  several 
minutes.  To  IJraxton  Hicks  we  are  indebted  for  the  thorough  elucidation  of 
this  sign,  which  is  often  referred  to  as  "  liraxton  Hicks'  sign  of  pregnancy." 

9.  Quickening  and  Fetal  Movements. — Quickening  is  the  sensation  ex- 
perienced by  the  mother  as  the  result  of  active  fetal  movements.  The  period 
when  these  active  movements  are  felt  is  quite  uncertain.  Usually  quickening 
is  considered  to  occur  about  the  middle  of  pregnancy,  consequently  the  time 
of  expected  parturition  is  based  on  this  event,  but  very  unreliably.  Certain 
sensations  of  motion,  sutih  as  fluttering  or  ]>ulsating,  are  sometimes  felt  by  the 
mother  earlier  than  these  active  motions.  As  pregnancy  advances  these  active 
motions  increase  in  frequency  and  become  more  marked,  and  toward  the  last 
they  are  seen  very  generidly.  When  felt  or  seen  by  the  physician,  as  can  be 
(lone  after  the  sixth  month,  fetal  movements  constitute  a  very  valuable  and 


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168 


AMKRICAX   TEXT-BOOK   OF  OBSTETRICS. 


positively  reliiiMe  sifjjii  not  only  of  pirj^imncy,  hut  also  of  a  live  child  in  nfero. 
This  sign  slioiiM  ni'vor  hv  iiiti'iTcd  to  exist  from  the  statements  of  tlie  patient. 
Supposed  fetal  movements  are  fretpiently  felt  by  the  patient,  and  are  thought 
to  Ih>,  but  are  not,  evidences  of  pregnancy  ;  frequently  they  are  only  illusory. 
These  seemingly  fetal  motions  come  from  the  abdominal  walls  in  false  preg- 
nancy or  fronj  the  intestines  in  tympanites. 

Failure  to  detect  letal  movements  does  not  negative  pregnancy,  for  the 
cliild  may  be  dead  or  its  motion  may  not  be  felt.  To  detect  tlu'se  movements, 
place  the  patient  on  her  back  njxm  a  table  or  a  bed,  with  the  thighs  flexed  and 
the  abdominal  walls  relaxed.  All  clothing  should  be  removed  from  the  abdo- 
men. Uy  palpation  and  renewed  prt'ssure  at  ditlerent  part.s  of  the  alxlomen 
the  active  fetal  movements  may  be  detected  ;  better,  .sometimes,  by  applying 
the  hands  to  the  abdomen,  after  fir.st  wetting  them  with  cold  water  to  excite  a 
refl<>x  action  of  the  fetus. 

10.  Uterine  Souffle. — This  murnuir  has  been  called  '*  placental,"  because 
it  was  thought  to  be  due  to  the  movement  of  the  blood  through  the  placental 
sinuses;  it  has  also  been  named  the  "abdominal  souffle,"  because  it  was 
thought  to  result  from  the  ])ressure  of  the  gravid  uterus  on  the  abdominal 
ves.sels.  Neither  of  these  two  theories  is  correct.  This  ])lacental  niurmiu' 
is  doubtless  due  to  the  movement  of  the  maternal  blood  through  the  uterine 
blood-vessels  ;  hence  it  should  be  called  "  uterine  .'iouftle."  Heard  first  in  the 
fourth  month,  on  the  sides  of  the  upper  part  of  the  uterus,  especially  the  left 
side,  which  lor  obvious  reasons  is  brought  nearer  the  anterior  abdominal  wall, 
the  murmur  is  at  all  times  synchronous  with  the  maternal  pulsation.  It  is 
very  uncertain  as  to  its  presence,  tone,  piti'h,  duration,  and  locsation  ;  if  once 
lieard,  it  soon  leaves,  to  return  at  another  time  or  at  another  jdace.  It  is  thus 
usually  heard  irregularly  as  to  time,  ])lace,  ])itch,  and  duration  until  the  end 
of  pregnancy.  Uterine  souffle  is  no  longer  regarded  a.s  a  ct>rtain  ]>roof  of 
pregnancy.  A  sound  exactly  resembling  it  is  not  unfrequently  hearil  in  inter- 
stitial fibroids  of  the  uterus,  and  it  may  be  heard  when  ovarian  tumors  are 
present.  In  the  majority  of  cases  of  parturition  it  is  heard  for  the  first  two 
or  three  days  in  the  lying-in  state. 

11.  Petal  Heart-sounds. — These  sounds  are  a  comparatively  modern 
dLscoverv.  Maver  of  Genoa  first  heard  them  in  1818,  in  examining  the  abdo- 
men  of  a  pregnant  woman.  The  fetal  heart-sound  cjumot,  as  a  rule,  be 
heard  earlier  than  the  fifth  month  in  utero-gestation.  A  practised  ear  may 
.sometimes  detect  it  a  i\>\v  weeks  earlier,  as  in  the  fourth  month.  As  this 
sound  becomes  stronger  and  louder  in  advancing  pregnancy,  its  detection  in 
the  last  few  months  becomes  very  easy.  The  sound  may,  of  course,  be  (|uite 
feeble.  If  normally  vigorous,  .some  non-conducting  material,  as  a  tumor,  may 
intervene,  impeding  its  transmission,  or  there  may  be  a  ])osterior  position  of 
the  child,  thus  making  it  less  distinct ;  hence  the  inability  to  hear  the  fetal 
heart-sound  ought  not  to  negative  a  pregnancy.  When  attempts  are  made 
for  its  detection,  the  room  should  be  (piiet  and  the  patient  should  be  in  the 
dorsal  posture,  with  the  head  on  a  pillow  and  the  thighs  flexed  lightly  to 


'"*i. 


'■^'^ 


'-■^^■_ 


«>!^'.-'*' 


^ 


i 


'-f 


DIAGNOSIS    OF  I'UK^^aNCY. 


169 


the  body  or  extended.  'P  ,e  stethosroiK"  ouf,'lit  to  l)e  utilized,  from  motivoa  of 
modesty,  in  loeii'- "  ^  the  .soimd  of  the  fetal  heart.  This  instrument  should 
l)e  applied  t|\the  alnlomen  below  a  tnuisverse  line  passin^j^  through  the  umbili- 
cus, oeduise  the  head  of  the  fetus  is  more  often  lower  than  the  breeeh.  Since 
the  occiput  in  most  instances  points  toward  the  left  side  of  the  maternal  pelvis, 
the  fetal  heart-sound  is  most  frequently  heard  with  greatest  distinctness  upon 
the  left  lower  sjmce  of  the  abdomen  (space  D,  Fig.  141).     If  not  heard  in 


Fio  141.— Locution  nnd  intensity  of  fetal  heiirt-sounds  in  the  left  occiplto-anterior  position  (the  four 
quttdnints  nro  indicated  by  flie  reti  lines ;  tlie  poce  is  from  Spigelius). 

this  space,  search  for  it  should  be  made  over  other  spaces  (as  b,  c,  a).  If 
heard  well  in  regions  c,  D,  the  inference  is  that  the  head  is  the  lowest  part  of 
the  fetus,  and  that  the  back  of  the  fetus  is  anterior;  if  heard  best  in  regions 
A,  B,  it  is  to  be  inferred  that  there  is  a  pelvic  presentation. 

The  mean  frequency  of  the  pulsations  of  the  fetal  heart  is  about  from  135 
to  140  to  the  minute;  they  are  less  frequent  in  large  than  in  small  children,  and 
probably  are  less  frequent  in  males  than  in  females.  A  tcm]>orary  variation 
iu  their  frequency  and   force  is  very  common.     The  sound  is  double  and 


i 


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u 


11 


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I 

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170 


A.VKIifCAN   7'/y{^'y-/^<''>^>A'   OF   OliSTETPTCfi. 


! 


ihytlunic,  tlie  first  soiiiul  boiuj;  more  clonr  iiiid  (,'"''t>.i»'t  tliuH  the  second  ;  then 
conies  11  hrief  pause,  wlien  tlie  secontl  sound  is  iieard  ;  ^  longer  pause  follows 
before  th(>  double  rhythniie  sound  is  a^ain  heard.  The  al)ove-.?iP"t'«"«^  ^«*o- 
queney  indicates  that  there  is  no  relation  of  the  fetal  heart-sound  to'^^inii- 
sations  (>f  the  lu'^t'  .'r's  heart.     These  two  sounds  are  perfectly  independent. 

lieeause  of  the  varying  frc(|uency  of  the  fetal  heart-sounds,  attempts  have 
been  made  to  bjise  some  reliable  predictions  as  to  the  eex  of  the  fetus  hi 
ulero ;  but  experience  has  proven  that  but  little  reliance  can  be  placed  on 
such  attempts. 

The  sound  of  a  fetid  heart  well  heard  when  the  uterus  is  relatively  small 
— too  small  to  accommodate  a  fetus  ^)f  five  or  more  months'  development — 
should  at  once  create  suspicions  of  an  extra-uterine  pregnancy. 

As  auscultation  with  the  stethoscope  reveals  the  presence  of  the  uterine 
souffle  and  the  fetal  heart-sound,  the  practised  ear  may  also  detect  the  funic  or 
umhilmd  muffiv — an  intermittent  hissing  sound  synchronous  with  the  fetal 
heart.  It  is  referable  to  the  umbilical  cord.  It  is  heard  in  but  the  smallest 
number  of  cases,  and  its  causation  is  conjectural.  As  a  sign  of  pregnancy  it 
has  very  little  value. 

There  are  also  heard  sounds  produced  by  active  movements  of  the  fetus  m 
uhro.  Fetal  movements,  for  instance,  may  be  heard  by  the  ear  instead  of 
being  felt  by  the  hand.     Their  value  is  significant. 

12.  Petal  Contour. — Inspection  of  the  shape  of  the  alxlomen  in  preg- 
nancy is  also  valuable  ;  a  careful,  well-trained  touch  by  palpation  may  detect 
the  size,  shape,  and  presentation  and  position  of  the  fetus,  as  well  as,  at  times, 
the  presence  of  twins  in  ntevo. 

13.  Mental  and  Emotional  Phenomena. — Pregnancy  quite  generally 
motlifics  the  nature — i)hysical,  mentid,  and  emotional — of  a  woman.  At  times, 
she  is  more  vigorous,  buoyant,  and  cheerful  than  in  the  non-pregnant  state. 
More  generally,  however,  she  is  more  or  less  irritable,  excitable,  and  fretful. 
As  the  physical  appetites  for  foixl  in  quantity,  quality,  and  variety  are  fre- 
quently changed,  so  also  is  the  moral  sense  sometimes  seriously  deranged. 

Classification  of  the  Phenomena  of  Utero-gestation. — The  symptoms 
and  signs  of  pregnancy  may  now,  for  convenient  study,  be  classified  as  to  the 
time  of  their  occurrence.  For  instance,  the  nine  calendar  months  of  utero- 
gestation  may  be  divided  into  three  periods,  and  a  classification  may  be  made 
of  the  aforesaid  phenomena  as  to  these  three  periods. 

Fii'd  Period  of  rtero-r/cstafion. — This  period  comprises  the  first  three 
calendar  months — the  time  during  which  the  gravid  uterus  is  enclosed  within 
the  true  pelvic  cavity.  The  si/mptoms  are — (1)  Menstrual  suppression;  (2) 
gastric  disorders  ;  (3)  mammary  changes ;  (4)  vesical  irritation.  The  signs 
are — (1)  Beginning  jmtulousness  of  the  os  uteri ;  (2)  softening  of  the  infra- 
vaginal  cervix,  gradually  extending  higher  ;  (3)  uterus  slightly  lowere<l  during 
the  first  and  second  months,  and  antevertwl  in  the  third  month  ;  (4)  flattening 
of  the  abdomen,  with  increasing  depression  of  the  umbilicus,  the  depression 
gradually  disappearing  toward  the  fourth  month  ;  (o)  violet-colored  vaginal 


/ 


/■\ 


r  r 


nr.Aaxosis  of  PRKaxANcv. 


171 


hI  ;  then 
follows 
)iied  fre- 

ulciit. 
)t.s  hnvp 
l(.'tijs  In 
aced  on 


walls  iind  corvix  iiti-ri  ;  ((5)  irt'>i;ar's  siirn  (contpivsHihility  of  lowi'i*  iktcriiKt  seg- 
ment), with  Hot'tened  and  ronnded  ntcrine  Ixxly. 

Second  Period  of  Llero-f/eddtton. — This  period  enii)iiu'es  the  fonrtli,  fifth, 
and  sixth  montlis.  The  hh/uh  and  xijiiiptouiH  are — (1)  Menses  still  absent ; 
(2)  subsidence  of  the  gastric  disturbances;  (.'!)  increasing  and  j)rogressive 
development  of  the  mammary  signs ;  (4)  vesical  irritation  imj)roved  ;  (5) 
the  uterus  higher,  ascending  into  the  alHlominal  cavity  ;  (6)  cervix  higher  in 
vagina ;  navel  no  longer  depressed  ;  (7)  fundus  uteri  two  fingers'  breadth 
above  pubes  at  the  end  of  the  fourth  month  ;  at  the  und)ilicus  toward  the  end 
of  the  sixth  month ;  (8)  cervix  more  softened  and  patulous ;  (9)  fetal  active 
motion  (quickening)  experienced  toward  the  end  of  the  fourth  or  in  the  fifth 
month;  (10)  ballottenjent  detected,  becoming  more  «listinct ;  (11)  intermit- 
tent contnietioui,  also  detected,  increasing  in  force  ;  (12)  uterine  soufHe  audible 
in  the  fourth  or  fifth  month  ;  (1.'})  fetal  heart-sounds  easily  detecteil,  usually 
first  in  the  fifth  month. 

Third  Period  of  Utero-gestation. — This  period  embraces  the  seventh,  eighth, 
and  ninth  months.  The  m/m  and  symptomn  are — (1)  Menses  continue  absent ; 
(2)  gastric  symptoms  slight  >  •  only  occasional ;  (3)  further  progressive  develop- 
ment of  the  mammary  signs,  colostrum  sometimes  present ;  (4)  uterus  continues 
to  rise  in  the  abdominal  cavity,  reaching  midway  between  the  navel  and  the  ensi- 
form  cartilage  at  the  end  of  the  seventh  month ;  reaching  the  ensiform  car- 
tilage in  the  first  two  weeks  of  the  ninth  montli ;  after  which  period  it  grad- 
ually becomes  lower;  (6)  ballottement  continues  until  the  eighth  month,  when  it 
is  doubtful ;  it  is  absent  in  the  ninth  month ;  (6)  umbilicus  commencing  pro- 
gressively to  protrude ;  (7)  vaginal  cervix  seemingly  shortened,  more  thick- 
ened, soflened,  and  patulous,  getting  higher;  (8)  fetal  movements  felt  or  seen 
after  the  sixth  month ;  (9;  in  last  two  weeks  the  fundus  uteri,  having  reached 
its  maximum  height  and  size,  begins  to  descend,  when  the  cervix  undergoes 
a  real  shortening.  Now  the  cervical  lips  become  thinner.  The  presenting 
part  of  the  fetus,  having  partially  entered  the  pelvic  inlet,  is  more  easily 
detected  by  vaginal  touch.  Pi'essure-symj>toms  of  the  chest  and  the  stomach 
disapi)ear,  though  edema  of  the  limbs  and  the  genitals  may  show  themselves. 

Relative  Value  of  the  Symptoms  and  Signs  of  Pregnancy  in  Point 
of  Diagnosis. — Very  properly  we  may  classify  all  the  symptoms  and  signs 
of  pregnancy  as  medical  evidence  of  the  presumptive,  the  probable,  and  the 
positive  kind.     They  naturally  rank  in  value  inversely  in  the  order  named. 

The  presumptive  evidences  ofj-'ef/nanct/  are — (1)  Menstrual  suppression  ;  (2) 
morning  sickness ;  (2)  irritable  bladder ;  (4)  mentid  and  emotional  phenoiuena. 

The  probable  evidences  are — (1)  Mammary  changes ;  (2)  the  bimanual 
signs ;  (3)  abdominal  changes  in  size,  shape,  and  color ;  (4)  changes  in  cer- 
vix uteri  in  size,  shape,  consistency,  and  color;  (5)  uterine  nuirnnu';  (6) 
intermittent  contractions. 

The  positive  signs  are — (1)  Active  movements  of  the  fetus ;  (2)  passive 
movements  of  the  fetus  (ballottement) ;  (3)  fetal  heart-sounds. 

Differential    Diagnosis   of    Pregnancy. — Nothing    can    be   of   greater 


ill 


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II. 


172 


AMIJRTCAX   TEXT-BOOK   OF    OBSTETRICS. 


moment,  on  tlie  one  hand,  than  a  correct  diagnosis  of  pregnancy,  and  on  the 
other  of  the  many  conditions  sinuilating  pregnancy.  Not  only  does  a  correct 
estimate  of  the  actnal  condition  concern  the  patient  and  her  family  in  a  physi- 
cal, mental,  or  moral  sense,  bnt  the  professional  repntation  of  the  physician  is 
also  serioHsly  involved.  The  legal  and  social  relations  of  some  pregnancies 
possess  a  deep  and  painfnl  interest;  therefore  let  no  opinion  be  expressed  in 
any  case  nntil  a  reasonable  certainty  can  be  arrived  at.  Time  niay  be  needed 
to  clear  np  all  donbts. 

As  pregnancy  im])lies  a  certain  variable  amonnt  of  abdominal  enlarge- 
ment after  the  fourth  month,  its  existeni'e  must  necessarily  be  differen- 
tiated from  the  many  other  con<litions,  physiological  and  morbid,  that  are 
attended  with  the  same  sign.  In  the  <litferential  diagnosis  not  mnch  diflH- 
cultv  need  exist  after  this  eidargement  is  fairlv  well  advanced.  Most  mis- 
takes  are  doubtless  made  when  the  gravid  uterus  is  still  within  the  pelvis; 
there  is  then  often  much  doubt.  There  will  fii-st  l)e  considered  the  differential 
diagnosis  of  pregnancy  and  the  morbid  conditions  simulating  it  during  the 
first  three  months.  Just  here  comes  into  play  the  diagnostic  value  of  the 
sign  so  forcibly  elucidated  by  Hegar.  The  peculiar  shape  of  the  uterus  in 
the  second  and  third  months  of  pregnancy  (see  p.  1(54)  is  not  simulated  by 
anything  else.  While  in  a  measure  resembling  subinvolution  of  the  uterus, 
it  is  to  be  remembered  that  in  this  morbid  condition  there  is  an  organic  enlarge- 
ment uniform  in  all  directions.  In  chronic  metritis  attended  with  hyperemia, 
with  or  without  flexion,  the  uterus  is  not  jug-shaped,  and  the  elasticity  and 
compressibility  of  its  uterine  walls  are  absent.  Chronic  metritis  attended  with 
parenchymatous  hyperplasia  of  the  uterine  body,  shows  the  uterine  walls 
dense,  hard,  sensitive  to  touch,  not  elastic,  doughy,  or  boggy.  An  interstitial 
fibroid  in  either  uterine  wall  is  dense,  hard,  and  uneven.  Doubt  is  apt  to 
pertain  to  cases  of  ]>regiiancy  associated  with  chronic  retroversion,  but  then 
a  careful  analysis  of  the  presumptive  symptoms  will  always  be  helpful  in  dif- 
ferentiation. A  clear  study  of  the  j)hysical  signs  of  the  cervix  and  the  corpus 
uteri  as  to  color,  size,  shape,  and  consistency  are  of  inestimable  value  in  the 
first  three  months.  A  search  for  Hegar's  and  the  other  bimanual  signs 
ought  never  to  be  neglected.  Pregnancy  may  be  concealed,  feigned,  and 
imagined.     These  possibilities  must  be  considered  and  be  cleared  up. 

When  ])regnan(y  has  created  material  abdominal  enlargement,  the  diagno- 
sis ought  to  be  differentiated  from  all  other  conditions  attended  by  the  same 
sign,  such  as  ascites,  ovarian  tumor,  uterine  fibroid,  distended  bladder,  tym- 
panites, pseudo-cyesis  (false  ])regnan('y),  enlarged  uterus  from  gas  (physo- 
metra)  or  from  water  (hydrometra),  retained  menses  (hematometra),  obesity, 
enlarged  abdominal  viscera,  malignant  disease,  etc.  In  differentiating  these  con- 
ditions the  three  ])ositive  signs  of  pregnancy  should  always  be  borne  in  mind. 

In  ascites  finctuatiou  is  most  distinct ;  the  resonant  note  (m  j>ereussi()n  is 
always  changeil  in  location  according  to  the  ])osition  of  the  patient.  Cardiac, 
hepatic,  or  renal  disease  can  usually  be  detected  as  a  causative  factor  of  the 
ascites,  and  the  symptoms  of  pregnancy  are  absent. 


\ 


DIAGNOSIS    OF  PREGNANCY. 


173 


Til  ovarian  tumor  a  fluctuation  of  the  abdomen  is  also  present,  though  less 
distinct;  the  aMominal  enUirgcment  has  come  on  more  slowly  and  has 
n  peculiar  shape.  INIenstruatioii  is  ordinarily  present,  and  the  signs — iiitra- 
polvic  and  abdominal — ot"  pregnancy  are  entirely  absent.  The  area  ofdulness 
jind  tympanites  is  not  essentially  altered  by  posture.  As  pregnancy  and  an 
ovarian  tumor  quite  often  coexist,  a  constant  watch  ought  to  be  made  for  this 
pt)ssibility  in  every  case  of  an  abdominal  enlargement.  The  presence  of  two 
tumors  of  different  consistency  with  an  intervening  sulcus  is  quite  significant ; 
when  both  are  present,  the  uterus  itself  by  a  vaginal  examination  shows 
enlargement,  and  there  are  present  the  presumptive  symptoms  of  pregnancy, 
while  there  are  also  the  signs  of  an  ovarian  cyst. 

A  uterine  fibroid  creates  an  abdominal  enlargemeiiC  which  is  more  firm, 
hrrd,  and  dense  than  any  of  the  above-mentioned  conditions ;  it  is  nodular 
ami  very  often  asymmetrical,  is  quite  slow  of  growth,  and  menstruation  is  not 
only  present,  but,  as  a  rule,  is  also  increa^ied  in  quantity  and  lengthened  in 
duration.  While  the  uterine  murmur  may  be  very  well  marked,  there  are 
present  no  positive  signs  of  pregnancy. 

A  distended  bladder  is  of  comparatively  short  duration,  is  attended  with 
much  discomfort,  is  associated  with  dribbling  of  the  urine,  and  is  quickly 
relieved  by  the  use  of  a  catheter. 

Fecal  accumulation  is  dissipated  by  a  copius  rectal  enema  and  free  catharsis. 

Tympanitic  distention  of  the  abdomen  is  always  very  resonant  on  per- 
cussion, is  variable  in  size  on  diflerjiit  days,  does  not  fluctuate,  and  quickly 
disappears  by  ])roper  treatment. 

Pseudo-cyesis,  or  false  pregnancy,  occurs  oftcnest  toward  the  menopause, 
and  its  false  appearances  are  quickly  unmasked  by  the  administration  of  an 
anesthetic. 

Obesity  shows  the  abdominal  walls  soft,  doughy,  and  easily  palpated 
between  the  fingers  of  either  liand,  and  there  are  uo  intrapelvic  signs  indicative 
of  pregnancy. 

Hydronietra  and  physometra  are  extremely  rare.  There  is  always  with 
ihem  an  absence  of  most  of  the  probable  and  all  the  positive  signs  of  preg- 
nancy. The  uterus  in  both  diseases  enlarges  more  slowly,  and  never  to  the 
extent  of  an  advanced  pregii;uicv. 

Diagnom  of  Krtra-Hfcri)ic  I'lrrfnnncii. — A  judicious  differential  diagnosis 
of  intra-uterine  pre  i;nancy  implies  a  careful  consideration  of  the  possible  or 
])robal)le  existence  of  extra-uterine  pregnancy.  This  is  especially  the  tiict 
wiien  the  gravid  uterus  or  the  extra-uterine  sac  is  still  within  the  true  pelvis, 
for  if  the  diagnosis  is  the  best  guide  for  treatment,  now  is  the  time  of  all  others 
to  know  the  exact  condition  of  atlliirs.  The  following  symptoms  and  signs 
are  worthy  of  most  reliance  from  a  diagnostic  point  of  view.  When  extra- 
uterine pregnancy  exists,  there  are — 

1.  The  general  and  reflex  symptoms  of  pregnancy  ;  they  iiavc  often  come 
on  after  an  uncertain  period  t)f  sterility.  Nausea  and  vomiting  appear 
aggravated  (Winttkel). 


/il 


I  I 


174 


AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 


; 


2.  Then  comes  a  disordered  menstruation,  especially  metrorrhagia,  accom- 
panied with  gushes  of  blood,  and  with  pelvic  pain  coincident  with  the  above 
symptoms  of  pregnancy.  Pains  are  often  very  severe,  with  marked  tender- 
ness within  the  pelvis.     Such  symi)toms  are  highly  suggestive. 

3.  There  is  the  presence  of  a  pelvic  tumor  characterized  as  a  tense  cyst, 
sensitive  to  touch,  actively  pulsating.  This  tumor  has  a  steady  and  pro- 
gressive growth.  In  the  first  two  months  it  has  the  size  of  a  pigeon's 
egg;  in  the  third  montli  it  has  the  size  of  a  hen's  egg;  in  the  fourth  month 
it  has  the  size  of  two  fists. 

4.  The  OS  uteri  is  patulous ;  the  uterus  is  displaced,  but  is  slightly  enlarged 
and  empty. 

6.  Symptoms  No.  2  may  be  absent  until  the  end  of  the  third  month,  when 
suddenly  they  become  severe,  with  spasmodic  pains,  followed  by  the  general 
symptoms  of  collapse. 

6.  Expulsion  of  the  decidua,  in  part  or  in  whole. 

Numbers  1  and  2  are  presumptive  symptoms  of  extra-uterine  pregnancy; 
Numbers  3  and  4  are  probable  signs  of  extra-uterine  j>regnancy ;  Numbers 
5  and  6  are  jjositii-e  signs  of  extra-uterine  pregnancy. 

Some  of  the  above-mentioned  symptoms  resemble  those  of  early  abortions. 
In  all  cases  with  the  history  of  a  supposed  abortion,  when  an  intrapclvic  mass 
is  then  or  afterward  felt,  there  should  be  suspicion  of  an  extra-uterine  preg- 
nancy. In  consideration  of  the  possibility  or  probability  of  extra-uterine 
pregnancy,  based  on  the  detection  of  a  lateral  extra-uterine  sac,  we  are  neces- 
sarily obliged  also  to  exclude  in  the  difi'erentiation  a  small  ovarian  tumor,  an 
enlarged  ovary,  a  hydrosalpinx  or  a  pyosalpinx,  and  pelvic  exudates  (cellu- 
lar or  peritoneal).  A  distinct  sulcus  between  the  sac  or  the  tumor  and  the 
uterus  may  be  a  physical  sign  to  guide  in  the  diagnosis.  The  symptoms  of  a 
severe  and  overwhehning  pain  are  quite  generally  manifested  by  the  end  of  the 
third  month,  because  most  cases  are  tubal  in  some  form.  Tiiose  symptoms 
are  not  noticed  when  the  extra-uterine  pregnancy  is  entirely  abdominal.  The 
possiI)ility  of  mistakes  in  diagnosis  is  to  be  considered  with  reference  to — (a) 
Retroflexion  of  the  gravid  uterus ;  (b)  pyosalpinx  with  amenorrhea,  or 
causing  abortion;  (c)  malignant  tumors  of  the  abdomen  with  ascites;  ((?) 
normal  ])regnancy  complicated  with  abdominal  tumors;  (r)  coincident  intra- 
and  extra-uterine  pregnancy ;  (_/")  pregnancy  in  a  deformed  uterus. 

Didc/noxis  of  MuUiph'  J'ref/na))ci/, — Susj)icions  of  a  twin  pregnancy  are 
rarely  excited  ;  but  the  presence  of  nuiltiple  ])regnan('y  may  be  conjectured 
from  the  following  data  :  (<i)  Very  large  size  of  the  abdomen  ;  (h)  exaggera- 
tion of  the  results  of  a  gravid  uterus  ;  (c)  irregularity  of  abdominal  enlarge- 
ment;  (d)  detection  by  palpation  of  the  abdominal  walls  of  two  fetal  heads 
and  other  parts  of  fetuses;  (f)  ballottement  imperfect  or  impossible;  (/)  fetal 
movements  distinctively  felt  in  different  j)arts  of  the  abdomen  ;  (,7)  recog- 
nition by  auscultation  of  two  fetal  heart-sounds,  not  synchronous  with  each 
other  and  heard  at  different  locations,  with  an  intervening  space  where  the 
heart-sounds  are  heard  feebly  or  not  at  all. 


i 


DIAGNOSIS    OF  PREGNANCY. 


175 


ley  lire 
rct\iro(l 
jtrgera- 
lilartri!- 
hoads 
f)  ibtal 
oog- 
|i  each 
ire  tlu' 


Diagnosis  of  a  Prior  Prrf/nanci/.- — In  tlie  earlier  months  tlie  diagnosis  of 
anv  previous  pregnancy  must  always  be  obscure,  even  if  search  has  been 
made  for  evidences  of  a  previous  pregnancy  within  a  few  days  after  the  expul- 
sion of  the  uterine  contents.  Of  coui"se  we  would  expect  to  find  the  uterus 
more  or  less  enlarged,  some  local  hyperemia  of  it,  the  os  uteri  patulous,  and 
tliere  may  be  present  some  lochial  discharge.  But  these  distinctive  differences 
between  the  uterus  which  has  suffered  an  early  abortion  within  the  first  three 
or  four  months  and  the  chronically-enlarged  uterus  menstruating  are  not  suf- 
ficient to  be  surely  reliable.  In  case  of  doath  a  post-mortem  examination 
would  probably  throw  much  light  on  the  question  of  gestation.  In  an  aborted 
uterus  some  remains  of  the  placenta  or  of  the  decidua  might  be  detected,  the 
placental  site  would  be  imj)erfectly  involuted,  and  in  the  ovaries  the  corpus 
luteuni  of  pregnancy  might  be  found. 

The  physical  evidences  of  a  previous  pregnancy  are  most  distinctly 
marked  when  parturition  has  occurred  late  during  pregnancy  or  at  term. 
The  uterus  by  palpation  in  the  hypogastric  region  is  then  felt  much  larger ; 
the  lochial  discharge  is  more  characteristic ;  a  fatty  degeneration  can  be  de- 
tected in  the  uterine  walls ;  the  placental  site  will  be  well  marked ;  the  vagina 
is  patulous  and  relaxed ;  the  corpus  luteura  of  pregnancy  is  quite  distinct. 
Sliould  the  cervix  uteri  or  the  perineum  have  been  lacerated  in  the  previous 
parturition,  they  will  be  observed  either  ununited  or  secondarily  healed.  The 
vulvar  fourchette  is  always  destroyed  after  the  first  delivery.  Very  often — 
quite  generally,  indeed — unmistakable  proof  of  a  previous  pregnancy  and 
delivery  is  noticed  by  vaginal  touch.  An  iusi)ection  of  the  cervix  uteri  shows 
tliat  the  OS  is  oval,  with  imperfectly-healed  rents.  A  careful  examination  after 
death  will  show  the  same  condition,  and  the  cervical  canal  will  be  found  less 
fusiform  •  the  uterus  is  enlarged  and  heavier,  the  corporeal  cavity  having  lost 
its  clearly-defined  triangular  shape,  the  fundus  uteri  being  no  longer  convex, 
as  in  a  nullipara,  but  flat  or  concave. 

All  general  appearances  of  recent  deliveries  are  very  uncertj\in  ;  there  are 
none  which  may  not  be  produced  by  other  conditions.  Some  women  look 
perfectly  well  alter  a  delivery,  and  one  unacquainted  with  the  clinical  history 
would  never  susjieet  that  parturition  had  occurred.  Inspection  of  the  abdo- 
men is  more  to  be  depended  on.  A  soft  and  relaxed  abdominal  wall,  with  the 
skin  thrown  into  folds,  traversed  by  white  shining  lines  (linea;  albicantes) 
extending  from  the  groin  to  the  navel,  is  strong  probable  proof  of  recent 
delivery.  The  l)reasts  after  the  first  few  days  are  fuller,  are  tumid,  •vnd  they 
contain  the  lacteal  secretion.  The  presence  of  colostrum-corpuscles  bespeaks 
:i  recent  delivery.     The  nipples  show  the  characteristic  areolic. 

(Chloasma  uterinum  usually  occurs  on  the  face  of  pregnant  women,  and 
lasts  for  many  years.  But  the  same  skin  affection  is  also  met  with  in  single 
women,  and  even  in  men.  It  is  due  to  physiological  and  pathological  changes 
in  the  litems  and  to  various  disorders  of  the  menstrual  functions. 

Diagnosis  of  the  Life  or  the  Death  of  the  Fetus. — The  fetus  may  from 
some  cause,  maternal  or  fetal,  die  in  utero  before  its  time  of  viability.     Such 


ff< 


176 


AMERICAN    TEXT-BOOK    OF   OBSTETRICS. 


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a  death  generally  shows  itself  sooner  or  later  by  certain  niaternal  symptoms. 
The  patient  has  a  feeling  of  languor  and  physical  depression,  with  impaired 
appetite ;  there  will  be  noticed  a  furred  tongue,  nausea,  vomiting,  and  a  pale 
and  sallow  color  of  the  patient.  Chilliness  with  some  fever  is  sometimes 
observed.  The  abdomen  does  not  progressively  enlarge ;  the  breasts  become 
flaccid  and  diminished  in  size ;  and  a  fetid  discharge  from  the  vagina,  contain- 
ing exfoliated  epidermis,  is  a  certain  but  not  common  indication.  The  absence 
of  the  fetal  heart-sounds,  especiully  if  once  heard,  and  the  cessation  of  active 
motion  of  the  child,  once  felt,  if  pregnancy  has  advanced  beyond  the  sixth 
month,  are  positive  proofs.  Should  the  fetal  head  have  presented,  its  scalp 
becomes  soft  and  flabby;  the  cranial  bones  are  loose  and  movable,  overlapping 
one  another.  The  lips  of  the  fetal  mouth  in  face  presentations  become  flabby 
and  motionless.  No  caput  succedaneum  can  form  in  delivery,  for  there  is  no 
fetal  circulation  to  assist  in  its  production.  Large  quantities  of  meconium  may 
be  discharged,  although  the  breech  does  not  })resent.  Should  the  breech  present, 
the  examining  fiuger  discovers  that  the  inal  sphincter  of  the  fetus  will  not 
spontaneously  contract.  The  umbilical  crd,  prolapsing  in  shoulder  or  other 
presentations,  is  cold,  flaccid,  and  pulseless,  contrary  to  its  warm,  full,  and 
pulsating  condition  during  fetal  life. 

The  rapidity  of  maternal  infection  from  retention  within  the  uterus  of 
a  dead  fetus  will  depend  u|K)n  her  vital  resistance,  the  condition  of  her  general 
health,  and — the  most  important  factor — whether  or  not  the  membranes  have 
been  ruptured  and  atmospheric  air  has  entered  the  uterine  cavity. 

2.  Duration  op  Pregnancy. 

Parturition  or  childbirth  means  the  end  of  pregnancy.  The  end  of  preg- 
nancy, or  the  time  of  expected  labor,  is  always  important  to  foretell,  not  only 
for  the  physician's  but  also  for  the  patient's  sake.  Cazeaux  has  given  expres- 
sion to  tiie  statement  that  conception  is  more  apt  to  follow  when  a  voluptuous 
sensation  or  a  general  erethism  occurs  during  or  following  coitus ;  but  this 
cannot  be  true.  jNIany  women  are  always  passive  in  coitus,  and  all  women  are 
entirely  j)assive  in  conception. 

The  normal  duration  of  pregnancy  is  nine  calendar  months  or  about  ten 
lunar  months.  To  be  more  exact,  its  duration  is  between  two  hundred  and 
seventy  and  two  hundred  and  eighty  days,  from  the  flrst  day  of  the  last  oc- 
curring menstrual  period,  or  about  two  hundred  and  seventy-five  days,  calcu- 
lated from  its  cessation.  Various  methoils  have  been  suggested  to  obtain  the 
time  of  the  expected  parturition  ;  the  most  reliable  of  these  methods  is  as  fol- 
lows :  Deteniiine  the  exact  day  at  which  the  last  menstruation  appeared. 
Count  forward  nine  months,  or,  better,  count  backward  three  months,  and  then 
add  seven  days.  Irrespective  of  the  time  of  the  year  from  which  this  couiil 
is  begun,  a  very  close  approximation,  from  two  hundred  and  seventy-eiglit 
to  two  hundred  and  eighty  days,  is  obtained.  This  is  the  rule;  but  it  is  un- 
certain and  excej)tions  are  not  uncommon.  Many  difficulties  are  experienced 
in  detern)ining  the  date  of  the  expected  parturition.     As  most  pregnancies 


i  * 


it 


DIAGNOSIS    OF  PREGNANCY. 


177 


l)ont  ten 

Ired  aiul 

last  oc- 

Is,  C'llU'U- 

[)tain  tlif 
Is  as  lol- 
|[)poar(Hl. 
luul  then 
[is  count 
lty-('igl>i 
It  is  un- 
leriencotl 
rnaneies 


occur  in  married  womeu,  we  canuot  base  any  calculations  on  a  single  act  of 
coitus.  Even  if  there  has  been  but  one  coitus,  all  physiologists  admit  that 
there  is  a  variable  period  in  different  women,  and  in  the  same  woman  at  dif- 
t'oreut  times,  between  insemination  and  the  fertilization  of  the  ovum. 

When  the  impossibility  of  ascertaining  the  precise  time  of  fertilization 
and  the  probable  variation  in  the  length  of  gestation  itself  are  considered, 
the  reasons  for  this  uncertainty  become  apparent.  Recognizing  with  His 
that  the  moment  of  fecundation  marks  the  beginning  of  pregnancy,  the  pos- 
sibility of  fixing  this  occurrence  becomes  of  great  interest.  The  uncertainty 
becomes  still  greater  owing  to  our  inadequate  knowledge  as  to  the  length  of 
time  during  which  the  sexual  elements,  the  ova  and  the  spermatozoa,  retain 
their  vitality  after  liberation  from  their  respective  sources. 

Wiiile  the  exact  time  during  which  the  matured  but  unfertilized  ovum 
retains  its  power  of  successfully  receiving  the  male  element  is  unknown,  the 
obsc-rvations  conducted  on  lower  animals  render  it  probable  that  the  ovum  is 
capable  of  impregnation  at  any  time  during  its  sojourn  within  the  oviduct  and 
l)ef"ore  reaching  the  uterus,  or,  probably,  for  a  period  of  about  one  week  from 
its  escape  from  the  Graafian  follicle. 

The  remarkable  vitality  of  tlie  spermatozoa  even  under  far  less  favorable 
conditions — direct  observation  showing  that  these  elements  retain  their  move- 
ments for  over  nine  <lays  outside  the  body — renders  it  almost  certain  that  their 
powers  of  fertilization  are  maintained  for  a  longtime  after  they  are  depositefl 
within  the  healthy  female  generative  tract ;  the  assumption  of  His,  Haus- 
mann,  and  others  that  the  spermatoza  arc  capable  of  fertilization  after  their 
sojourn  of  three  or  more  weeks  within  the  oviduct  is  well  foiuided. 

(Consideration  of  these  facts  renders  apparen.t  the  impossibility  of  fixing 
with  certainty  the  Uginning  of  pregnancy,  since  concej)tion  may  result  from 
the  union  of  tlie  ovum  liberated  at  the  commencement  of  menstruation  with 
the  spermatozoa  introduced  toward  the  end  of  the  period  ;  or  it  may  result,  as 
pointed  out  by  His,  from  the  meeting  of  the  male  elements  already  within  the 
oviduct  with  an  ovum  discharged  a  day  or  two  before  the  occurrence  of  the 
menstrual  phenomena.  The  i)ossible  discrepancies  arising  from  these  causes 
have  been  represente<l  graphically  by  Marshall  as  follows : 

I.,  2,  .3,  4,  5,  6,  7 26,  27,  28,  II. 

in  which  I.  is  the  first  day  of  the  last  actually  occurring  menstrual  pericxl, 
and  II.  is  the  first  day  of  the  first  omitted  period.  Should  pregnancy,  how- 
ever, occiu'  under  the  conditions  regarded  as  possible  by  His — that  is,  by  the 
i'crtilization  of  an  ovum  precociously  discharged  just  prior  to  the  first  omitted 
period,  a  discrepancy  of  over  three  weeks  woidd  appear  between  the  actual 
termination  of  pregnancy  and  the  esti.nated  date  of  labor,  when  calculated  in 
tlie  usual  manner  from  the  first  day  of  the  last  occurring  menstruation.  The 
general  consensus  of  opinion,  however,  regards  the  time  immediately  following  the 
menstrual  period  as  that  most  favorable  for  fertilization,  the  upper  third  of  the 
oviduct  being  probably  the  locality  where  fecundation  most  usually  takes  place. 
Should  impregnation  have  occurred  following  the  menstrual  period,  the 

12 


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178 


AMERICAN   TEXT-liOOK   OF   OBSTETRICS. 


next  expected  period  will  almost  certainly  Im?  absent ;  but  if  it  has  taken  place 
within  a  few  days  before  an  expected  period,  the  expected  flow  may  not  physi- 
ologically be  suspended,  but  simply  be  diminished  in  (piantity  or  be  short- 
ened in  duration.  The  prediction  of  the  date  of  labor  from  the  last  menstrua- 
tion is  likewise  very  unreliable  in  all  women  in  whom  its  previous  occurrences 
have  been  irregular  or  uncertain  in  time. 

Quickening,  as  a  rule,  is  noticed  by  the  female  in  the  fourth  month — about 
four  and  one-half  months — and  it  is  not  unusual  for  counts  to  be  made  from 
this  period.  But  as  quickening  (active  movements  of  the  child)  is  felt  at  un- 
certain times,  this  rule  has  been  found  to  be  very  fallacious.  At  a  certain  time 
it  proves  to  be  the  most  reliable  of  any  rule  for  adoption — namely,  when  men- 
struation has  physiologically  been  suspended  by  an  intercurrent  lactation. 
Then  there  is  no  last  menstrual  period  to  count  fi'oni,  and  we  have  but  to  add 
four  and  one-half  months  to  this  time  of  quickening  to  determine  the  approxi- 
mate time  of  the  exjiected  labor. 

It  is  no  wonder  that  the  duration  of  pregnancy  in  the  human  female  has 
been  such  a  fruitful  topic  for  discussion  among  obstetricians.  Not  only  the 
moral  character  of  a  woman,  but  also  the  legitimacy  and  the  hereditary  rights 
of  a  child,  may  depend  upon  a  fair  solution  of  this  question.  Is  it  j)ossible 
for  a  women  to  give  birth  to  a  child  ten,  eleven,  or  twelve  months  after  the 
death  or  the  continued  absence  of  her  husband?  is  a  medico-legal  question 
concerning  which  the  obstetrician  may  be  called  upon  to  express  an  opinion. 
Experience  witli  some  of  the  lower  animals  in  whom  the  date  of  a  single 
coitus  is  well  fixed,  and  the  records  made  by  numerous  distinguished  obstetric 
authorities,  make  such  exceptional  instances  as  reliabh  creditable.  Most  of 
such  offspring  are  very  large  male  children. 

3.  Prolongation  op  Pregnancy. 

Sir  Charles  Clark  in  1816,  when  giving  his  evidence  in  the  famous  Gard- 
ner-Peerage case  before  the  House  of  Connnons,  said  :  "  I  have  never  yet  seen 
a  single  instance  in  which  the  laws  of  nature  have  been  changed,  believing  the 
law  of  nature  to  be  that  parturition  should  take  place  forty  weeks  after  con- 
ception." ]\Iany  jihysicians  of  the  present  day  hold  that  the  law  of  nature 
is  quite  fixed  in  this  res])ect — that  human  pregnancy  never  exceeds  this  term. 
But  we  have  now  sufficitnit  evidence  to  show  that  human  pregnancy  is  not  so 
definitely  and  precisely  fixed  as  some  think.  The  duration  of  pregnancy  may 
be  shorter  or  lonjver  than  280  days. 

To  what  exteut  may  ])regnancy  be  jirolonged,  and  what  are  the  evidences 
of  its  prolongation?  It  is  easy  to  understand  the  moral  and  legal  aspects  of 
1;;  iiportiint  question.  The  moral  charact*  r  of  ilie  female,  and  the  iidieritcid 
is  and  legitimacy  of  an  ofispring  may  depend  on  a  fair  and  just  fixation  dl' 
1!-  Duuriiity,  and  on  the  determination  of  the  possibility  of  the  prolongation 
of  liitinan  pregnancy,  as  when  a  woman  gives  birth  to  a  child  ten,  eleven,  or 
twelve  months  after  the  death,  or  the  forced  absence,  of  the  husband.  Laws 
ou  this  question  vary  in  diffei'ent  countries.     In  France  legitimacy  cannot  bf 


^2M 


Gai-d- 
t  seen 

lllg  tllL' 

r  con- 
11  at  lire 

term. 

not  so 
•y  may 

kleiiccs 
Iccts  tit' 

lioritcd 
It  ion  (if 

Igation 

rcii,  or 
Laws 

inot  be 


DIAGNOSIS    OF  PREGNANCY. 


179 


contested  until  300  days  have  elapsed  since  the  death  of  the  husband,  and  in 
Austria  and  Prussia  about  the  same  time  is  allowed.  In  England  and  in  the 
United  States  no  time  is  fixed. 

Numerous  cases  are  on  record  of  a  prolongation  of  pregnancy  to  336,  332, 
"24,  and  319  days,  respectively,  after  the  last  menstruation.  Granting  that 
conception  in  these  cases  did  not  take  jilace  within  a  few  days  after  the  last 
menstruation,  as  is  the  rule,  but  w'as  postponed  to  just  before  the  first  missed 
iieriod  of  that  function,  we  «ui  subtract  about  23  days  from  these  periods  of 
gestation,  and  will  then  have  313,  309,  301,  and  296  days,  each  exceeding  the 
ordinary  duration  of  pregnancy. 

Admitting  that  the  first  menstrual  cessation  was  due  to  some  abnormal 
(•■msc — a  mere  possibility — we  will  still  have  a  prolonged  duration  of  preg- 
iKincy.  Hence  the  possibility  of  a  variation  of  a  conception  being  uncertain 
its  to  time  does  not  account  for  the  great  variation  in  gestation  so  often 
(il)sorved.  It  is  extremely  uncommon  in  healthy  young  women  for  a  men- 
strual period  to  be  skij)ped  for  one  time  only  without  there  being  some  notice- 
able change  in  the  bodily  health. 

Variations  in  the  duration  of  pregnancy  occur  in  cows,  in  which  there  have 
l)oen  careful  records  of  a  single  coitus.  When  impregnation  occui*s  in  the  human 
female  as  the  result  of  a  single  coitus,  the  date  of  which  is  accurately  recorded, 
as  among  single  women  or  among  married  women  whose  husbands  have  been 
absent  for  months,  possible  errors  of  the  date  of  conception  may  be  avoided. 
If,  then,  pregnancy  is  at  times  prolonged,  to  what  extent  is  there  any  pro- 
traction ?  Meigs,  Atlee,  and  Simpson  have  mentioned  instances  when  the 
duration  was  prolonged  to  almost  or  quite  a  year.  Dewecs  records  a  case 
which  was  prolonged  to  ten  calendar  months.  Playfair,  Liisk,  and  Leishnian 
mentioned  cases  of  considerable  prolongation.  Taylor  and  Beck  in  their  work 
on  ^Medical  Jurisprudence  record  numerous  instances  of  protracted  gestation. 

Other  physiological  functions  of  life,  such  as  dentition,  puberty,  or  men- 
struation, may  vary  as  to  the  time  of  occurrence.  Some  women  appear  to  go 
uniformly  beyond  the  usual  time  for  parturition.  The  degree  of  uterine  activity 
must  be  less  with  them.  More  frequently  the  sex  of  the  forthcoming  delayed 
cliild  is  male  rather  than  female.  We  are  forced,  then,  to  the  conclusion,  by 
a  study  of  the  analogy  of  other  functions  of  the  body,  by  observations  in  the 
lower  animals,  and  by  accurate  reliable  data,  from  women  in  particular,  to 
believe  that  pregnancy  may  be,  and  often  is,  prolonged.  Gestation  may  be 
lengthened,  parturition  may  be  delayed,  from  a  few  days  to  several  months. 

The  causes  which  conduce  to  labor — the  maturing  of  the  dccidua  vera,  its 
preparatory  disintegration,  and  the  final  detachment  of  the  membrane  of  the 
ovum  from  the  uterine  lining — do  not  always  occur  at  the  same  time  or  with 
the  same  degree  of  activity  ;  hence  gestation  may  be  jirolouged. 


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AMERICAN    TEXT-BOOK    OF   OBSTETRICS. 


III.  HYGIENE  AND  ^fANAGEAIENT  OF  PREGNANCY. 

Hygiene  of  Pregrnancy. — To  be  ciirrii'd  sat'oly  through  the  period  of  utero- 
gestatioti,  tlie  most  critical  time  of  her  life,  physiologictilly  speaking,  the  preg- 
nant woman  nct'ds  special  care.  Particniar  attention  is  to  be  given  her  in 
the  selection  oi'  diet,  exercise,  rest,  sleep,  clothing,  and  bathing.  Her  mental 
condition  is  to  be  watched  ;  her  attention  diverted.  The  condition  of  the 
breasts  calls  for  some  prophylactic  treatment. 

DU'f, — Very  early  in  pregnancy  the  desire  for  food  is  diminishe<l  and  cer- 
tain unnsnal  articles  of  food  may  be  craved.  Fair  quantities  of  food  are 
always  needed.  Kespect  must  be  paid  to  her  morbid  longings  in  taste.  Thus 
the  time,  j)lace,  and  social  association  in  partaking  of  food,  and  its  kind  and 
variety,  are  always  to  be  considered.  The  morning  sickness  is  thus  sometimes 
best  abated.  In  the  fourth  month  the  gastric  irritability  usually  spontaneously 
subsides,  the  ap|)etite  reappears,  and  the  digestion  improves.  All  foods,  ani- 
mal and  vegetable,  that  are  reasonably  well  digested  and  mitritious  are  best 
suited  to  her  condition.  In  a  word,  the  diet  of  a  pregnant  woman  should  be 
plain,  simple,  easy  of  digestion,  highly  nutritious,  and  partaken  of  at  regular 
intervals,  A  good  general  supply  of  nitrogenous  food,  with  vegetables  and 
fruits,  is  called  for.  No  inflexible  rules  can  be  made  for  all  cases.  As  some 
foods  do  Mot  agree  equally  well  with  all  patients,  personal  likes  and  idiosyn- 
crasies must  be  consulted.  A  generous  diet  improves  hematosis,  increases  func- 
tional activity,  augments  body-weight  and  body-heat,  imparts  tone  and  firm- 
ness to  the  blood-vessels  and  tissues,  and  diminishes  the  susce])tibility  of  the 
nervous  system  to  pain  and  reflex  irritation.  That  the  diet  must  directly 
influence  the  growth  and  development  of  the  fetus  in  utero  is  reasonably  clear. 

In  the  latter  ]>art  of  pregnancy  the  gravid  uterus  has  risen  to  and  presses 
upon  the  stomach,  hence  food  has  to  be  taken  in  greater  moderation  and  at 
shorter  intervals,  A  milk  diet  is  at  times  especially  needed.  Albuminuria  is 
a  condition  calling  for  the  use  of  milk,  as  recommended  by  Tarnier.  Its 
absolute  use,  strictly  enforced,  gives  very  good  results  in  tliis  complication. 

Exercise. — Moderate  exercise  can  almost  always  be  well  borne.  Violent 
exercise  and  excessive  fatigue  are  invariably  to  be  avoitled.  Extraordinary 
exercise,  such  as  riding  horseback  or  over  rough  roads,  dancing,  or  lifting 
heavy  weights,  is  injurious.  Long  journeys  by  water  or  by  land  should  be 
postponed  if  i)ossil)le. 

Is  parturition  made  more  easy  by  unusual  physical  exercise?  Affirmatory 
ojiinions  have  been  entertained.  Doubtless,  women  whose  habits  have  accus- 
tomed them  to  considerable  jjliysical  exercise  can,  all  things  being  equal, 
undergo  parturition  easily  and  quickly;  but  those  unaccustomed  to  any  special 
physical  exercise  should  undertake  only  what  can  comfortably  be  borne.  If 
active  exercise  is  not  well  borne,  then  ])assive  exercise  may  be  highly  bene- 
ficial. Riding  in  the  open  air  gives  the  j)regnant  woman  the  necessary  fresh 
air   and   sunlight.     Crowded   and    ill-ventilateil    rooms   are  to   be  avoided. 


HYGIENE  AND   MANAGEMENT   OF  PREGNANCY. 


181 


tirin- 


fuatory 

accus- 

eqiial, 

I  special 

|e.     If 

beiio- 

f'rcsli 

wided. 


While  moderate  exercise  is  needed  in  many  or  in  most  cases,  its  continnance 
is  objectionable  in  cases  where  the  normal  relaxation  of  the  pelvic  jointK 
becomes  excessive.  The  pubic  joints,  most  often  atte(!ted,  are  so  relaxed  at 
times  that  locomotion  is  impeded  and  rest  is  demanded. 

Rest. — A  pregnant  woman  needs  abundance  of  sleep,  because  of  its  health- 
tjiving,  restoring  influence.  A  portion  of  each  day,  after  the  mid-day  meal, 
may  well  be  selected  for  the  assumption  of  the  recumbent  posture,  to  obtain 
lor  an  hour  or  two  either  rest  or  sleep. 

Clothing. — Great  care  is  to  be  taken  that  the  clothing  is  so  adjusted  as  not 
to  compress  the  alMlomen  and  the  chest.  While  the  quantity  and  the  quality 
of  the  clothing  are  to  be  determined  by  the  season  of  the  year,  the  garments 
))]aced  around  the  waist  are  to  be  as  light  as  ])racticable  consilient  with  com- 
fort. The  clothing  is  best  suspended  from  the  shoulders.  The  corset  and 
tight-fitting  skirts  are  injurious,  impeding  as  they  do  the  expansion  of  the 
Sii'owing  uterus  and  its  contents,  and  favoring  the  development  of  symptoms 
of  a  not  uncommon  complication  of  pregnancy — albuminuria  with  uremia. 
Multipara!  with  relaxed  abdominal  walls  often  experience  comfort  by  giving 
support  to  these  parts  with  an  abdominal  bandage,  thereby  maintaining  the 
uterus  in  a  more  normal  position,  wherein  there  is  better  accommodation  of  the 
fetus.     All  possible  pressure  of  the  pelvic  and  renal  veins  is  to  be  removed. 

Bathing  is  to  be  administered  to  the  body  at  the  usual  intervals  observed 
in  health — daily  in  warm  weather,  and  at  least  twice  a  week  in  cold  weather. 
The  baths  are  to  be  general,  with  an  abundance  of  water  and  soap.  The  tem- 
])erature  of  the  bath  may  be  either  warm  or  cool,  according  to  previous  habits 
and  to  the  season  of  the  year.  The  functional  activity  of  the  skin,  quite  often 
impeded  in  the  last  weeks  of  pregnancy,  should  be  maintained  carefully  by  the 
free  use  of  the  bath. 

Vaginal  injections  are  not  required  if  there  is  no  leucorrhea,  vaginal  or 
uterine.  If  an  injection  is  given  because  of  this  complication,  there  is  nothing 
better  than  a  saturated  solution  (one  quart)  of  boric  acid  given  with  a  fountain 
syringe  in  a  very  gentle  current. 

Sexual  intercourse  is  to  be  regulated  carefully,  for  very  often  it  is  found  to 
be  injurious  to  pregnant  women.  While  especially  enjoyetl  by  some  pregnant 
women,  coitus  is  distasteful  to  most  women  at  this  period,  and  it  be(!oraes  the 
source  of  nuich  pelvic  discomfort  to  not  a  few ;  it  may  create  an  abortion. 
Even  uncivilized  nations  have  condemned  the  privilege  of  sexual  intercourse 
during  the  period  of  pregnancy,  and  have  visited  ])unishment  on  the  offender. 
During  the  first  few  months  of  pregnancy,  wdien  so  many  abortions  occur,  and 
toward  the  last  of  pregnancy,  it  is  best  for  the  husband  and  wife  to  occupy 
separate  beds. 

May  local  treatment  to  the  diseased  cervix  and  canal  be  carried  on  during 
pregnancy?  With  proper  precautions  and  due  care,  this  question  is  answered 
in  the  affirmative.  INIost  of  the  accidents  causing  the  induction  of  abortion 
by  local  interference  have  arisen  from  a  neglect  to  investigate  atid  deter- 
mine the  condition  of  the  body  of  the  uterus,  and  to  ascertain  whether  it  may 


182 


AMKltlCAX   TKXT-nOOK   OF   OJiSTETRICS. 


:!? 


have  boon  gravid.  l'rc<jiianc'y  a<i<;ravatos  chronic  cervical  endometritis  in  that 
it  increases  the  cervical  catarrh,  the  granuhir  degeneration,  the  secondary 
vaginitis,  and  the  vulvar  pruritus.  Hy  the  genth;  use  of  warm  vaginal  injec- 
tions of  a  uiiii'orm  temperature,  and  by  the  topical  use  of  astringents  and  emol- 
lients, and  in  rarer  cases  of  the  nitrate  of  silver  in  solution,  not  only  may  the 
patient  l)e  made  more  comfortable,  through  an  imj)rovement  in  the  local  con- 
dition and  the  arrest  of  reflex  disorders,  such  as  nausea  and  vomiting,  but  par- 
turition itself  may  also  be  made  easier. 

The  mental  vondition  of  pregnancy  is  always  im])ortant  to  consider. 
P^motional  susceptibility  is  usually  somewhat  increased.  The  pregnant  woman, 
quite  excitable  and  irritable,  readily  responds  to  external  iiiHuences  by  which, 
in  the  non-gravid  condition,  she  would  not  be  influenced.  Sometimes  she  feels 
unusually  well,  is  intellectually  brightened  and  more  active,  takes  greater 
interest  in  her  household  affairs,  and  says  she  is  positively  happier.  At  other 
times  a  certain  despondency  creeps  over  her  mental  state;  she  is  unusually 
morose ;  there  is  observed  irritable  moodishuess  or  ]ieevishness  beyond  the 
control  of  the  will ;  the  senses  of  sight,  hearing,  smell,  and  taste,  and  the  sen- 
sory or  motor  nerves,  are  frequently  perverted  without  any  structural  changes 
in  the  nerves  concerned.  All  these  pervei-sions  or  exaltations  of  function  are 
doubtless  directly  or  indirectly  attributable  to  the  quantitative  and  qualitative 
changes  of  the  blood  from  pregnancy,  and  to  the  physical  changes  going  on  in 
the  sexual  organs,  creating  reflex  disorders.  Structural  alterations  in  the 
growing  fetus  may  be  effected,  modified,  or  perverted  by  psychical  influences. 
Certain  fetal  disorders  may  I'esult  from  maternal  impressions.  Monstrosities 
do  at  times  so  occur. 

Physiologists  admit,  and  observations  prove,  that  the  maternal  emotions 
do  affect  the  development  of  the  exterior  of  the  fetus.  Likewise  may  the 
mental  ilevelopment  be  altered  in  its  complex  and  delicate  organization. 
Idiocy  may  so  result.  The  mind  influences  and  modifies  the  body  in  ways 
unexplained. 

In  view  of  these  facts  the  wise  physician  should  aim  to  direct  the  mental 
condition  of  his  patient.  ^Vhiic  all  sudden  unpleasant  news,  frights,  and 
physical  shocks  are  carefully  to  be  avoided,  those  circumstances  which  im- 
properly harass  the  pregnant  woman  are  to  be  dismissed.  Kind  assurances  are 
ever  holj)ful.  A  judicious  amount  of  amusement  is  not  to  be  forgotten.  The 
mind  is  to  be  occupied  pleasantly,  and  diverted  into  new,  pleasing,  surprising 
channels,  into  associations  agreeable  and  cheerful.  Around  the  patient  should 
be  thrown  a  gentle,  protective  care,  and  she  should  ever  be  treated  with 
considerate  kindness.  It  becomes  the  duty  of  the  husband  to  give  his  wile 
an  intelligent  co-operation  to  bear  her  burden. 

Management  of  Pregnancy. — It  becomes  the  duty  of  every  practitioner 
of  medicine  engaged  to  attend  a  woman  in  an  expected  parturition  not  only  to 
give  her  some  general  hygienic  directions  as  to  diet,  dress,  exercise,  and  the 
regulation  of  her  bowels  and  skin,  but  also  in  a  general  way  he  should  assume 
some  professional  care  of  her  throughout  her  pregnancy.     Many  disorders  and 


a 
\ 


f  i 


IIYGIEXE   AND    MANAGEMENT   OF  PREGNANCY 


183 


complications  are  apt  to  arise  during  tiiis  periiKl,  and  much  depends  upon 
prompt  and  well-directed  advice  in  their  judicious  management. 

First  of  all,  the  stomacJi  disorder  most  frequently  occurring  calls  for  some 
attention.  Reference  has  been  made  to  its  dietetic  management,  more  effi- 
cacious, it  may  be,  than  the  medicinal.  In  this  connection  the  writer  has 
realized  general  good  results  from  the  administration  for  a  time  of  koumiss. 
Failing  with  the  retention  of  tlie  food  on  the  stomach,  rectal  administration  of 
food  is  next  to  be  utilized.  For  the  physiological  nausea  and  vomiting  of 
pregnancy  the  writer  has  found  the  following  remetlies  efficient :  Tincture  of 
nux  vomica,  weak  solutions  of  atropia,  sodium  bromid,  cocain,  and  electricity. 
Faradization  (secondary  current)  of  the  stomach  and  the  doi-sal  spine,  and  gal- 
vanization of  the  central  sympathetic  are  worthy  of  a  more  extended  use  for 
this  affi'ction  than  they  have  yet  received. 

Next,  the  alvine  evacuations  are  to  be  maintained  daily.  A  good  diet  and 
regularity  of  habits  show  their  good  results.  The  mineral  waters,  such  as 
Congress,  Hathorn,  the  sulpho-saliue  waters,  or  a  solution  of  phosphate  of 
sodium  or  Carlsbad  salts  or  the  Seidlitz  powdei-s,  are  indicated.  Purgation  is 
seldom  called  for.  The  best  laxative  remedies  are  aloeiu,  podophyllin,  and 
cascara  sagrada. 

Above  all,  it  is  important  that  careful  attention  be  given  to  the  renal  func- 
tion. Once  a  month  at  least,  during  the  latter  half  of  pregnancy,  should  the 
])hysical,  chemical,  and  microscopical  elements  of  the  urine  be  ascertained,  to 
detect  any  possible  alterations  in  its  quantity  and  quality.  Not  a  few  cases  of 
puerperal  eclampsia  from  uremia  may  thus  be  averted  or  be  modified  by 
a  supervision  of  the  kidney  excretion.  "  To  be  forewarned  is  to  be  fore- 
armed "  was  never  better  illustrated  than  just  here.  Albuminuria  is  present 
in  at  least  from  5  to  10  per  cent,  of  the  cases  of  pregnant  women  ;  some  claim 
that  the  proportion  is  larger. 

A  careful  examination  of  the  abdomen  may  very  properly  be  made  after 
fetal  viability.  The  external  examination  by  palpation,  together  with  an 
internal  vaginal  examination,  is  called  for  in  all  cases  toward  the  last  two 
weeks  of  pregnancy,  to  determine  not  only  the  fetal  viability  and  a  possible 
multiple  pregnancy,  but  also  to  ascertain  the  presentation  and  position  of  the 
fetus  in  ufero,  the  existence  of  any  complications,  as  hydramnion,  and  to 
a})preciate  the  cervical  condition  in  shajie,  size,  and  patulousness,  in  order 
more  correctly  to  estimate  the  time  of  the  approach  of  the  expected  parturi- 
tion. The  pelvis  of  every  woman  should  be  examined  by  external  and 
internal  pelvimetry  in  the  seventh  or  eighth  month  of  pregnancy,  if  in  her  first 
j)regnancy  or  if  she  has  had  any  special  difficulty  in  a  previous  parturition. 
At  the  time  of  this  examination  directions  may  be  given  as  to  the  })re])aration 
of  the  room,  the  bed,  the  garments,  and  as  to  obtaining  all  needed  articles. 

The  exact  methods  of  diagnosis  that  prevail  in  maternity  hospitals  ought 
also  to  exist  in  private  practice.  If  the  labor  promises  to  be  long,  difficult,  or 
very  painful  from  obstructions  of  any  kind,  the  obstetrician  ought  to  know  it  in 
advance,  that  he  may  elect  at  a  proper  time  before  parturition  whether  to  choose 


jTnf     ^  ill 


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184 


AMKRICAy    TEXT- BOOK   OF   OliSTEritlCS. 


the  iiidiK'tiui)  of  a  piviiiatiin!  lubor,  to  (h^pciid  on  tin;  use  of  the  forceps,  or  to 
resort  to  a  podalic  version,  a  syinpliysiotoiny,  or  a  ('esareau  section.  How 
many  craniotomies  could  tlius  be  avoided  and  maternal  deaths  prevented  ! 

The  mammary  glands  need  ample  room  for  their  development  to  prepare 
them  for  the  coming  function  t)f  hu^tation.  The  nipples,  especially  if  retracted, 
should  always  he  drawn  out  by  i\w  application  of  the  index  finger  and  the 
thumb  for  a  few  minutes  each  day  during  the  last  six  weeks  of  pregnancy. 
Exposure  of  the  glands  and  the  nipples  to  the  air  dctubtless  tends  to  diminish 
their  tcsndcncy  to  become  sore  and  fissured.  Daily  ablutions  with  cold  water 
are  always  essential.  A  topical  appli(^ation  of  the  following  as  a  jirophylactic 
remedy  for  sore  and  fissured  nipples  is  to  be  reeouimeniled  wheu  it  is  thought 
desirable  to  use  an  astringent  application  : 


I^.    Tannin, 
Glycerina?, 
Aqufe  rosa>, 
Sig.  Apply  daily  as  directed. 


.5ss ; 
.?ss.— M. 


As  no  two  pregnant  women  are  alike,  and  as  no  two  ])regnaneies  in  the 
same  woman  are  alike,  no  absolute  rule  can  be  framed  for  all.  The  expectaut 
treatment  is  largely  called  for.  Discretionary  powei-s  are  necessarily  given 
the  pliysiciau  in  charge.  Only  general  principles  cjui  be  laid  down  for  guid- 
ance. Special  (lirections  are  called  for  when  there  are  special  disorders  and 
complications.  A  very  frequent  danger  is  that  an  abortion  or  a  premature 
delivery  may  be  precipitated  by  uterine  contractions.  Any  constitutional  dis- 
ease, especially  syphilis,  nuiy  require  special  medication.  Doubtless  there  are 
remedies  which  often  favor  uterine  tonicity  and  become  prophylactic  against 
abortions.  Viburmun  j)rnnifolium,  aletris,  and  cimicifuga  doubtless  favor 
the  normal  completion  of  gestation.  In  all  eases  as  little  medicine  as  possible 
ought  to  be  given.  Pregnancy  is  a  purely  physiological  condition,  and  it  is 
best  managed  by  an  observance  of  the  hygienic  instructions. 


'  i 


TlIK   PATllOLOUY    OF   PltKd NANCY. 


185 


IV.  THE  PATHOLOGY  OF  PREGNANCY.* 

I.  Diseases  op  the  Several  Systems. 


Thk  remarkable  clianj^es  occnirriii}';  in  the  genital  organs  of  woman,  and 
also  tliroiigliont  her  entire  body,  as  gestation  advunees,  occasion  conditions 
which  often  transcend  the  bounds  of  health  and  Iwcome  states  of  disease.  As 
these  changes  are  most  pronounced  in  the  uterus  and  its  appendages,  it  will  be 
appropriate  to  consider,  first,  the  pathological  conditions  of  the  uterus  and  its 
appendages  induced  or  exaggerated  by  the  pregnant  state.  It  will  then  be 
proper  to  study  those  geneial  derangements  which  the  condition  of  pregnancy 
invites  ;  next  in  order,  to  treat  of  the  influence  of  the  various  infectious  agents 
upon  the  pregnant  organism ;  and  finally,  the  surgical  injuries  and  processes 
observed  during  this  period. 

1.  Pathological  Conditions  of  the  Uterus  and  Appendages. 

The  Uterus  during  Pregnancy. — While  the  position  of  the  jiregnant 
uterus  is  subject  to  frequent  change,  it  has  been  found  by  Ferguson '  and 
others  to  be  rotated  to  the  right  in  80  to  90  per  cent,  of  all  pregnant  women. 
<Jreat  distention  of  the  bladder  may  temporarily  lessen  the  degree  of  rotation 
upon  its  axis.  Occasionally  this  dextro-torsion  becomes  excessive,  as  in  a  case 
reported  by  Wenning,''  in  which  the  uterus  at  six  months'  pregnancy  was  so 
strongly  rotate<l  toward  the  right  as  to  sinndate  extra-uterine  pregnancy  upon 
that  side.     The  left  tube  was  greatly  eidarged. 

The  terni  "  hypertrophy  "  best  describes  the  normal  condition  of  the  preg- 
nant uterus  in  the  various  ]>hases  of  gestation  :  its  peritoneal  covering,  its 
interlacing  niu.scular  and  elastic  tissues,  and  its  glandular  lining  membrane,  all 
become  enlarged  by  production  of  new  elements  from  nuclei  already  exi.sting. 
The  enormous  increa.se  in  area  and  in  blood-supply  is  especially  remarkable 
in  the  ])regnant  woman  :  although  the  deciduous  njembranos  represent  the 
greatest  development  of  its  epithelial  elements,  still  the  eiulonietrium  shares 
extensively  in  the  general  hypertrojihy.  It  is  readily  seen  that  this  condition 
of  plethora  naliu-ally  favors  the  rapid  development  of  any  neoplasm  previously 
existing  in  the  uterus,  especially  any  neoplasm  whose  elements  closely  resemble 
normal  uterine  structures  ;  such  neo})lasms  are — 

Myomata  of  the   uterus,   sometimes  termed   fibro-myomata  or  uterine 

fibroids.     As  has  been  .'•hown  by  C'room'  and  others,  although  myomata  exist 

frequently  among  childbearlng  women,  they  do  not  alway*  attract  attention 

during  pregnancy,  and  are  often  undetected   at  labor.     Such  tumoi-s  grow, 

*  The  guperinr  figures  (')  occurrinj;  throughout  tlie  te.xt  of  this  article  refer  to  the  bihli- 
ography  given  in  the  Kefereuce  List  on  page  'M'.\. 


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186 


AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 


however,  with  groat  rapidity  during  pregnancy,  often  interfering  with  the 
circuUition  in  the  lower  extremities.  Many  cases  in  which  early  pregnancy 
is  complicated  by  edema  of  the  legs,  and  in  which  abortion  occurs  at  four 
or  five  months,  accom^^anied  by  profuse  hemorrhage,  are  cases  of  fibroids 
complicating  pregnancy  :  their  bulk  causes  interference  with  the  functions  of 
the  bladder  and  the  rectum,  while  they  alter  the  position  of  the  uterus,  causing 
abnormal  presentations  of  the  fetus  and  prolapse  of  the  cord  at  labor.  Their 
encroachment  upon  the  uterine  muscle  interferes  with  its  normal  contraction 
and  retraction  ;  hence  the  rhythmic  contractions  of  the  uterus  commonly  exist- 
ing dnring  pregnancy  are  unusually  painful,  and  sometimes  are  excessive  in 
strength.  The  substance  of  the  uterus  may  be  so  altered  that  rupture  of  this 
organ  may  occur,  as  in  a  case  described  by  Hogan,*  where  a  fibroid  pregnant 
uterus  ruptured  spontaneously  at  about  the  fourth  month  of  gestation.  When 
rupture  docs  not  take  place,  spontaneous  I'cduction  of  a  displacetl  fibroid  uterus 
sometimes  results  from  the  stimulus  to  growth  and  intermittent  contractions 
furnished  by  pregnancy.  Spontaneous  reduction  is  frequently  followed  by  rup- 
ture of  the  membranes  and  abortion,  as  pointed  out  by  Loviot.*  Although 
fibroid  tumors  of  the  uterus  are  often  supposed  to  prevent  conception,  cases 
are  on  record  where  sterility  persisting  for  some  years  in  such  patients  had  been 
replaced  by  pregnancy  so  late  as  forty-five  years  of  age.®  Pregnancy  exerts 
a  remarkable  influence  upon  fibroid  tumors  of  the  uterus,  not  only  in  causing 
their  rapid  growth,  but  also  in  frequently  bringing  about  a  condition  of  well- 
marked  softening  and  fatty  degeneration  :  this  pathological  condition  sometimes 
decides  the  choice  of  a  method  of  treatment  in  these  cases. 

The  treatment  of  pregnancy  complicated  by  fibroid  tumors  when  interference 
is  necessary  is  by  operative  procedure.  Submucous  tumors,  if  they  become 
pedunculated  and  distend  the  lower  uterine  segment,  frequently  present  before 
tho  fetal  head,  and,  excitiiig  premature  labor,  may  be  removeil  by  the  obstet- 
rician in  advance  of  the  child.  Intramural  tumors  require  no  treatment  during 
pregnancy  unless  the  results  of  their  pressure  upon  important  viscera  oblige 
the  obstetrician  to  perform  hysterectomy.  Subserous  fibroids  in  the  pregnant 
patient  may  often  be  removed  without  terminating  the  j)regnancy,  as  in  cases 
reported  by  FronuneF  and  others.  Should  extensive  fibro-cystie  changes  in 
the  uterus  occur,  complicating  pregnancy,  this  condition  should  not  be  allowed 
to  go  on  to  term,  but  hysterectomy  should  i>romptly  be  performed. 

Routicr*  reports  a  successful  myomectomy  during  pregnancy,  and  he  has 
collected,  with  his  own,  15  eases  in  which  the  operation  was  performed,  ten 
of  which  recovered.  Strauch '  also  reports  the  successful  removal  of  a 
fibroid  as  large  as  a  goose-egg  from  a  pregnant  uterus  by  abdominal  section. 
Phillips '"  gathered  reports  of  282  cases  of  fibroids  complicating  pregnancy  : 
his  statistics  indicate  a  high  mortality  from  radical  jiroccdures.  Pozzi, "  from 
his  collection  of  these  cases  and  his  personal  exj)crience  with  them,  considers 
simple  myomectomy  the  preferable  procedtu'e  in  suitable  cases. 

The  occurrence  of  s])ontaneous  abortion  sometimes  necessitates  immediate 
operation  in  cases  of  pregnancy  complicated  by  fibn  id  tumors  ;  thus  Bourcart  '^ 


.J  i,  iii 


THE   PATHOLOGY   OF  PREGXANCY. 


187 


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reports  t^.e  case  of  a  pregnant  patient  whose  gestation  was  coniplioatcd  by 
iiiyonia  of  the  uterus  and  by  excessive  ;;orsion  of  the  uterus  and  its  append- 
ages. Spontaneons  abortion  was  followed  by  chill  and  fever.  Taking  advan- 
tage of  a  fall  in  the  t>^uaj)erature,  liourcart  performed  hysterectomy.  The  result 
was  successful.  Attention  has  recently  been  called  by  Hofmeier  '*  to  the  intlu- 
encc  which  myomata  exert  upon  pregnancy  in  causing  abortion.  He  cites  from 
the  records  of  others  796  cases  of  pregnancy  with  this  complication,  and  finds 
that  aboilion  occurred  in  6.9  per  cent,  of  the  cases.  He  naturally  concludes 
that  the  majority  of  patients  who  suft'ei-  from  myomata  during  pregnancy  pass 
through  gestation  but  slightly  influenced  by  the  tumor  of  the  uterus. 

Ott  reports  a  case  of  pregnancy  nearly  at  term  complicated  by  fibromyoma 
of  the  uterus  and  bronchitis.'*  Amputation  of  the  uterus  was  performed ; 
the  stump  was  covered  with  peritoneum  and  dropped.  The  patient  and  her 
child  made  a  good  recovery. 

Gordon "'  rept)rts  a  successful  myomectomy  by  which  a  fibroid  was 
removed  from  the  anterior  wall  of  the  pregnant  uterus :  although  the  uterine 
wall  was  left  thin  and  vascular,  hemorrhage  was  controlled  by  stitching  the 
peritoneum  and  the  base  of  the  wound  with  fine  catgut.  Recovery  was  rapid 
and  pregnancy  was  nninterru])ted. 

Staveley  '"  collected  a  considerable  number  of  cases  of  fibroid  tumors  com- 
plicating pregnancy,  and  he  adds  from  the  records  of  the  Johns  Hopkins  Hos- 
jiital  two  oases  in  which  myomectomy  was  performed  successfully  during  preg- 
nancy without  interrupting  gestation.  Staveley's  tables  embrace  33  cases  with 
a  maternal  mortality  of  24.25  ])er  cei^t.  Statistics  show  that  in  late  years 
nivomectomy  for  this  condition  is  more  successful  than  before  antiseptic  sur- 
gery attained  its  present  perfection  in  technique.  During  the  last  eight  years 
the  mortality-rate  of  myomectomy  in  these  cases  has  fallen  to  11.75  per  cent.* 

Cancer  of  the  uterus,  complicating  pregnancy,  increases  in  oases  of 
.•arcinoma  with  great  rapidity  during  the  pregnant  state,  and  with  even 
greater  vigor  during  the  puerperal  condition.  Wl-.cn  pregnancy  has  not 
advanced  beyontl  the  fourth  iiionth,  \ ..w  dor  Veer"  and  others  practise 
vaginal  extirpation  of  the  uterus.  In  oases  whore  carv.  noma  attacks  the 
cervix  the  prognosis  is  most  uiifavorable.  If  delay  is  practised,  the  tissues 
surrounding  the  cervix  soon  become  infiltrated,  and  delivery  by  abdominal 
section,  should  life  persist  to  full  term  of  ]irognancy,  is  the  only  alternative. 
The  fact  that  caroinonm  grows  with  greatest  ra]>i(lity  during  tho  puerperal 
condition  obliges  the  obstetrician,  whenever  possible,  to  perfor.n  oomploto 
extirpation  of  the  uterus,  either  at  the  time  when  the  fetus  is  '^"li veered  or  as 
soon  as  possible  thoroaftor.  The  danger  of  septic  infection  follow  i'lg  Cesarean 
section  is  so  groat  that  the  majority  of  operators  prefer  hystere.  ^oniy  or  total 
extirpation. 

Cancer  ocoasioually  involves  the  uterine  tissue  so  ex,  'nf.vely  as  to  result  in 

rupture  of  the  uterus.     This  extensive  involv(>ment  vjctMirs  in  cases  where  preg- 

*  Tlie  literature  of  this  subject  given  on  page  313  will  iiiteitst  (lK>-,e  who  desire  to  [tursue  it 
fiu'tlier. 


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nancy  supervenes  upon  the  existence  of  the  cancerous  condition.  The  great 
stimulus  which  pregnancy  causes  in  malignant  growths  results  in  the  rapid 
dissemination  of  malignant  tissues,  which  gradually  destroy  the  elasticity  and 
the  resisting  power  of  tl»e  muscular  layers  of  the  womb.  Rupture  occurs  in 
these  cases  during  abortion  or  during  labor  at  term.  The  prognosis  is  exceed- 
ingly grave,  for,  even  should  the  patient  rally  immediately  from  the  rupture, 
the  malignant  growth  must  sooner  or  later  end  her  life. 

Auvard  repoits  the  case  of  a  patient  in  her  eleventh  pregnancy  who  had  ute- 
rine cancer  for  two  years.'*  Labor  was  exceedingly  slow,  the  pains  being  very 
weak  but  persistent.  When  partial  dilatation  was  present  the  os  was  incised 
in  several  directions  and  the  fetus  was  found  in  breech  presentation.  Extraction 
by  the  feet  was  performed,  and  persistent  hemorrhage  ensued ;  on  exrjnination 
the  uterus  was  found  ruptured  transversely  at  the  upper  edge  of  the  lower 
uterine  segment.     The  patient  succumbal  to  shock. 

Cancerous  infiltration  of  the  tissues  of  the  cervix  often  necessitates 
multiple  incisions  in  any  necessary  manipulation  during  pregnancy  or  at 
labor.  Von  Herff "  illustrates  the  value  of  free  incisions  in  cancerous  cases. 
Cesarean  section  had  been  decided  upon,  but,  as  a  last  resort,  multiple  incis- 
ions \vere  freely  made,  and  they  proved  efficacious.  Early  pregnancy  compli- 
cated by  uterine  cancer  invariably  demands  total  extirpation,  from  which  even 
unfavorable  cases  recover  and  the  operation  has  prolonged  life,  as  illustrated 
by  Moller.^  In  his  patient  the  cancerous  uterus  was  extirpated  with  great 
difficulty  by  reason  of  the  infiltration  of  surrounding  tissue.  A  rent  was  left 
in  the  peritoneal  cavity,  through  which  rent  a  loop  of  intestine  protruded. 
Notwithstanding  these  unfavorable  features,  the  patient  made  a  good  recovery, 
and  some  time  after  the  operation  was  comparatively  free  from  cancer.  Sutu- 
gin  reports  two  cases  of  amputation  of  the  uterus  at  term  for  cancer,  in  each  of 
which  cases  the  life  of  the  child  was  saved.  Tayhtr  of  Jaj)an  records*'  a  very 
unfavorable  case  of  cancer  in  which  vaginal  extirpation  was  performed  with 
great  difficulty.     A  favorable  result  followed. 

In  cases  where  the  cervix  only  is  involved  the  diseased  tissue  should  at 
once  be  removed  by  the  knife  and  cautery,  with  the  ho])e  that  the  progress  of 
the  disorder  may  be  checked  temporarily  while  the  pregnancy  advances,  thus 
affording  the  child  a  better  opportunity  for  life.  In  carcinoma  of  the  preg- 
nant uterus  complete  extirpation  is  the  only  treatment  that  promises  a  favor- 
able result.  If  the  i)atient  is  seen  for  the  first  time  in  pregnancy  advanced 
bevond  the  fourth  month,  delav  mav  be  advised  in  the  interest  of  the  child 
so  long  as  the  tissues  about  the  uterus  do  not  become  involved.  Under  the 
improved  methods  now  followed  in  performing  total  extirpation  the  prognosis 
for  the  nujther  is  no  longer  desperate,  a  fair  chance  for  recovery  from  the  opera- 
tion and  the  prolongation  of  life  being  thus  given  her.^^ 

In  epithelioma  of  the  cervix  complicating  i)r(>gnancy,  Edis^  reports  a 
ease  in  which  an  epitheliomatous  mass  was  found  involving  nearly  the  whole 
cervix  and  extending  down  upon  the  posterior  vaginal  wall,  rendering  the  pas- 
sage of  the  fetal  head  ini})ossible.     The  ch'ld  was  delivered  by  Cesarean  s(  „ 


$ 


THE  PATHOLOGY   OF  PREGNANCY. 


189 


i 


tion,  and  seven  months  after  the  operation  the  epithelioma  had  made  but  little 
progress. 

The  decidual  lining  of  the  uterus  may  occasionally  become  the  seat  of 
malignant  disease,  as  observal  by  Sanger  and  Chiari.^*  This  form  of  cancer 
is  describctl  by  these  writers  as  a  true  sarcoma  of  the  dccidua :  its  symptoms 
are  foul  discharge  and  hemorrhage  persisting  after  labor,  and  its  fatal  termi- 
niition  usually  occurs  within  six  or  seven  months  after  delivery.  Metastatic 
deposits  are  not  uncommon,  the  cells  of  which  bear  the  characteristics  of 
decidual  cells.  There  \z  an  innocuous  form  of  this  growth,  also  described  by 
Siingcr,^  that  is  not  to  be  mistaken  for  decidua  remaining  adherent  after  a 
i'onner  pregnancy. 

Hypertrophy  of  the  decidua  occurring  during  pregnancy  may  be  non- 
nialignaiit  and  not  dependent  upon  the  existence  of  syphilis;  thus,  Hermann'^ 
ilcscribes  cases  of  decidual  hypertrophy  in  which  the  tissue  measured  one-fiftieth 
of  an  inch  in  thickness :  microscopic  examination  revealed  the  presence  of 
large  cells,  with  large  nuclei,  five  or  six  in  number,  without  intercellular  sub- 
-tance,  but  infiltrated  and  containing  leucocytes.  A  similar  condition  has  also 
I  Ml  described  by  Virchovv,  ^  Strassman,^  Dohrii,  ^  Gusserow,  ^^  Klebs,**  and 
Matthews   Duncan.^^ 

Sponttineous  rupture  of  the  uterus  occasionally  happens  during  preg- 
nancy. Such  cases  are  usually  found  to  have  been  complicated  by  a  fibroid 
tumor  or  by  displacement  of  the  uterus,  with  adhesions  binding  it  in  its  dis- 
placed position.  ^Manipulation  intended  to  replace  the  uterus  has  sometimes 
hastened  its  rupture;  thus  in  a  case  reported  by  Dickey^  the  patient  was  in 
the  third  month  of  her  fifth  pregnancy:  an  eftbrt  had  been  made  to  replace 
a  retroverted  womb,  the  effort  causing  the  patient  considerable  distress.  A 
few  days  afterward  something  was  felt  to  give  way,  and  the  patient  perished 
ill  a  few  hours  from  shock.  Post-mortem  examination  showed  early  p  -"ancy 
and  the  ui(  riis  ruptured  transversely  from  one  Fallopian  tube  to  the  otiier. 

Spoi'hmcoiis  rupture  of  the  uterus  may  result  from  the  rapid  development 
of  a  largo  fetiis  in  a  uterus  whose  tissues  have  been  weakened  by  previous 
disea  ?.  I'lio  lietus  may  escape  into  the  abdominal  cavity,  as  illustrated  in  a 
case  repon,  '1  bv  Aladurowicz,'*  in  which  fatty  degeneration  of  the  uterine 
wall  at  tiie  jn.iction  of  the  fundus  and  cervix  was  found.  The  fetus  had 
heco.ne  partially  encapsulated.  Purulent  jieritonitis  ensued,  and  the  ab- 
doiiinal  wall  opened  spontaneously  with  the  discharge  of  pus.  The  patient 
died  of  exhaustion. 

Endometritis  during  pregnancy  results  from  an  aggravation  of  a  pre- 
existing inflammatory  condition,  and  it  is  a  familiar  and  frequent  cause  of 
ear!  I'oortion.  In  patients  who  complete  the  jieriod  of  gestation  the  existence 
of  !'  .  .'undition  nuiy  be  susjiected  when  occasional  discharges  of  blood  or  of 
watciy  aiicus  occur.  While  the  pregnancy  is  not  likely  to  go  to  term,  still  its 
coiitiiuiance  must  not  be  despaired  of  because  of  these  discharges.  An  endo- 
metritis set  up  or  aggravated  by  ])regnancy  not  infrerpiently  causes  adherence 
of  the  membranes  about  the  cervix  and  the  lower  uterine  segment,  often  com- 


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190 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


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plicating  labor  by  premature  rupture  of  the  bag  of  waters  and  protracted  dila- 
tation of  the  birth-canal.  It  is  noticed  in  women  who  conceive  shortly  after 
an  abortion  that  an  endometritis  arising  at  the  abortion  may  persist  through- 
out pregnancy,  becoming  aggravated,  and  resulting  finally  in  the  firm  adhe- 
rence of  the  placenta  and  in  complicated  labor;  thus,  Lohlein**  reports  a  case 
of  tills  character  in  which  the  pregnancy  went  to  term,  its  latter  portion 
being  complicated  by  intermittent  pyrexia  and  by  a  very  firmly  adherent 
placenta. 

The  treatment  of  this  condition  is  entirely  in  the  interest  of  the  mother, 
as  the  prospect  of  her  retaining  th.e  ovum  to  maturity  is  so  slight  that  exhaust- 
ing hemorrhage  or  febrile  disturbance  should  lead  to  the  prompt  emptying  of 
the  uterus  :  this  should  only  bo  done  in  the  most  thorough  surgical  manner 
and  under  strict  antiseptic  precautions.  Sufficient  dilatation  to  permit  the  use 
of  the  sharp  curette  and  of  draiii  q;e  should  be  secured  by  using  the  fingers 
or  solid  metal  dilators.  ShouL  t.?ptic  infection  and  fever  be  present,  the 
blunt-edged  douche-curette  may  I  j  red  to  great  advantage,  thoroughly 

emptying  the  uterus  under  a  stream  antiseptic  fluid.  Where  sepsis  and 
fever  are  absent  the  sharp  curette  followed  by  antiseptic  irrigation  will  be 
found  eflficie  it.  Drainage  with  iodoform  gauze,  with  repeated  intra-uterine 
irrigation,  is  indicated,  should  fever  and  foul  discharge  continue.  Curetting 
is  best  performed  at  the  time  of  abortion  or  premature  labor,  or,  if  this  oppor- 
tunity is  omitted,  it  should  be  done  when  the  patient  has  recovered  strength  and 
the  interior  of  the  uterus  has  ceased  to  furnish  a  foul  discharge. 

Salping-itis  existing  during  pregnancy  complicates  the  pregnant  condi- 
tion largely  by  reason  of  the  adhesions  and  the  inflammatory  exudates  usually 
present  with  the  salpingitis.  As  the  uterus  increases  in  size,  tension  upon  these 
adhesions  causes  very  considerable  pain,  and  if  the  adhesions  are  firm,  binding 
down  the  uterus,  abortion  is  not  infrequently  the  final  result.  A  frequent  cause 
of  retroversion  and  retroflexion  of  the  gravid  uterus  is  to  be  found  in  salpingitis 
and  in  the  adhesions  and  exudates  which  accompany  this  condition ;  in  such 
cases  obstinate  nausea  and  vomiting,  and  finally  abortion,  may  bo  the  direct 
consequence  of  the  salpingitis  present.^®  ^'  Salpingitis  is  by  no  means  a  trifling 
complication  of  pregnancy,  as  cases  are  recorded  in  which  acute  sepsis,  with 
general  peritonitis  developing  twenty-four  hours  after  labor,  has  caused  death. 
It  is  certainly  true  that  a  patient  suffering  from  salpingitis  should  avoid  preg- 
nancy, and  should  subject  herself  to  prompt  and  thorough  treatment  if  the  lia- 
bility to  pregnancy  exists. 

Diseased  conditions  of  the  ovary  complicating  pregnancy  are  usu- 
ally made  worse  by  the  gravid  condition  ;  thus,  ovarian  cysts,  solid  tumors  of 
these  organs,  and  inflammatory  conditions  are  greatly  aggravated  during  preg- 
nancy. Acute  oiiphoritis  complicating  pregnancy  is  of  rare  occurrence,  and  it 
may  result  from  an  exacerbation  of  a  chionic  process  or  septic  infection  from 
a  previous  abortion.  Three  cases  of  this  affection  are  rejiorted  by  Coe  ;'^  in 
each  of  two  cases  tubal  and  ovarian  abscess  formetl  and  was  emptied.  All 
three  patients  recovered,  although  convalescence  was  prolonged.     The  treat- 


THE  PATHOLOGY  OF  PREGNANCY. 


191 


ineiit  of  this  condition  is  largely  expectant,  abdominal  section  being  most 
successful  before  the  fifth  month  of  pregnancy. 

Thomson^'  has  shown  that  while  the  tubes  undergo  a  marked  hyper- 
trophy during  pregnancy,  the  ovary  itself  does  not.  The  alterations  observed 
in  the  ovaries  during  pregnancy  are  caused  by  foreign  growths,  and  not 
by  the  increase  of  elements  normally  present.  In  addition  to  the  danger  of 
abortion  which  the  size  of  an  ovarian  tumor  occasions,  there  is  possible  risk 
tliat  such  a  tumor  may  twist  its  pedicle,  and  that  gangrene  may  be  added  to 
the  complications  of  labor  in  this  condition.  It  has  repeatedly  been  shown 
that  the  operation  of  ovariotomy  is  safe  and  satisfactory  during  pregnancy, 
and  this  fact  calls  for  the  removal  of  ovarian  tumors  as  soon  as  their  presence 
is  detected.  In  these  cases  adhesions  are  not  often  present,  nor  does  the  preg- 
nant condition  predispose  to  their  formation. 

The  rapid  development  of  a  cystic  condition  of  the  '^vary  may  completely 
mask  an  early  pregnancy,  as  in  a  case  reportetl  by  Polaillon,^'^  in  which  preg- 
nancy could  not  positively  be  diagnosticated  until  a  cystic  ovary  and  an 
adherent  tube  were  removed.  This  operation  did  not  interfere  with  the  preg- 
nant condition,  the  patient  going  to  term  and  being  delivered  of  a  healthy  child. 

Spontaneous  cure  of  a  pelvic  cyst  complicating  pregnancy  occasionally 
happens  in  the  case  of  broad-ligament  cysts,  which  disappear  by  spontaneous 
rupture.  Rnge"*^  describes  a  case  four  months  pregnant  in  which  under 
anesthesia  a  pelvic  cyst  was  pushed  up  above  the  brim  of  the  pelvis,  relieving 
pressure  upon  the  uterus.  Abortion  followe<l,  and  after  recovery  the  abdomen 
was  opened ;  no  cyst  was  foiuid,  and  its  disappearance  is  ascribed  to  spon- 
taneous rupture.  The  evidence  in  favor  of  the  operative  treatment  of  ovarian 
cysts  complicating  pregnancy  is  greatly  in  the  ascendant  over  any  other  form 
of  treatment ;  this  is  shown  by  the  results  of  Schroeder  and  Olshausen, 
Flaisclilcn^^  and  Dsirne;*'  the  mortality  of  the  operation  ranges  from  9.8 
per  cent,  to  5.9  per  cent. 

^langiagalli "  and  Acconci  *'  similarly  report  good  results  from  ovari- 
otomy during  pregnancy. 

Tcrrillon  ^^  advises  against  puncture  of  ovarian  cysts  during  pregnancy, 
and  urges  ovariotomy  not  earlier  than  the  third  nor  later  than  the  fifth 
month. 

Disorders  of  the  vulva  may  occur  during  pregnancy  as  the  result  of 
mechanical  injury  or  be  associated  with  some  constitutional  condition.  Hema- 
toma of  the  vulv  is  especially  likely  to  happen  by  reason  of  the  congested 
condition  of  the  parts  caused  by  pregnancy.  An  illustrative  case  is  reported 
by  Eiirendorfer  :*^  incision  under  antiseptic  precautions  and  tamponing,  ])ref- 
erably  with  iodoform  gauze,  resulted  in  speedy  cure.  Pruritus  of  the  vulva 
is  one  of  the  most  annoying  complications  of  the  pregnant  condition.  In  cases 
where  there  is  no  reason  to  suspect  the  neglect  of  cleanliness,  pruritus  is  to  be 
considere<l  as  due  to  one  of  two  classes  of  causes.  The  first  class  comprises 
the  many  diseases  which  alter  profoundly  the  condition  of  the  skin  ;  chief 
among  these  are  disorders  of  the  digestive  and  excretory  systems,  as  diabetes 


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m 


and  nephritis.  The  treatment  of  the  pruritus  in  such  cases  resolves  itself, 
first,  into  the  treatment  of  the  general  condition,  and  then  into  such  local 
applications  as  njay  be  found  of  use.  The  latter  embraces  the  various 
antiseptics  and  anesthetics  which  are  available  in  the  ]>ractice  of  dermatology. 
The  second  class  is  those  cases  in  which  no  diseased  condition  of  the 
general  organism  can  be  found  to  account  for  the  pruritus,  and  in  which  the 
disorder  is  purely  local.  This  class  is  treated  by  local  applications,  and  in 
obstinate  cases  resection  of  the  diseased  tissues  may  prove  the  only  alternative, 
Sanger**  has  shown  that  in  these  cases  partial  or  total  extirpation  of  the 
vulva  is  thoroughly  legitimate,  and  should  include  the  removal  of  the  glans 
clitoridis.  Where  the  entire  vulva  is  affected  plastic  operation  may  be 
necessary  to  cover  surfaces  exposed  in  the  extirpation.  In  circumscribed 
pruritus  of  the  vulva  it  may  be  possible  to  limit  the  extirpation  to  the  affected 
part. 

Elephantiasis  of  the  labia  may  complicate  pregnancy,  and  prove  an 
annoyance  to  the  obstetrician  at  the  time  of  labor.  The  appended  illustration 
(Fig.  142)  is  taken  from  a  case  under  the  observation  of,  and  described  by,  the 
writer.  The  patient,  who  wa'*  pregnant  for  the  first  time,  gave  no  history  of 
venereal  disease ;  the  growth  persisted  for  several  months  before  the  occurrence 
of  pregnancy,  and  increased  slowly  during  gestation.  Aside  from  its  bulk  it 
occasioned  no  suffering.  During;  labor  it  rendered  thorough  vaginal  examina- 
tions difficult,  and  at  tlie  moment  of  delivery  impeded  somewhat  the  dilatation 
of  the  birth-canal.  Especial  precautions  were  taken  to  maintain  the  parts  in 
an  antiseptic  condition  at  the  moment  of  delivery.     The  patient's  convales- 


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Fi(i.  142.— Elephantiasis  of  the  labia  ((int'-fourtli  liff  ^izo). 

cence  was  uninterrupted,  as  no  serious  wound  of  the  iiypertrophied  tissue 
occurred  during  the  labor.  During  tiio  puerperal  period  the  injured  tissue 
decreased  verv  sliglitlv  in  size. 


I.  i-:-,i 


THE   PATHOLOGY   OF  PREGNANCY. 


193 


The  presence  of  bacteria  in  the  genital  tract  of  the  healthy  pregnant 
]):itient  is  an  interesting  qnestion  which  lias  occasioned  extensive  research. 
The  results  go  to  show  that  pathogenic  bacteria  are  not  present  in  the  healthy 
pregnant  patient.  Among  the  most  thorongh  of  such  investigations  are  those 
of  Winter,*'  made  at  the  suggestion  of  Schroeder  :  he  found  that  the  Fallo- 
l)ian  tubes  containefl  normally  no  micro-organisms  :  this  is  also  true  of  the 
normal  uterine  cavity.  In  half  the  uteri  examined  germs  were  present  at 
the  internal  os ;  in  the  secretion  of  the  cervix,  antl  also  in  the  vagina,  there 
were  found  abundant  micro-organisms.  These  germs  were  found  to  be  patho- 
genic, but  not  ])ossessing  the  virulence  which  characterizes  them  when  observed 
;iniid  tissues  in  a  pathological  condition.  It  was  found,  however,  that  when 
pathogenic  organisms  were  introduced  from  without  the  germs  already  present 
ill  the  genital  canal  assumed  a  virulent  character. 

Diseased  conditions  of  the  vagina  occasionally  comjilicate  the  pregnant 
condition ;  thus,  Rissrnan*"  reports  a  case  in  which  a  polypoid  degeneration  of 
the  connective  tissue  of  the  vaginal  wall  attained  such  proportions  as  to  pro- 
hipse  before  the  fetal  head  during  labor  and  to  offer  an  obstat'"  to  delivery; 
in  this  case  the  condition  was  accompanied  by  gonorrheal  infection. 

Vesico- vaginal  fistula  caused  by  pressure  in  a  previous  labor  may  become 
a  serious  complication  at  labor,  by  reason  of  the  thickened  condition  of  the 
tissues  about  the  fistula  and  the  excessive  pain  which  pressure  occasions.'* 

Displacements  of  the  pregnant  uterus  are  not  infrequent,  often  causing 
great  discomfort,  and  sometimes  seriously  complicating  and  even  terminating 
pregnancy.  If  the  patient  has  already  borne  children,  the  supports  of  tlie 
uterus  are  frequently  so  weakened  that  when  repeatetl  pregnancy  ensues  dis- 
placement readily  occurs. 

The  most  frequent  uterine  displacement  complicating  pregnancy  is  retrover- 
sion of  the  gravid  uterus :  this  produces  the  usual  symptoms,  pain  and  drag- 
ging sensation  in  tiie  back,  interference  with  the  functions  of  the  rectum  and 
often  of  the  bladder,  and  a  sensation  of  weight  and  heaviness  relieved  only  by 
the  recumbent  position  upon  the  side  or  the  assumption  of  the  knee-chest  posi- 
tion. On  vaginal  exaiiiination  the  os  and  cervix  are  found  directed  upward 
and  fijrward,  and  the  fundus  of  the  uterus  is  below  the  promontory  of  the 
sacrum.  In  uncomplicated  cases,  where  no  peritoneal  adhesions  exist  binding 
down  the  uterus,  retroversion  of  the  pregnant  womb  is  a  comparatively  simple 
matter.  As  the  uterus  increases  in  size  the  womb  gradually  rises  in  the  pelvis, 
until  at  four  or  five  months  it  passes  above  the  brim  and  remains  permanently 
ill  the  abdominal  cavity. 

The  treatment  of  uncomplicated  retroversion  of  the  pregnant  uterus  con- 
sists in  supporting  the  womb  by  tampons  of  autisejitic  mooI  smeared  with 
an  antiseptic  ointment.  A  preparation  containing  10  grains  of  powdered 
boraeic  acid  to  the  \  ounce  each  of  lanolin  and  vaselin  is  most  useful  in  these 
cases.  Oner  in  four  or  five  days  such  a  tampon  should  be  removed  and  the 
vagina  be  irrigated  gently  with  warm  water  or  with  a  saturated  solution  of 
boraeic  acid.  A  Sims  speculum  should  then  be  used,  and  the  pelvic  floor 
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AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


be  (Iruwii  downward  nnd  backward,  when  a  tampon  of  antiseptic  wool, 
rolled  into  a  shape  fitting  the  pelvic  floor,  should  be  introduced  and  carried 
across  from  side;  to  side,  puttinj;  the  utoro-satTal  ligaments  slightly  upon  the 
stretch  and  raising  the  fundus  of  the  uterus,  Snch  tampons  have  the  great 
advantage  over  the  hard-rubber  pessary  that  they  create  no  irritation,  support 
the  uterus  comfortably,  and  mould  themselves  perfectly  to  the  contour  of  the 
parts.  Their  use,  however,  re(iuires  discrimination  in  fitting  the  tampon 
properly,  and  calls  for  regular  supervision  of  the  ])hysician  at  comparatively 
frecpient  intervals.  Cases  are  occasionally  met  with  in  which  it  is  impossible 
for  the  patient  to  have  the  services  of  a  physician  except  at  intervals  of  several 
weeks :  it  is  then  often  advantageous  to  fit  a  carefully-moulded  hard-rubber 
pessary  which  shall  raise  the  uterus  to  its  proper  level.  It  is  often  asserted 
that  such  a  pessary  n)ay  cause  abortion :  the  fact,  however,  remains  that  it  is 
not  a  well-fitting  pessary  that  produces  abortion,  but  it  is  the  displacement  of 
the  uterus  resulting  from  a  lack  of  such  support  as  the  jKJssary  should  give. 
Cases  of  habitual  abortion  caused  by  displacement  of  the  womb  are  not  infre- 
quently tnu'cd  by  raising  the  pregnant  womb. 

^lany  cases  of  retroversion  of  the  uterus  are  associated  with  chronic  pelvic 
peritonitis,  and  are  complicated  by  ])rolapse  of  one  or  both  of  the  Fallopian 
tubes  and  of  the  ovaries,  and  the  presence  of  adhesions  binding  the  displaced 
organs  in  their  artificial  situation.  With  these  patients  the  pain  as  the  uterus 
increases  in  si/e  is  vei-y  distressing,  and  residts  from  traction  uj)on  adhesions 
which  occasionally  yield,  greatly  adding  to  the  patient's  comfort.  In  other 
cases  the  separation  of  these  peritoneal  adhesions  is  accompanied  by  very 
considerable  shock,  which  simulates  to  some  extent  the  shock  of  rupture  of 
the  sac  in  tubal  ectopic  gestation.  In  still  other  cases  these  adhesions  are  so 
firm  and  tense  that  spontaneous  separation  of  them  is  impossible,  the  womb 
remaining  fixed  in  the  position  it  occupied  at  the  time  of  the  original  perito- 
neal infiammation.  The  continued  growth  of  the  uterus  may  so  stretch  these 
adhesions  as  to  enable  the  wond)  to  rise  into  the  abdominal  cavity.  Should 
the  peritoneal  surfaces  not  yield,  however,  a  retroverted  and  incarcerated  uterus 
will  be  tiie  result,  and,  as  the  fetus  increases  in  size,  the  adhesions  not  yielding, 
abortion  is  inevitable;  and  should  fresh  septic  infection  occur  and  the  patient 
survive,  her  condition  will  be  aggravated  by  fresh  adhesions,  and  chronic 
invalidism  will  restdt. 

The  frcf|uency  of  this  eomi)lication  may  be  estimated  by  the  report  of 
Martin,''^  who  found  in  24,000  women  121  cases  of  retroversion  and  retro- 
flexion of  the  titerus  persisting  dm'ing  pregnancy.  In  27  of  these  cases  the 
defi>rmity  was  congenital,  and  one  ease  is  cited  in  which  a  jiatient  sufl'cred  for 
three  and  a  half  years  with  congenital  retroflexion  and  with  gonorrhea,  but 
conceived  after  recovery  from  the  gonorrhea.  Sterility  in  cases  of  congenital 
retroflexion  depends  upon  a  diseased  endometrium  or  disease<l  condition  of  the 
tube,  and  not  upon  the  congenital  deformity.  In  94  of  the  eases  the  retro- 
version persisted  after  repeated  pregnancies.  Nine  of  these  patients  wore 
pessaries    at   the    time    when    conception    occurred.       The    most   significant 


THE  PATirOLOGY   OF  PREGNANCY. 


lOf) 


svinptoin  which  dnnv  the  patient's  attention  to  the  backward  disphicomcnt  of 
the  uterus,  and  tor  which  she  sought  medical  aid,  was  dysuria.  When  spon- 
taneous restitution  fails  no  time  shouhl  be  lost  in  accomplishing  the  same  by 
instrumental  means.  Tiiat  retroflexion  and  Incarceration  of  the  pregnant 
uterus  is  a  serious  condition  may  be  inferred  from  the  report  and  collection  by 
Treub  of  50  cases  of  death  from  this  cause."^.  He  found  that  out  of  the  50 
ilcaths,  thirteen  were  from  uremia,  eleven  from  rupture  of  the  bladder  (Fig. 
143),  six  from  sepsis;  ten  followed  peritonitis  and  cystitis;  three  were  caused 
l)y  jn'cmia,  two  by  rupture  pf  the  peritoneum,  and  five  cases  followed  acci- 
dents occiu'ring  during  an  effort  to  replace  the  uterus. 

These  statistics  have  recently  been  amplified  by  Gottschalk,**  who  col- 
lected G7  deaths  from  backward  dis-  ..cm" 
placement  of  the  pregnant  uterus,  the 
immediate  causes  of  which  he  describes 
as  follows  :  Uremia  and  collapse,  six- 
teen cases ;  se[)ticemia  arising  from  the 
bladder,  four ;  gangrene  of  the  bladder, 
tiiree ;  rupture  of  the  bladder,  eleven  ; 
peritonitis  from  disease  of  the  bladder, 
seventeen  ;  pyemia,  three;  ruptureof  the 
peritoneum  and  vagina,  two  ;  improper 
efforts  at  reposition,  five;  gangrene  of 
the  intestine  and  peritonitis,  one ;  oc- 
<lusion  of  the  intestine,  one  ;  and  four 
eases  in  which  the  inunediate  cause  of 
death  is  not  described.  Gottschalk  in 
his  i>aper  reports  an  interesting  case 
imder  his  own  observation  in  which  the 
retrovertcHl  pregnant  uterus  ]iroduced 
intestinal  occlusion  without  ileus.     He 

Fi(i.  lis.— Frozen soction of retroviTted utonis of 
performed   abdominal    section,  but  was      throo  ami  a  half  to  four  months.    Doath  from  rup- 

m.able  to  save  the  patient.  '"'^"  ^'^ '•'"-'''^■■-  (•"•'"-'•  '••""■  '"""•  "•  i'"'-  ^'  ^-  '»■ 

Ecto])ic  gestation  may  be  sinudated  by  a  retroverted  pregnant  uterus,  as  in 
n  case  re|)orted  by  Barbour,*''  in  which  the  physical  signs  of  retroversion  in 
the  pregnant  Jiterus  were  perfectly  present.  In  the  treatment  of  this  con- 
dition Colin  stein,'"'  in  treating  five  severe  cases  of  incarceration  of  the  preg. 
nant  uterus,  first  emptied  the  bladder  by  a  stiff  catheter,  and  then  drew  down 
tiie  cervix  and  vaginal  wall  with  a  tenaculum,  while  the  cervix  was  pressed 
backward  by  downward  pressiuv  behind  the  symphysis.  While  the  cervix 
was  drawn  downward  and  backward  by  a  tenaculum  the  fundus  was  raised 
with  file  free  hand  of  the  operator. 

Retroversion  of  the  pregnant  uterus  is  occasitmally  found  complicated  by 
the  existence  of  disease  of  the  pelvic  bones;  in  these  cases  the  pelvic^  deform- 
ity is  often  such  that  spontaneous  restitution  of  the  uterus  is  impossible.  It 
is  then  necessary  to  relieve  the   patient  by  operative  means,  and,  as  a  last 


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AMERICA X   TEXT-nOOK   OF   OliSTEriUCS. 


resort,  to  extirpate  the  uterus  per  vaginam  if  possible.  An  interesting  ease  of 
osteomalacia  eoni}>lieating  retrofl(!xiou  of  the  gravid  uterus  is  reported  by 
Jienckiser ;"  efforts  had  previously  been  made  to  produce  abortion  and  to 
puncture  the  fetal  sac  through  the  posterior  vaginal  wall. 

The.  treatment  of  retroversion  of  the  pregnant  uterus  when  adhesions  are 
present  must  be  conducted  with  great  caution.  A  gentle  effort  should  be  made 
to  stretch  the  adhesions,  gradually  allowing  the  womb  to  regain  its  lost  position  : 
this  is  best  accomplished  by  the  use  of  the  antiseptic  wool  tampon,  combining 
with  it  an  alterative  api)lication  which  shall  aid  in  the  absorption  of  exudates 
in  the  pelvis  and  shall  loosen  adhesions.  At  present  a  favorite  remedy  fortius 
purpo.se  is  ichthyol,  as  follows : 


Ichthyol, 

Lanolin, 

Vaselin, 


aa 


5j; 

.Ijss. 


An  ointment  stronger  in  ichthyol  is  occasionally  employetl  with  good 
results.  Once  or  twice  weekly  the  patient  may  take,  with  advantage,  a  hot 
vaginal  injection  if  this  bo  practised  very  gently.  In  cases  of  sudden  and 
severe  abdominal  pain  with  great  shock  occurring  in  patients  in  the  early 
months  of  pregnancy  and  with  retroverte<l  uteri  prompt  incision  of  the  abdo- 
men, with  assiduous  examination  of  the  pelvic  organs,  may  residt  in  finding 
a  small  focus  of  infection  or  a  ruptured  adhesion,  which  can  be  dealt  with 
successfully  by  surgical  means.  If  such  adhesions  do  not  yield,  abortion  is 
inevitable,  and  especial  precautions  must  be  taken  that  septic  infection  is  pre- 
ventwl  in  uteri  so  bound  down. 

The  fact  that  hematosalpinx  or  jn-osalpinx  very  frequently  accompanies 
such  peritoneal  adhesions  indicates  the  danger  of  rupture  of  such  accumula- 
tions and  of  acute  septic  infection  which  may  follow.  Should  such  rupture 
occur,  evidenced  by  pain  in  the  abdomen  and  symptoms  of  shock,  the  abdomen 
should  be  opened  at  once,  the  parts  be  carefully  inspected  while  the  patient  is 
in  the  Trendelenburg  posture,  and  all  foci  of  infection  should  thoroughly  and 
completely  be  removed.  With  free  irrigation  with  saline  fluid  and  drainage  it 
is  possible  that  such  a  patient  may  escape  general  infection  of  the  abdominal 
cavity. 

2.  General  Disorders  of  Pregnancy. 

The  UUETIIHA,  nLADDKiJ,  and  t^ijetkus  share  during  pregnancy  the  condi- 
tion of  increased  vascularity  and  irritability  that  characterizes  the  pelvic  organs. 
The  bladder  in  early  ]ireguaucy  is  less  capable  t)f  distention  antcro-posteriorly, 
and  hence  enlarges  laterally  as  gestation  goes  on.  In  the  latter  monthsof  pregnancy 
the  uterus  rises  in  the  abdomen,  drawing  the  bladder  with  it  above  the  pelvic 
brim  ;  this  seems  a  conservative  j)rovision  to  protect  the  bladder  from  injury  by 
pressure.  The  bladder  accompanies  the  uterus  in  the  displacements  frequently 
seen  during  pregnancy.     The  urethra  becomes  elongateti  as  the  uterus  rises  in 


THE  PATHOLOGY   OF  PREGNANCY. 


197 


the  pelvis.  The  uretlira  may  become  completely  or  partly  oceliulecl  in  some 
of  the  uterine  displacements  observed  during  early  pregnancy.  If  the  dis- 
placement of  the  uterus  be  not  eorrectal,  there  follow  over-distcntion  of  the 
bladder,  paralysis  of  its  muscular  layer,  and  decomposition  of  the  retained 
urine,  with  erosion,  ulceration,  and  final  perforation. 

Cystitis  and  hematuria  complicating  pregnancy  demand  rest  in  the  recum- 
iM'ut  posture,  and  if  the  inflammation  of  the  bladder  be  gonorrheal  in 
character,  its  careful  treatment  is  strongly  indicated.  Labor  in  such  cases, 
by  making  traction  upon  pelvic  adhesions,  may  comj)ress  the  ureters,  favoring 
the  development  of  uremic  poisoning  and  eclampsia.  Subinvolution  of  the 
uterus  is  very  apt  to  occur  in  such  cases,  while  the  inflammation  of  the  uri- 
nary tract  may  become  chronic.  Diphtheritic  inflammation  of  the  bladder  is 
seen  in  cases  where  an  incarcerated  uterus  prevents  the  passage  of  urine  and 
where  a  catarrhal  condition  of  the  mucous  membrane  has  previously  been 
])rescnt.  In  cases  where  during  pregnancy  the  gernjs  of  gonorrhea  have 
been  retained  in  and  about  the  urethra,  labor,  by  reason  of  the  pressure  and 
disturbance  of  the  parts  which  then  o(!cur,  may  cause  migration  of  these 
germs.  Cystitis  is  the  first  result  of  such  added  infection,  and  later  this 
infection  travels  up  the  ureters  to  the  kidney,  and  acute  parenchymatous 
nephritis  may  be  the  result :  this  whole  process  occupies  several  weeks  for 
its  full  development  and  consummation,  and  its  issue  is  usually  fatal,  the 
patient  perishing  from  septicemia.** 

The  Kidneys  during  Pregnancy. — There  is  abundant  evidence  to  show 
that  th(>  kidneys  share  with  the  other  viscera  the  congested  and  hypertrophietl 
condition  common  during  pregnancy.  This  peculiar  engorgement  of  the 
kidney  has  given  rise  to  the  term  "  kidney  of  pregnancy."  Much  discussion 
has  been  elicited  in  the  effort  to  differentiate  the  "kidney  of  pregnancy" 
from  beginning  nephritis.  It  is  evident  that  only  the  systematic  and 
microscopic  examination  of  the  urine  can  accurately  determine  whether 
simple  congestion  is  present,  or  whether  the  kidney  is  being  damaged  in 
its  essential  elements,  the  secreting  cells  of  the  tubules.  When  such  study 
of  the  urine  finds  only  hyaline  casts,  crystals  of  various  sorts,  and  the 
slight  epithelial  dehrk  which  may  be  found  in  healthy  individuals,  there 
is  no  reason  to  believe  that  nephritis  exists  ;  but  when,  on  the  other  hand, 
'.piihelial,  granular,  or  fatty  casts  are  persistently  present,  the  diagnosis  of 
nephritis  can  scarcely  Vr  denied.  It  is  upon  such  comparative  examinations 
that  a  diagnosis  mnfl  be  based,  and  not  upon  the  mere  presence  or  absence 
of  serum-albumin.  Attention  has  recently  been  called  by  Trantenroth ''' 
to  a  coiulition  of  beginning  fatty  d(>generation  in  the  kidney  which  causes 
no  symptom  in  the  urine,  and  which  may  suddenly  become  so  acute  as  to 
destroy  the  patient  by  sudden  kidney  failure.  Infective  process  as  present 
ill  these  cases  is  so  flir  wanting,  and  i)atients  thus  affected,  if  they  survive 
pregnancy,  do  not  become  nephritic  afterward.  An  acute  inflammation  of 
tlie  kidney  cannot  be  caused  by  pregnancy,  and  is  only  observed  in  the 
rare  cases  where  infective  bacteria  find  entrance  to  the  genito-urinary  tract 


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AMh:iiIC'AX   TEXT-nOOK   OF   OliSTETIiTCS. 


of  the  pregnant.  This  coiulition  of  conjjostioii  (hiring  prcgimnoy  is  iiiciriisod 
(hiring  hihor,  and  ronal  all)niniii  is  prosont  (hiring  th(!  progress  of  hibor  in 
eonsiderable  ainonnt.  J'atients  suffering  from  diseased  ki(hieys  and  becoming 
pregnant  have  the  ki«hiey  disorder  greatly  aggravated,  often  to  a  fatal  issue. 
The  causes  of  this  condition,  known  as  the  "  kidney  of  pregnan(y,"  arc  the 
increased  intra-abdominal  tension  to  which  all  tiic  viscera  are  sid)jected ; 
disturbances  in  the  nutrition  of  the  kidney  through  an  altered  condition 
of  the  blood  of  the  pregnant  patient ;  and  an  engorgement  of  the  spermatic 
veins  and  ureters  by  mechanical  pressure.  It  is  possible  for  eclampsia  to 
develop  without  lesion  of  the  kidneys,  although  in  most  cases  of  cclamj)sia 
a  diseased  condition  of  the  kidneys  can  plaiidy  be  discerned.  Fischer,  in 
studying  the  same  subject,'*'  found  in  70  cases  evidence  that  the  "  kidney  of 
})regnancy  "  was  present  in  tifty-eight ;  eight  cases  of  nephritis  occurred  among 
the  70  ])atients.  Fischer  found  red  blood-corpuscles  in  eonsiderable  amount 
in  cases  where  acute  nephritis  occurred.  Gramdar  and  epithelial  casts  indi- 
(\ited  chronic  nephritis.  Tlu^  occurrence  of  chronic  endarteritis  accompanying 
chronic  nephritis  e\])lains  the  rupture  of  blood-vessels  within  the  uterus 
and  the  intra-uterine  hemorrhage  which  sometimes  destroys  these  j)atients. 
Schauta"'  describes  a  typical  case  of  fatal  hemorrhage  in  which  chronic  inter- 
stitial nephritis  and  degeneration  of  the  muscle  of  the  heart  and  uterus  were 
found.     The  life  of  the  child  was  also  sacrificed. 

Albmninuria  is  of  such  fre«juent  occurrence  during  ])r(>gnaney  as  scarcely 
to  rc(]uire  serious  consideration,  except  as  a  symptom  in  connection  with 
others  of  ni^phritis.  Among  others,  Meyer  *^  from  an  elaborate  study  of  this 
subject  at  Copenhagen  found  albuminuria  in  5.4  per  cent,  of  pregnant  women. 
Casts  accompanied  the  albumin  in  2  p(M'  cent.  This  may  be  taken  as  an  indi- 
cation of  the  relative  frequency  of  kidney  involvement  in  cases  manifesting  albu- 
nunuria.  As  pregnancy  advanced,  albumin  became  more  abundant  until  during 
the  last  thirty  days  but  28.9  \wy  cent,  of  urine  examined  was  free  from  albumin. 
Premature  births  occurred  in  8  percent,  of  patients  witii  albiuuin,  and  in  21.0 
per  cent,  of  patients  who  had  casts  in  the  urine.  He  adds  other  clinical  details 
which  emphasize  the  significance  of  the  presence  of  casts  as  indicating  nephritis. 
Lantos  ^^  in  the  clinic  at  Budapest  found  albumin  so  fivquently  in  pregnant 
l>atients  that  he  considers  it  ]>hysiological  during  pregnancy  and  a  diagnostic 
symj)tom  of  the  condition.  Herman  calls  attention  in  this"  and  in  other 
l)apers  presented  at  the  Obstetrical  Society  of  London  to  two  conditions  of 
renal  disease  in  the  pregnant  woman  :  one  is  acute  kidney  failure  with 
extreme  diminution  in  the  (piantity  of  urine  and  deficiency  in  the  excretion 
of  urea,  which  quickly  ends  fatally  if  the  excretion  of  urea  is  not  rc- 
estal)lished.  The  otlr-r  process  resi'^mblos  interstitial  nephritis  in  its  shnv 
course  and  idtiniately  fatal  termir  ,  'on.  The  interesting  fact  that  a  patient 
may  have  uremic  convtdsions  din-ing  pregnancy  without  eclampsia  is  illus- 
trated l)v  Boudin,""  who  d(^scribes  a  patient  seven  months  pregnant  admitted  to 
the  hospital  unconscious  with  unMuic  convulsions.  On  establishing  the  secre- 
tion of  urine  and  purging  the  patient,  con.sciousness  returntKl,  and  the  follow- 


THE    PArifOLOGY   OF  PREC! NANCY. 


l!ll> 


iiig  (lav  a  seven  months'  fetii.s  was  stillUoni.  Syniptonis  of  iironiia  siipcr- 
vc'iiod,  l)iit  recovery  linally  ensued.  Tlie  patient  inanilested  no  symptom  of 
eclampsia  and  had  no  tnlema.  The  very  interesting^  (piestion  of  the  proj^nosis 
in  nephritis  (hiring  pregnancy  has  recently  received  consideration  at  the  hands 
of  Kohlaiuk.®"  In  a  series  of  77  patients,  r)!).7  per  cent,  showed  nothing 
pathological  in  the  urine  after  their  recovery  from  labor;  KJ.H  per  cent,  mani- 
fested slight  involvement  of  the  kidneys  as  shown  by  hyaline  casts  and  leuco- 
cytes, with  a  trace  of  alhni-iin  ;  in  \hA  per  cent,  a  catarrhal  condition  of  the 
urinary  tract  was  evidently  present ;  in  (i.o  j)er  cent,  the  patients  were  the 
victims  of  nephritis. 

The  presen(;e  of  sugar  in  the  urine  during  pregnancy  has  l)een  the  subject 
of  inv(!stigation  by  lierberotf  c"^  his  tests  were  thorough  and  ndnute,  and  his 
results  were  largely  negative,  a  trace  of  sugar  being  present  in  some  i)atieiits 
in  early  pregnancy,  and  disappearing  as  labor  a|)i)roached.  Polyuria  may  be 
observed  in  the  pregnant  patient  without  a  pathological  condition  of  the  urine, 
as  in  a  eas(3  reported  by  Voituriaz,**  Among  the  most  signiticant  of  the 
symptoms  presented  by  pregnant  patients  sulfering  from  nephritis  may  be 
reckoned  albuminuric  retinitis.  Abundant  evidence  of  the  signiticanee  of  this 
complicati(>n  is  afforded  by  the  literature  of  ophthalmoloi:!v  upon  the  subject. 
Tn  a  recent  paper  Randolph**  reports  5  eases,  with  a  pa ihologieal  study  and 
drawings  of  the  tissues  involved  :  he  regards  visual  disturbances  occurring 
in  the  first  six  months  of  pregnancy,  associated  with  violent  headache,  as  very 
significant  of  albuminuric  retinitis.  If  this  condition  be  found,  to  save  sight 
pn^gnancy  should  at  on(!e  be  terminated.  Visual  disturbance-*  during  the  last 
seven  weeks  of  pregnancy  are  of  less  grave  im)>ort.  The  occurrencte  of  renal 
retinitis  in  one  pregnancy  does  not  necessarily  mean  its  recurrence  in  a 
succeeding  pregnancy. 

The  treatment  of  disorders  of  the  urinary  tract  occurring  during  pregnancy 
necessitates,  first,  a  careful  examination  of  the  j)osition  of  the  uterus,  inasmu(>h 
as  j)ressure  upon  the  bladder,  ureters,  and  kidneys  by  a  disphu^ed  pregnant 
uterus  is  so  frequently  a  cause  of  disease.  A  retroverted  uterus  should  be 
raised  and  be  sup})orted  in  proper  ])osition  by  tampons  of  antiseptic  carded 
wool.  Cystitis  may  be  treat(Ml  by  douching  the  bladder  with  creolin  or  lysol, 
30  drops  to  the  pint  or  (piart  of  warm  water,  as  the  patient's  tolerance  will 
permit.  The  administrati(»n  of  salol,  of  boracic  acid,  or  of  sodium  salicylate 
internally  is  also  of  advantage.  If  the  ureters  become  involved,  catheterization 
of  these  ducts,  the  bladder  having  first  been  rendered  aseptic,  is  indicated  to 
determine  which  kidney  is  affected  if  pyelitis  is  present.  Should  this  ]>ro- 
c(Hlure  show  the  presence  of  pus  and  bacteria  in  one  kidney,  the  extirpation  or 
the  drainage  of  this  organ  is  indicated.  Such  disorders,  however,  compli- 
cating pregnancy,  are  unfavorable  and  dangerous  to  the  life  of  the  patient. 
Should  recovery  occur,  the  ])atient  is  liable,  after  the  birth  of  the  child,  to 
become  the  victim  of  some  form  of  chronic  nephritis. 

Suppuratingr  hydatid  of  the  abdomen  is  an  infrequent  but  dangerous 
complication  of  pregnancy.     The  diagnosis  is  made  by  the  presence  of  an 


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AMEJilCAX  TEXT-BOOK  OF  OBSTETRICS. 


abiloniiiial  tumor  not  attacluHl  to  tlie  uterus,  aii'l  by  the  contents  of  this  tumor 
obtained  through  tapping.  An  incision,  shoukl  be  made  throiigli  the  abdom- 
inal wall,  and  tiie  edges  of  the  sac  of  the  tumor  be  sewn  to  the  edges  of  the 
alxlominal  incision.  So  soon  as  adhesion  has  taken  place  the  cyst  should  be 
opened  and  its  contents  thoroughly  removcnl.  Pregnancy  is  not  necessarily 
interrupted  by  this  complication. 

Peritonitis  during  pregnancy/"  as  has  been  stated,  rcsidts  in  most  cases 
from  previous  iiiftammation  of  the  endometrium,  the  Fallopian  tubes,  or  the 
connective  tissue  of  the  pelvis,  causetl  by  septic  germs  or  their  spores.  There 
remain,  however,  cases  in  which  no  infection  can  be  traced,  but  in  which 
sudden  exposure  to  cold  or  to  dampness  may  produce  rapidly-extending  and 
fatal  peritonitis ;  thus,  instances  are  recorded  where  a  cold  bath  taken  while  the 
patient  was  overheatetl,  and  accompanied  by  the  drinking  of  cold  fluid,  was 
followed  by  rapidly-developing  and  fatal  general  peritonitis. 

Mechanical  iiijurv  or  a  severe  strain  may  be  followed  by  peritonitis  in  a 
])regnant  patient.  Gow  ^'  reports  the  case  of  a  patient  advanced  in  preg- 
nancy who  slipped  through  a  hole  in  the  floor  of  a  building ;  peritonitis 
supervened ;  the  patient  was  delivered  by  version,  but  ceased  breathing 
during  delivery.  Abdominal  incision  disclosed  no  blood  in  the  peritoneal 
cavity,  but  lymph  was  found  upon  the  peritoneum  and  uterus.  No  evi- 
dence of  rupture  of  the  uterus  or  other  organ  was  discovered.  Xo  focus 
from  which  the  inflammation  could  have  begun  was  found  upon  examination. 

Concealed  accidental  hemorrhage  is  among  the  most  dangerous  com- 
plications of  pregnancy.  One  of  the  most  extensive  recent  collections  of 
such  cases  is  that  by  Storer,"  who  contributes  an  account  of  46  in  his  own 
observation,  and  adds  the  collection  of  84  oases  by  Goodell  and  23  by  Braxton 
Hicks,  making  a  total  of  16.">.  46.7  per  cent,  of  the  mothers  perished,  and 
of  the  chiklren  514  per  cent.  Of  63  cases  which  received  no  treatment,  64 
per  cent,  died,  while  in  79  cases  in  which  the  contlition  was  detected  and 
treated,  29  per  cent.  died.  It  is  thus  apparent  how  insidious  is  the  danger 
and  how  difHcult  is  its  recognition  in  these  patients.  There  is  contributed  by 
Jardrin"  a  further  series  of  these  cases,  the  results  of  which  differ  in  no  partic- 
idar  from  those  observed  in  the  more  extensive  series  of  Storer.  As  so  nuich 
importance  naturally  attaches  to  a  diagnosis  of  this  complication,  it  must  be 
remend)ered  that  the  hemorrhage  is  concealed,  and  that  the  i)atic:it  may  be 
thrown  into  a  condition  of  danger  without  a])parent  flow  of  blood  :  her  symp- 
toir.s  then  will  divid(>  themselves  into  two  classes — namely,  those  j)ertaining  to 
her  general  condition,  and  those  which  have  to  do  with  the  uterus  itself;  of 
these,  the  first  furnishes  the  best  indications  of  danger  and  the  most  rational 
suggestions  for  treatment.  A  rapid,  weak  pulse,  lacking  in  tension  ;  an 
indifl'crent,  languid  attitude  of  mind  ;  respiration  becoming  more  and  more 
shallow;  a  jiale  or  pallid  face;  a  clammy  skin;  thirst;  dimness  of  visit)n 
and  "air-hunger;"  a  restless  irritability  which  is  a  very  significant  symptom 
of  a  certain  kind  of  shock, — these  furnish  an  array  of  symptoms  which  shoidd 
attract  the  attention  of  the  physician. 


THE    PATHOLOGY   OF  PREGNANCY. 


201 


If  conc'caletl  iU'cidoiital  heniorrhnge  occurs  during  labor,  labor-pains  may 
coa-^e  or  may  grow  weak,  and  the  usual  sensation  of  pain  in  the  uterus  may 
be  replaced  by  a  dull  constant  ache  above  the  pubes.  It  is  occasionally 
noticed  tliat  the  os  uteri  is  dilating  without  apparent  labor-pains.  The 
uterus  may  become  enlargetl,  forming  an  asymmetrical  timior  of  the  abdo- 
men which  can  be  appreciated  by  palpation.  As  regards  those  symptoms 
which  can  be  observed  on  making  an  examination  of  the  genital  tract,  the  o« 
liter!  is  usually  slightly  dilated,  and  the  cervix  is  s(>ftened,  although  it  may 
not  be  effaced.  Slight  uterine  hemorrhage  is  generally  observed.  The  lower 
uterine  segment  becomes  distended  with  clot ;  as  the  hemorrliage  persists  the 
sensation  conveyed  to  the  linger  resembles  that  in  placenta  pncvia.  Inetfectual 
and  spasmodic  uterine  contractions  and  the  accumulation  of  blood  between  the 
Ictus  and  the  wall  of  the  uterus  will  cause  irregular  enlargement  of  the  womb. 

Concealed  accidental  hemorrhage  from  some  other  source  than  the  uterus 
or  the  placenta  may  occur  during  pregnancy,  the  blood  escaping  into  the 
abdominal  cavity.  An  illustrative  case  is  reported  by  Sutugin"  of  a  multi- 
gnivida  who,  three  days  before  ailmission  to  the  hos})itaI,  had  fallen  while  carry- 
ing a  heavy  load.  Two  days  after  her  fall  she  was  seiziHl  with  weakness,  and 
felt  no  fetal  movements  after  this  time.  When  examined,  no  dilatation  of  the 
OS  and  cervix  was  present.  The  fetal  heart-sounds  were  absent.  The  patient 
complained  greatly  of  pain  in  the  uterus,  probably  caused  by  uterine  con- 
tractions. Shortly  after  <lelivery  the  piitient  luul  clonic  spasm  of  the 
extremities,  and  <lied  in  collapse.  On  post-mortem  examination  a  large 
amount  of  clotted  blood  was  found  in  the  abdomen.  The  source  of  the 
hemorrhage  was  a  torn  vessel  of  the  mesocolon.  The  uterus  contained  a  fetus 
nearly  at  term  an('  dead. 

As  regards  the  <Ii(i(/no.si)i  of  this  condition,  it  must  be  based  ujion  symp- 
toms of  prostration  and  shock  greatly  out  of  proportion  to  the  amount  of 
licinorrhage  that  may  be  present.  The  dangerous  character  of  this  complica- 
tion of  pregnancy  and  lal)or  should  lead  the  physician  to  take  alarm  prompt- 
ly and  to  interfere  as  quickly  as  |)ossible.  The  method  of  interference  will 
depend  somewhat  upon  whether  the  licmorrhagc  occurs  during  labor  or  before 
tiie  beginning  of  actual  labor.  One  of  the  most  plainly  indicated  expedients  in 
these  cases  is  rupture  of  the  membranes,  which  will  lead  to  a  closer  coaptation 
of  the  uterus  upon  the  fetal  body,  thus  making  pressure  upim  its  blood-vessels. 
Accompanying  this  rupture,  the  administration  of  ergot  or  ergotin  is  indicated 
for  similar  reasons.  Treatment  by  these  expr'dienis  may  be  considered  the 
expectant  method,  which,  in  G.'i  cases  reported  by  Storer,  gave  a  mortality  of 
forty.  Rapid  dilatation  of  the  os  and  cervix  and  delivery  by  version  or  by 
the  forceps  give  a  better  prognosis,  as  in  18  forceps  deliveries  four  deaths  are 
reported.  Where,  however,  the  hemorrhage  is  sudden  and  severe,  and  the 
liirth-canal  is  not  sufliciently  dilated  to  p(>rmit  delivery,  the  uterus  should  be 
emptied,  and  the  bleeding  be  controlled  by  abdominal  incision  and  hysterec- 
tomy or  by  total  extirpation  of  the  uterus.  The  use  of  the  tampon  of  antisep- 
tic gauze  is  indicated  in  cases  where  hemorrhage  externally  is  considerable  and 


202 


AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 


it 


)i 


'i 


the  OS  and  cervix  are  too  tiglitly  closed  to  permit  of  rapid  delivery.  In  intro- 
ducing the  tampon  it  is  well  to  pack  the  end  of  the  strip  of  gauze  into  the  os 
and  cervix,  thus  furthering  dilatation  and  checking  external  hemorrhage. 
The  "prognosis  for  the  fetus  in  these  cases  is  exceedingly  grave  and  is  almost 
necessarily  hopeless.  Loss  of  blood  induces  rapid  asphyxia,  and  the  rapid 
fetal  movements  accompanying  the  partly  asphyxiated  state  may  explain 
some  of  the  obstinate  uterine  pains  from  which  these  patients  suffer. 

The  causal  relation  existing  between  involvement  of  the  kidneys  and 
intra-uterine  hemorrhage  has  been  describetl  in  treating  of  Nephritis  and  its 
consequences.  In  a  series  of  clinical  lect  ires  upon  the  subject  of  hemorrhage 
during  pregnancy  Budin  ''^  describes  the  case  of  a  patient  suifering  from 
hematuria  with  albuminous  urine.  Profuse  intra-uterine  hemorrhage  com- 
plicated labor;  the  child  perished. 

The  Posture  and  Bearing  of  the  Pregnant  "Woman. — Accompany  .; 
the  changes  in  the  jx'lvis  peculiar  to  pregnancy  we  find  certain  variations 
in  the  posture  and  bearing  of  the  patient  as  pregnancy  advances.  This 
has  been  the  subject  of  study  by  Knhnow,^^  who  found  two  types  among 
patients  in  the  latter  months  of  pregnancy.  The  most  frequent  is  a  back- 
ward curve  of  the  entire  body,  while  in  20  per  cent,  of  cases  a  backward 
bend  of  the  trunk  only  was  present.  Tiie  cervical  vertebrse  are  straightor, 
the  thoracic  curve  is  greater  and  more  projecting,  the  lumbo-dorsal  region  is 
straighter,  its  curve  being  lower  and  flatter,  while  the  pelvic  curve  is  often 
lessened  in  the  later  months  of  pregnancy,  and  is  sometimes  unchanged.  The 
hip-joints  are  usually  carried  ))osteriorly,  while  the  sternum  projects  at  its 
lower  extremity,  increasing  the  diameter  of  the  thorax. 

Relaxation  of  the  Pelvic  Ligaments. — Among  the  general  changes 
caused  by  pregnancy  are  those  affecting  the  joints  of  the  pelvis.  The  fact 
that  an  increased  secretion  of  synovial  fluid  is  present  in  the  pelvic  articu- 
lation during  pregnancy  has  long  been  recognized,  and  has  been  accurately 
studied  by  Driver:"  in  his  examination  of  300  cases  he  found  the  amount 
of  relaxation  is  ])roportionate  to  the  general  strength  and  firmness  of  the 
patient's  tissues.  Age  has  nothing  to  do  with  it,  nor  does  the  amount  of 
relaxation  influence  the  patient's  walking.  Some  of  those  whose  joints 
were  most  relaxed  could  walk  without  difficulty ;  conversely,  consid- 
erable motion  produced  in  some  patients  marked  lameness.  Pain  at  a 
sacro-iliac  joint  showed  that  the  ilium  moved  upon  the  sacrum  upon  that 
side.  This  phenomenon  is  sometimes  observed  in  patients  who  are  not  preg- 
nant. Some  patients  recovered  spontaneously  from  a  serious  condition  of 
lameness,  while  others  were  not  benefited  by  prolonged  and  thorough  treat- 
ment. A  slight  degree  of  relaxation  may  facilitate  delivery  and  obviate  the 
use  of  forceps.  The  most  successful  treatment  described  was  an  abdominal 
bandage  of  twilled  cotton  5  inches  wide,  with  padded  perineal  bands  1  incli 
wide.  Where  the  ])atient  was  deficient  in  general  strength  cold  baths  auid 
massage  were  sometimes  useful. 

The  Toxemia  of  Pregnancy. — The  interesting  metabolism  characteristic 


THE  PATHOLOGY   OF  PBEGNANCY. 


203 


! 


of  pregnancy  has  not  yet  been  sufficiently  elucidated  to  explain  clearly  the 
origin  of  toxic  material  which  not  infrequently  jeopardizes  the  lives  of  mother 
and  i;hild.  The  fact  that  nutrition  and  its  converse  are  going  on  in  two  organ- 
isms, each  dependent  upon  the  other  for  proper  assimilation  and  excretion, 
explains  the  ease  with  which  these  processes  may  pass  the  bounds  of  physio- 
logical activity  and  become  disease.  The  character  of  the  poisons  produced 
in  the  body  of  the  mother  and  the  fetus  places  them,  so  far  as  we  know,  in 
the  class  of  animal  poisons,  alkaioidal  in  nature,  denominated  toxins.  The 
symptoms  they  produce  upon  the  pregnant  patient  are  especially  addressed  to 
tlie  nervous  system,  hence  the  study  of  toxemia  in  pregnancy  appropriately 
leads  to  a  consideration  of  nervous  disorders  during  this  condition. 

Various  observers  by  differing  methods  of  investigation  have  isolated 
several  poisonous  principles  from  the  urine  of  pregnant  women  in  whom 
elimination  was  deficient:  Diihrssen^*  lays  great  stress  on  the  retention  of 
creatin  and  creatinin  in  the  kidneys  of  the  pregnant  patient.  Actual  nephritis 
ho  rarely  observed,  but  congestion  and  accumulation  of  urine  through  pressure 
upon  the  ureters  and  by  hydronephrosis  are  common.  Creatin  and  creatinin 
accumulating  in  the  vessels  of  the  cerebral  cortex  produce  cerebral  irritation. 
It  is  natural  that  such  a  condition  should  be  commonest  in  patients  in  whom 
excretion  is  habitually  deficient.  Poisons  absorbed  from  the  intestinal  tract 
stand  in  close  relation  to  the  toxemia  of  pregnancy,  as  shown  by  Budin.^' 
This  is  especially  true  where  retr(»version  of  the  pregnant  uterus  produces 
intestinal  stasis.  In  many  of  these  cases  the  bacterium  coli  communis  pene- 
trates the  wall  of  the  bowel,  causing  peritonitis  in  adjacent  tissues. 

Culture  experiments  by  inoculation  demonstrating  the  toxicity  of  urine  in 
pregnancy  have  been  performed  by  Ciiarpentier,*'  who,  following  Bouchard's 
researches,  injected  such  urine  into  rabbits,  producing  tetanic  convulsions  and 
speedy  death.  Acute  congestion  in  the  kidneys  of  these  animals  was  the  only 
lesion  found  to  account  for  the  fatal  issue.  Similar  injections  beneath  the 
skin  of  other  animals  less  susceptil)le  than  rabbits  produced  death  after  longer 
intervals.  The  condition  of  congestion  of  the  kidneys  in  patients  suffering 
from  toxemia  in  jiregnancy  is  also  described  by  Prutz.*"  He  notes  a  verv 
interesting  point,  that  but  slight  structural  alterations  were  present  in  many 
exceedingly  severe  cases  of  toxemic  poisoning.  In  the  kidneys  of  infants 
burn  from  mothers  suffering  from  toxemia  there  were  observed  congestion 
and  transudation  of  serum,  witii  the  formation  of  casts  in  the  tubes  and 
great  distention  of  the  veins.  A  similar  congestion  in  the  livers  of  toxemic 
patients  is  described  by  Pilliet  and  Delansorme."^  This  condition  of  con- 
gestion in  the  kidney  of  the  pregnant  wonian  was  found  in  two-thirds  of 
the  cases  examined  by  Fischer  during  the  second  half  of  jiregnancy.*'^ 

The  state  of  the  blood  in  these  patients  has  been  studied  by  P»Ianc,*^  who 
made  cultures  and  inoculated  animals  with  their  jjroducts,  producing  alinimi- 
nuria  and  siip])ression  of  urine.  Convulsions  were  also  caused,  and  intense  con- 
gestion of  the  kidneys  was  observed.  Additional  testimony  as  to  the  extensive 
disorganization  of  the  blood  and  tiie  pathological  condition  of  the  liver  in  the 


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toxemia  of  pregnancy  is  affordwl  by  Papillon  and  Audain.*''  The  accumulation 
of  ptonia'ins  in  sufficient  quantities  to  produce  poisoning  has  been  observed  by 
Koffer  and  Kuudrat.**  Paultauf  and  Kundrat  have  also  reported  similar 
cases  in  the  Records  of  the  Pathological  Institute  of  the  Vienna  University. 

Among  many  interesting  contributions  to  the  bacteriology  of  this  question 
is  that  made  by  Gerdes.*^  In  common  with  other  observers,  he  is  inclined  to 
ascribe  to  bacteria  a  causal  relation  in  these  cases.  As  bearing  upon  this  point 
we  note  the  observations  of  Tarnier  and  Chambrelent,**  who  found  in  toxemic 
pregnant  w^omen  that  the  degree  of  intoxication  present  could  well  be  estimated 
by  observing  the  toxicity  of  the  blood-scrum  of  these  patients.  It  is  interest- 
ing in  this  connection  to  note  that  any  disorder  caused  by  bacterial  invasion 
predisposes  to  toxemia  in  pregnancy;  thus,  Lang®*  finds  that  twice  as  many 
pregnant  women  who  are  syphilitic  show  symptoms  of  threatened  toxemia  in 
pregnancy  as  are  observetl  in  non-syphilitic  pregnant  patients. 

The  precise  toxic  agent  responsible  for  the  gradual  development  of  toxemia 
with  threatened  eclampsia  has  not  yet  been  isolated,  although  a  number  of  sub- 
stances have  been  charged  witii  this  result.  The  significance  of  a  diminished 
quantity  of  urea  in  these  cases  has  been  brought  to  the  attention  of  the  pro- 
fession by  Hermann**  and  Davis:"  the  latter  in  84  cases,  vitli  a  total  of  5G4 
examinations  to  determine  the  amount  of  urea  present  in  the  urine  of  pregnant 
and  parturient  women,  found  that  the  average  percentage  of  urea  in  the  urine 
of  a  iiealthy  })atient  before  labor  was  1.4.  After  delivery  this  percentage 
increased  to  1.9.  Considerable  diminution  in  this  quantity  was  first  accompa- 
nied by  symjitoms  of  irritation  of  the  nervous  systeru  and  threatened  intoxica- 
tion, and,  where  the  patient's  excretion  was  not  stimulated  and  the  amount  of 
urea  brought  up  to  nearly  normal,  eclampsia  develojted.  Davis  does  not  ascribe 
to  retained  urea  the  causal  role  in  toxemia,  but  he  regards  it  as  a  valuable  index 
in  estimating  the  excretory  activity  of  the  patient. 

A  well-marked  example  of  ptomain-intoxication  during  pregnancy  is  the 
case  described  by  Gustav  Braun.'^  The  patient,  seven  months  pregnant,  died 
from  pulmonary  edema  after  premature  labor.  The  urine  contained  casts 
and  albumin.  Tiie  ])()st-mortcm  examination  was  made  by  Paultauf,  who 
found  fatty  liver,  fluid  blood,  nejiliritis,  and  cerebral  edema.  Multiple 
rupture  of  capillaries  was  found  iu  the  viscera.  The  fact  that  the  blood  of 
patients  suffering  from  toxemia  may  contain  pathogenic  germs  has  been  illus- 
trated by  Blanc,'^  who  made  cultures  from  the  blood  of  such  a  patient, 
obtaining  in  forty-eight  hours  germs  which  caused  albuminuria  and  toxemia 
in  ral)l)its.  It  was  foiuid  on  experimenting  that  chloral  in  the  proportion 
of  4  parts  to  1000  of  tiie  culture-liquids  effectually  destroy  these  germs. 
Blanc"*  continued  his  experiments  by  injecting  the  urine  of  ])regnant 
j)atients  into  the  bodies  of  rabi)its  and  observing  tlic  result.  It  was  found 
that  while  tiie  urine  of  some  uon-j)regnant  patients  was  poisonous  when 
injected,  the  urine  of  pregnant  patients  was  far  more  toxic,  causing  distinct 
phenomena  of  decided  poison.  Van  Santvoord '"*  from  clinical  observation 
ascribes  toxemia   during  pregnancy  very  largely   to   deficient  action  of  the 


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liver,  by  which  an  insufficient  formation  of  urea  causes  the  patient  to  retain 
in  her  blood  toxic  material.  The  imnmnity  which  the  kidneys  display  in 
some  of  these  cases  is  illustrated  by  Prutz's  description  of  the  condition  of 
tiie  kidneys  in  22  cases  of  fatal  toxemia.  In  many  of  these,  beyond  a  general 
congestion,  no  pathological  condition  was  found.  Micro-organisms  were  absent 
from  the  kidneys,  and  there  was  no  relation  between  the  severity  of  the 
intoxication  and  the  condition  of  the  kidneys.  The  belief  that  peptones  are 
among  the  substances  causing  toxemia  has  led  observers  to  study  the  urine  of 
pregnant  patients  with  regard  to  tiie  presence  or  absence  of  these  substances. 
Thomson  ^  examined  the  urine  of  23  pregnant  and  puerperal  women  for 
jH'ptone ;  the  results  of  his  examination  were  negative.  Koettnitz"'^  made 
140  analyses  of  the  urine  of  31  pregnant  patients,  but  could  not  discover  that 
peptone  is  a  significant  ingredient  in  these  cases.  It  is  often  present  in  the 
urine  of  patients  who  suffer  during  pregnancy  from  any  severe  complication. 

While  the  entire  subject  of  the  toxicity  of  urine  offers  a  vast  field  of  inves- 
tigation and  has  produced  a  large  literature,  so  far  as  the  obstetrician  is  con- 
cerned there  is  abundant  proof  that  no  one  substance  is  especially  dangerous  to 
his  pregnant  patient,  but  that  the  gradual  accumtdation  of  nitrogenous  waste, 
of  potassium  combinations,  and  of  animal  alkaloids  produces  a  condition  of 
toxemia,  the  symptoms  of  which  are  first  observed  in  a  disordered  state  of 
the  nervous  system  demanding  the  attention  of  the  physician.  Following  the 
line  of  Bouchard,  additional  observation  is  required  for  a  more  precise  determi- 
nation of  the  relative  toxicity  of  the  various  substances  retained  in  the  blood 
ill  these  cases. 

The  jn-ophylaxin  of  the  toxemia  of  pregnancy  resolves  itself  into  mainte- 
nance of  excretion.  Remembering  the  interference  with  the  circulation  to 
which  the  patient  is  subjected  by  pressure,  a  first  and  very  important  precau- 
tion is  to  secure  suitable  clothing.  There  can  be  no  question  of  the  advisability 
of  laying  aside  completely  the  corset  or  any  other  form  of  support  for  skirts 
that  com|)resses  the  abdomen  and  forces  the  viscera  down  upon  the  brim  of  the 
pelvis.  The  art  of  dress  has  advanced  sufficiently  to  enable  the  patient  to 
obtain  comfortable  and  shapely  clothing  supported /entirely  from  the  shoulders. 
Poor  patients  can  make  for  themselves  from  cheap  materials  waists  which 
fulfill  the  same  indication.  While  the  intelligent  physician  will  ailvise  and 
strongly  urge  that  the  corset  be  laid  aside,  he  will  remend)er  that  this  is  one 
of  the  pieces  of  medical  advice  which  is  expected  and  is  rarely  followed.  The 
responsibility,  however,  is  not  his  after  ho  has  stated  the  case  fairly  and  clearly 
t(»  his  patient.  Constriction  of  the  blood-vessels  should  also  be  avoided  by 
wearing  loose  shoes,  by  dispensing  with  garters  that  encircle  the  legs,  and 
by  the  avoidance  of  constipation  so  far  as  possible.  In  this  latter  difficult 
])r()l)lenj  it  will  be  found  that  a  proper  mode  of  dress  is  of  the  utmost 
importance  by  avoiding  pressure  upon  the  large  intestine.  In  avoiding  con- 
stipation it  is  well  for  the  patient  in  addition  to  select  a  diet  not  rich  in 
nitrogenous  elements.  The  heavier  and  less  digestible  meats  should  be 
omitted.     Birds,  lamb,  mutton,  fish,  and  oysters  are  best  adapted  for  such 


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patients.  A  i  abundance  of  raw  fruit,  or  cooked  fruit  if  the  digestion  re- 
quires it,  is  oT  great  importance.  Whole  wheat,  Graham,  and  rye  bread  is  of 
vahie.  The  avoidance  of  large  amounts  of  sweets  and  stimulants  of  every 
form  is  also  indicattKl.  While  vegetables  are  useful,  they  are  inferior  to 
fruits  for  the  needs  of  such  patients.  An  abundance  of  water  is  a  prime 
necessity.  If  the  patient  cannot  obtain  bottled  waters,  ordinary  drinking- 
water  wiii(:!i  has  been  boiled  and  filtered  may  be  taken  in  abundance.  If  her 
means  allow  her  to  choose,  she  will  find  the  lightest  Vichy  or  any  of  the  slightly 
alkaline  and  effervescing  waters  agreeable  and  advantageous.  Milk  is  to  be 
taken  freely  by  those  with  whom  it  agrees ;  many,  however,  cannot  use  it 
without  producing  obstinate  constipation.  The  medicinal  treatment  of  intesti- 
nal torpor  threatening  toxemia  consists  in  the  use  of  such  laxatives  as  can  be 
employal  for  a  considerable  time  without  violent  purgation  and  without  losing 
their  eUcct.  Compound  licorice  powder  in  small  (piantities,  rhubarb  or 
colocynth  in  combination  with  extract  of  belladonna,  small  quantities  of  the 
lieavier  mineral  waters  (such  as  Himvadi  Janos)  and  cascara  sagrada  in  com- 
bination with  the  substances  mentioned,  have  been  found  efficient.  Where 
the  liver  is  evidently  at  fault,  the  occasional  use  of  calomel  and  soda,  followed 
by  a  saline,  is  distinctly  indicated.  W^here  hemorrhoids  complicate  the  patient's 
constipation,  rectal  suppositories  of  glycerin  1  drachm,  extract  of  belladonna  \ 
grain,  and  iodoform  5  grains  will  be  found  advantageous. 

In  addition  to  avoiding  constipation,  the  prophylaxis  of  toxemia  embraces 
such  care  of  the  skin  as  shall  promote  constant  and  free  elimination.  Fre- 
quent bathing  in  tepid  water,  flannel  (varying  in  weight  in  accordance  with 
the  climate)  worn  next  the  skin,  massage  of  the  limbs  and  the  upper  portion 
of  the  triuik,  and  gentle  exercise  are  not  to  be  neglected.  Remembering  the 
important  part  wiiich  the  lungs  ploy  in  excretion,  and  the  necessity  for  a 
free  supply  of  oxygen,  the  patient  must  have  an  abundance  of  fresh  air.  A 
mild  and  equable  climate  is  naturally  the  best  for  such  cases,  but,  as  this  is 
seldom  available,  the  patient,  properly  clad,  should  be  out  of  doors  in  all 
weathers.  It  is  of  imjiortance  that  tlie  amount  of  urine  secreted  be  observed, 
lieiice  tlie  patient  should  be  instructed  to  take  such  precautions  that  this 
information  is  availal)le  for  the  physician.  He  may  inform  her  that  an 
amount  varying  within  certain  limits  is  what  is  expected  and  desired,  and 
that  any  marked  decrease  from  this  should  at  once  be  reported  to  iiini. 
Examination  of  the  urine  of  ])regnant  patients  should  be  an  invariable  cus- 
tom not  to  be  omitted  in  any  case.  It  should  be  done  at  least  once  a  month 
through  the  entire  pregnancy,  or,  l)etter,  i>nce  in  two  or  three  weeks.  While 
this  imposes  additional  labor  upon  the  physician  and  inconvenience  upon  the 
j)atient,  yet  in  all  eases  of  primigravidie,  especially  in  women  whose  nutrition 
and  excretion  are  not  of  the  best,  "  Paternal  vigilance  is  the  ])rice  of  safety." 
If  this  be  reasonably  explained  to  a  patient,  she  will  rarely  object.  The 
examination  of  the  urine  in  pregnancy  requires  ciiemical  and  microscopic 
investigation.  By  the  first  we  search  for  albumin,  sugar,  and  urea  in  all  cases. 
Important  as  this  examination   is,  it  is  second  in  value  to  the  microscopic 


THE   PATHOLOGY   OF  PREGNANCY. 


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study  of  the  specimen.  By  tliis  study  we  derive  positive  and  valuable  infor- 
mation as  to  the  condition  of  the  parenchyma  of  the  kidney,  and  this  informa- 
tion can  be  obtained  in  no  other  way.  Hence  in  pregnancy  an  examination  of 
tlie  urine  that  does  not  include  its  microscopic  study  is  certainly  superficial 
and  deficient.  In  cases  where  a  suspicion  exists  that  toxemia  is  developing, 
in  addition  to  the  substances  already  mentioned  we  must  examine  chemically 
lor  indican,  acetone,  peptone,  pus,  and  blood.  In  complicated  cases  micro- 
scopic examination  must  be  patient  and  thorough. 

D'uKjnoHts. — In  diagnosticating  the  toxemia  of  pregnancy  two  clinical 
signs  are  of  especial  value:  first  in  importance  are  the  amount  and  character 
of  the  excretions ;  second  is  the  condition  of  the  nervous  system.  The  first 
sign  is  to  be  ascertained  by  careful  questioning  and  accurate  observation.  The 
second  sign  must  be  determined  by  closely  interrogating  the  various  functions 
of  the  jiatient's  nervous  system.  The  presence  or  the  absence  of  pain,  head- 
ache, thirst,  lassitude,  disturbances  of  vision,  of  hearing,  or  of  taste,  sleep- 
lessness or  lethargy,  irritability  or  apathy,  melancholia,  and  nausea  and  vom- 
iting, are  all  symptoms  to  be  recognized  or  be  eliminated.  The  condition  of 
the  skin,  as  affording  evidence  of  the  functional  integrity  of  its  excretory 
apparatus,  is  of  great  value.  Of  secondary  importance  are  the  occurrence  of 
swelling  of  the  feet  and  legs  and  the  presence  of  serum-albumin  only  in  the 
urine. 

The  treatment  of  the  toxemia  of  pregnancy  consists  in  the  prompt  stimu- 
lation of  all  the  elimiuative  organs  of  the  body.  In  view  of  the  hepatic 
condition  present  there  can  be  no  question  regarding  the  efficiency  of  mer- 
curials in  a  few  repeated  doses.  The  remarkable  diuretic  effect  of  calomel 
is  also  of  value  in  these  cases.  In  selecting  saline  cathartics  it  is  best  to 
avoid  those  containing  potassium  salts,  as  potassium  has  been  shown  to  be 
ail  irritative  element  in  the  urine.  Those  purgatives  producing  a  free  flow 
of  watery  fluid  from  the  bowel,  such  as  colocynth,  elatcrium,  and  jalap,  are 
ospe(Mally  indicated.  Rectal  injections  of  glycerin,  combined  with  sodium 
salts  and  spirits  of  tiu'peutine,  are  excellent  in  [)roducing  copious  watery 
evacuations.  The  beneficial  effect  of  such  elimiuative  treatment  on  the  ner- 
vous system  is  remarkable  in  many  cases,  the  patient  passing  from  a  condition 
of  melancholia  and  great  restlessness  to  a  feeling  of  comfort  and  good  health. 
Warm  and  hot  baths  in  these  cases,  taken  befi)re  retiring,  are  an  excellent 
moans  of  treatment.  If  the  patient's  symptoms  are  threatening  and  a  con- 
dition of  hysteria  is  present,  the  hot  pack  will  i)r()vc  a  most  valuable 
resource.  The  diet  in  cases  of  toxemia  should  be  restricted  to  milk,  fruit, 
l)iead,  and,  if  tiie  patient  requires  more  than  this,  fish,  oysters,  and  gruel. 
Meats,  eggs,  vegetables,  pastry,  and  all  forms  of  stiundants,  including  tea 
and  coffee,  should  absolutely  be  forbidden  while  symptoms  of  toxemia  are 
present.  In  examining  the  urine  two  points  are  especially  valuable :  one  is 
tlie  smiount  i)assed  daily  ;  the  second,  the  amount  of  urea  excreted  by  the 
patient.  If  the  condition  of  the  kidney  passes  beyond  congestion  to  actual 
nephritis,  the  practitioner  will  be  aware  of  this  through  the  microscopic  study 


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of  the  urine,  wlieii  casts,  bloody,  epithelial,  or  fatty,  will  be  prep^iit.  The 
presence  of  senun-albuinin  and  hyaline  casts  is  of  very  little  moment  so  long 
as  a  free  amount  of  urea  is  excreted,  and  microscopic  study  of  the  urine  finds 
no  evidence  that  the  parenchyma  of  the  kidney  is  diseased. 

It  is  evident  from  what  has  been  stated  regarding  the  toxemia  of  preg- 
nancy that  simple  albuminuria  is  of  little  moment  in  the  pregnant  condition. 
The  com])licatio'.is  of  pregnancy  ascribed  to  albuminuria  do  not  result  from 
the  presence  of  S!>rum-albumin  in  the  urine,  but  from  the  circulation  through 
the  body  of  the  mother  and  her  placenta  of  blood  rendered  irritating  by  toxic 
material.  The  occurrence  of  thickening  and  induration  in  the  walls  of  the 
placental  blood-vessels,  the  partial  separation  of  a  placenta  in  fatty  degeneration 
following  this  process,  with  the  consequent  hemori-liage  and  asphyxia  of  the 
fetus,  are  familiar  complications  of  the  toxemia  of  pregnancy  and  they  follow  the 
diffusion  of  toxic  material  in  the  placental  blood.  Simple  albuminuria  is  often 
seen  in  multigravidic  in  whom,  by  reason  of  the  large  size  of  the  fetus  or  by 
tiie  relaxed  condition  of  the  uterus  and  the  abdominal  walls,  the  ureters  are 
pressed  upon  and  the  kidneys  are  in  a  constant  state  of  congestion  and  accunui- 
lation  of  urine.  Many  of  the  women  thus  affected  have  edema  of  the  extremities, 
they  remain  entirely  free  from  those  disturbances  of  the  nervous  system  seen  in 
toxemia.  The  condition  of  such  patients  docs  not  demand  the  production  of 
abortion,  but  it  requires  that  the  heart-muscle  be  stimulatetl,  the  circulation  be 
maintained  in  every  way,  and,  if  possible,  that  the  pressure  of  the  pregnant 
womb  upon  the  ureters  be  relieved  by  a  supporting  bandage  when  it  can  be 
used. 

In  sharp  distinction  to  these  cases  are  those  of  the  toxemia  of  pregnancy, 
where,  notwithstanding  prompt  treatment  addressed  to  the  organs  of  elim- 
ination, the  patient's  nervous  symptoms  continue,  while  her  excretory  processes 
are  plainly  deficient.  In  such  cases,  in  the  present  state  of  our  knowledge, 
the  prompt  termination  of  pregnancy  is  the  only  rational  and  conservative 
treatment.  If  the  toxemia  of  pregnancy  be  recognized  and  the  patient  will 
submit  to  her  physician's  advice,  eclampsia  should  become  more  rare  than 
puerperal  septic  infection. 

The  tenilency  which  patients  who  suffer  from  toxemia  of  pregnancy 
exhibit  to  pass  into  nephritis  after  pregnancy  or  during  a  subsequent  gestation 
must  be  borne  in  mind.  In  a  woman  who  has  once  shown  marked  evidence 
of  the  toxemia  of  ])regnaney  each  succeeding  gestation  brings  added  risk  of 
fatal  poisoning.  If  her  condition  be  undetected  and  her  general  health  after 
parturition  be  neglected,  she  will  not  infrequently  become  the  victim  of 
nephritis. 

Disorders  of  the  Nervous  System  ix  the  Pre(ixant  Patient. — Neur- 
algia.— The  ])rcgnant  patient  is  peculiarly  susceptiljle  to  various  disorders  of  the 
nervous  system.  Conuuon  among  these  affections,  and  occasioning  great  distress, 
are  the  various  forms  of  neuralgia  often  observed  diu'ing  gestation.  As  is  gen- 
erally the  case,  these  neuralgias  usually  have  as  a  starting-point  some  portion 


THE  PATHOLOGY   OF  PREGNANCY. 


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of  the  nervous  system  in  which  a  patliological  condition  is  present.  The 
decay  of  the  teetii  so  often  seen  during  pregnancy  accounts  for  many  of 
tiie  cases  of  obstinate  toothaclie  which  annoy  and  distress  these  patients. 
In  women  who  sutier  from  habitual  constipation  during  pregnancy,  and  in 
whom  the  size  of  the  fetus  is  so  great  as  to  cause  pressure  upon  tlie  nerve- 
trunks  at  the  brim  of  the  pelvis,  obstinate  cramp  and  sciatic  pain  may  occasion 
great  distress  and  may  seriously  depress  the  patient's  general  health.  Some 
of  the  worst  of  these  cases  result  from  the  pressure  of  hardenetl  fecal  matter 
upon  nerve-trunks  above  the  brim  of  the  pelvis,  and  upon  branches  of  nerves 
so  situated  that  they  may  be  pressed  upon  in  the  pelvic  cavity.  In  some  of 
these  cases  the  uterus  will  be  found  retroverted,  thus  preventing  proper 
evacuation  of  the  bowels  and  adding  to  the  pressure  which  retained  fecal 
matter  causes.  In  other  patients  there  is  great  complaint  of  cramp  and  of 
sudden  spasmodic  contraction  of  the  muscles  of  the  thigh,  often  worse  at 
night.  Where  the  disorder  is  severe  an  obstinate  i)ain,  radiating  down  the 
tliigh  as  far  as  tiic  knee  or  even  below  the  kuee,  is  often  observed. 

In  dealing  with  these  cases  the  fii-st  duty  of  the  obstetrician  is  to  ascertain 
accurately  the  position  of  the  uterus :  if  it  be  found  retrovertetl  and  not 
bound  down  by  adhesions,  it  is  a  comparatively  simple  matter  to  raise  it  to  or 
above  the  brim  of  the  pelvis,  and  to  sustain  it  by  tampons  of  carded  wool. 
If  the  uterus  be  found  bound  down  by  adhesions,  the  problem  is  much  more 
difficult.  If  the  patient  be  put  at  rest  in  bed  and  the  bowels  be  thoroughly 
moved  by  salines,  a  very  efficuent  form  of  tampon  in  these  cases  may  be  found 
in  a  strip  of  surgeon's  lint  3  or  4  inches  wide  thoroughly  soaked  with 
glycerin.  A  Sims  speculum  is  introduced,  and  this  strip  is  packed  with  the 
aid  of  dressing-forceps  thoroughly  behind  the  cervix,  pushing  the  uterus  up 
as  far  as  possible  without  causing  positive  pain.  This  application  is  followed 
by  a  very  copious  discharge  of  watery  mucus,  greatly  relieving  congestion  and 
softening  adhesions  which  are  not  extraordinarily  tenacious.  The  growth  and 
development  of  the  uterus  will  frequently  separate  such  adhesions,  and  sur- 
prisingly good  results  are  observetl  in  cases  where  the  uterus  has  been  partially 
bound  down  in  the  pelvis.  The  fact  that  pregnancy  exists  contra-indicates, 
naturally,  uterine  massage  and  any  instrumental  interference. 

If  the  uterus  be  in  good  position,  the  next  step  to  be  taken  in  relieving 
pelvic  pain  radiating  down  the  thighs  is  to  empty  the  bowel  thoroughly  :  this 
should  be  done  with  the  same  care  exercised  in  preparing  a  patient  for  an 
abdominal  section.  In  addition  to  the  purgatives  usually  employed,  the  colon 
should  be  flushed  thoroughly  by  frequent  and  copious  injections  of  warm 
water  and  sulphate  of  magnesia,  or  injections  containing  soapsuds  and  castor 
oil  to  which  turptntine  is  added.  If  impaction  of  feces  is  present,  an  ounce 
of  ox-gall  dissolved  in  a  quart  of  hot  soapsuds  should  be  injected  through  a 
rectal  tub?  as  high  into  the  bowel  as  possible.  This  injection  is  to  be 
retained  so  ioiig  as  the  ])atient  can  do  so,  and  when  an  inclination  to  evacuate 
the  bowels  is  felt  a  second  injection  of  sulphate  of  magnesia,  glycerin,  and 
turpentine  will  usually  result  successfully.  Some  cases  of  obstinate  pelvic 
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AMERICA X   TEXT-BOOK   OF   OBSTETRICS. 


neuralgia  occurring  during  pregnancy  are  cured  by  erai)tying  the  bowel  of 
hard  and  irritating  feces. 

Where  the  uterus  is  in  proper  position  and  the  intestine  is  free  from  fecal 
matter,  if  pelvic  neuralgia  still  persists,  it  will  be  found  to  depend  upon 
anemia,  depressing  causes  which  affect  the  nervous  system,  or,  possibly,  upon 
malarial  infection.  Treatment  appropriate  for  this  condition  will  result  in 
the  gradual  relief  of  the  neuralgia. 

Facial  neuralgia  with  hemi(!rania  is  often  observed  in  pregnant  patients  in 
whom  no  exciting  cause  in  bad  teeth  can  be  discovered.  Many  attacks  follow 
exposure  to  cold  or  to  damp ;  others  are  caused  by  loss  of  sleep.  The  pain  is 
often  paroxysmal,  and  frecpiently  an  irregular  interval  may  be  observed  between 
tiie  attacks ;  thus,  some  patients  will  sleep  during  the  night,  but  are  seized 
with  violent  pain  in  the  early  morning ;  others  suffer  more  in  the  afternoon 
or  at  night.  The  face  and  scalp  are  often  tender  to  pressure  in  these  cases, 
and  tlie  conjunctivae  on  the  affected  side  are  frequently  reddened. 

Wl'.ere  painful  spots  can  be  isolated  local  treatment  may  be  instituted  by 
painting  the  part  with  menthol  or  with  iodin,  or  by  spraying  it  with  ether  or 
with  some  other  anesthetic.  The  constitutional  treatment  of  this  condition 
consists  in  thoroughly  emptying  the  intestine  to  relieve  the  patient  of  fecal 
poison  which  may  be  depressing  the  nervous  system.  Absolute  rest  in  a 
darkened  warm  room  of  ecpiable  temperature,  systematic  feeding  of  easily- 
digested  food,  and  tonics — irouj  arsenous  acid,  and  quinin — and,  if  the  pain  be 
severe,  alcohol,  at  regular  intervals  are  to  be  recommended.  When  sleep  is 
impossible  by  reason  of  pain,  jihenacetin  with  caffeine  and  sodium  bicarbonate 
is  often  used  to  advantage.  If  pelvic  neuralgia  be  present,  phenacetin  may 
be  given  by  rectal  suppositories  of  10  grains  each.  Morphia  and  atropia 
mav  be  given  hypodermatically  when  other  remedies  fail.  Chloral  and  the 
bromids  are  of  comparatively  little  value  and  often  disappoint  in  these  cases. 
It  should  be  explained  to  the  ])atient  that  the  loss  opium  she  takes  the  sooner 
she  will  recover ;  and  where  her  suffering  is  n(»t  severe  ever}'  effort  should 
be  made  to  imjirove  her  general  condition  by  tonic  treatment  rather  than  by 
narcotizing  her  with  opium. 

Salivation. — Derangement  of  various  secretory  nerves  is  sometimes  observed 
during  gestation;  the  salivation  of  pregnancy  is  a  faniiliar  instance.  Hyperse- 
cretion of  tears  is  seen  in  patients  suffering  from  salivation,  as  shown  in  a  case 
reported  by  Xeidon.*'  So  abundant  was  the  secretion  as  to  keep  the  eyes  con- 
tinually suffused  and  to  cause  an  eczematous  eruption  of  the  lids.  The  tear 
secretion  was  weakly  alkaline,  the  eyes  W'Cre  normal,  and  no  appreciable  cause 
was  found  for  the  condition  ]iresent.  The  patient  was  finally  cured  by  a  5  jier 
cent,  cocain  solution.  Salivation  of  pregnancy  is  a  most  obstinate  and  annoy- 
ing condition  often  re])eated  in  subsequent  pregnancies  and  resisting  all  forms 
of  treatment.  It  is  without  apparent  cause,  as  a  rule  usually  affecting  women 
of  nervous  tem])eraraent,  especially  if  the  general  health  be  depressed.  Treat- 
ment is  usually  palliative  only,  and  it  should  consist  in  the  free  administration 
of  tonics  and  in  those  milder  sedatives  which  interrupt  least  of  all  the  patient's 


THE   PATHOLOGY   OF  PREGNANCY. 


211 


imti'itioii.  The  bromids  have  boeii  given  freely,  both  by  the  stomach  ami  by 
spray  applied  to  the  interior  of  the  mouth.  Cocain  may  also  be  sprayed  into 
the  mouth,  the  effort  being  to  cocainize  the  mucous  membrane  near  the  opening 
of  Steno's  duct.  Tliis  condition  rarely  if  ever  becomes  serious.  Another  form 
of  al)normal  secretion  occurring  in  pregnancy  is  that  of  excessive  perspiration, 
wliich  is  commonly  met  with  in  poorly-nourished  and  neurasthenic  cases. 

Herpes  is  found  among  the  interesting  disorders  of  the  nervous  system  to 
which  tlie  pregnant  patient  is  liable.  Fournier"'  rejwrts  a  case  in  which 
the  lesions  were  distributed  irregularly  over  the  body,  especially  upon  the 
i'orearms,  the  anterior  part  of  the  thorax  and  feet,  and  the  abdomen. 
Accompanying  these  lesions  were  patches  of  nnlness,  in  some  instances 
these  areas  being  covered  with  biillse  as  large  as  an  olive  or  a  small  (jherry. 
Tiie  usual  j)eriod  of  pregnancy  at  which  this  disorder  occurs  is  between  the 
liiird  and  the  fifth  month,  occasionally  i;s  late  as  the  sixth  or  the  eighth 
month.  In  other  cases,  more  rare,  the  lesion  does  not  show  itself  until  the 
second  or  the  third  day  of  the  puerperal  period.  There  is  a  strong  tendency 
in  this  disorder  to  recur  during  subsequent  pregnancies,  and  instances  are 
given  where  the  patient  has  suffered  from  herpes  during  five  successive  gesta- 
tions. Although  intolerable  it(;hing  and  burning  accompany  herpes  during 
prcirn^ncy,  yet  the  general  health  remains  remarkably  unaff>"c!ed.  The  occur- 
rence of  gestation  is  not  influenced  by  this  complication,  anJ  patients  usually 
recover  promptly  when  gestation  terminates.  Herpes  in  the  puerperal  period 
is  often  characterizetl  during  its  onset  by  fever,  persj)iration,  and  general 
pruritus.  In  from  twenty  to  twenty-four  hours  after  these  symptoms  occur 
the  characteristic  eruption  appears.  The  remarkable  tendency  of  herpes  to 
recu:'  is  illustrated  by  the  cases  of  Cottle,  Wilson,  Gale,  and  Hardy,  the  last 
of  whom  describes  a  patient  who  suffered  in  nine  out  of  ten  pregnancies 
with  this  disorder. 

There  is  no  evidence  that  the  fetus  and  its  appendages  are  affected  in  this 
disease.  Occasionally  mixed  forms  of  the  eruj)tion,  are  seen,  some  of  them 
resembling  pemphigus  and  others  assuming  a  sy])hiloid  type.  It  is  noticed 
that  young  women  are  oftener  attacked   by  herpes  than  those  older. 

The  treabnent  of  herjies  consists,  first,  in  j)roperly  regulating  the  functions 
of  the  body.  Herpetic  patients  are  generally  depressed  or  in  some  manner  are 
tlcfioient  in  nervous  energy,  and  they  will  be  found  to  improve  under  the  pro- 
iongcd  use  of  arsenic,  hypophosphites,  and  iron.  The  great  number  of  reme- 
dies which  have  been  administered  as  specifics  in  this  disorder,  and  their  failure 
to  influence  the  course  of  the  disease,  show  that  it  is  not  amenable  to  specific 
treatment.  When  the  ern])tion  first  begins  borated  vaselin,  glycerol  of 
starch,  and  lime-water  and  oil  will  be  found  soothing  a])plications.  When 
tlic  eruption  is  fully  developed  bismuth  and  starch  and  starch-and-talcum 
powder  are  useful  dressings.  For  the  intolerable  itching,  applications  of 
carbolic  acid,  hydrate  of  chloral,  menthol,  or  corrosive  sublimate  in  solution 
have  been  found  useful.  Wlicn  a  large  portion  of  the  body  is  involved, 
baths  containing  starch,  gelatin,  or  bran  may  be  employed. 


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AM  Kit  [CAN   TKXT-BOOK   OF   OliSTKriilCS. 


While  the  progiiortis  of  herpes  eoiiiplicatiug  gestation  is  f'avornhlo  ho  fur  as 
the  coiitimiance  of  pregiuuicy  is  eo'icenied,  still  this  coinplieation  exercises  a 
most  depressing  iiiHiienee,  and  r,my  lead  to  eoinplieated  labor  by  reason  of 
oxhuustion.  Care  shonld  be  tiiken,  then,  to  snpport  the  general  strength  of 
the  patient  in  every  possible  way,  to  promote  her  nntrition  by  a  earefidly- 
ordere<l  diet  an<l  tiie  persistent  nse  of  tonics,  and  to  see  to  it  that  during 
lal)or  her  strength  is  conserved  in  every  possible  mumier. 

Sudden  death  duriner  pregnancy  may  rcsnit  from  the  entrance  of  flnid 
or  of  air  into  the  enlarged  sinnses  of  the  nterns.  Ilektoen  ""•  narrates  the  ease 
of  a  patient  who,  while  taking  a  vaginal  injwtion,  fell  dead  :  it  was  fonnd  that 
she  had  been  nsing  a  Davidson  syringe,  i  he  autopsy  showed  the  tissues  of 
the  uterus  fdled  with  air  and  blood  and  the  placenta  partially  detached,  while 
the  riirht  ventricle  contained  frothv  blood,  but  no  clot.  Air  was  found  in 
the  subserous  vessels  and  also  in  the  vessels  of  the  pericardial  and  pleural 
cavities. 

The  condition  of  pregnancy  seems  to  predispose  to  sudden  heart  and 
respiratory  failure.  This  is  especially  the  case  where  nausea  and  vomiting 
have  been  well  markcil  during  the  first  months  of  pregnancy.  McCabe'"' 
reports  the  case  of  a  jjatient  wlio  desired  relief  from  obstinate  nausea  and 
vomiting,  and  to  whom  morphia  had  been  given  by  hypodermatic  injection. 
As  it  was  impossii)le  for  the  attending  physician  to  see  her  at  short  intervals, 
a  hypodermatic  injection  was  prepared  by  him  and  left  for  administration  during 
his  absence.  She  seemed  relieved,  but  a  few  days  after,  on  attempting  to 
move,  a  sudden  weakness  developed,  terminating  almost  immediately  in  death. 

The  same  observer  describes  tiio  case  of  a  young  woman  who  during  her 
second  jtregnancy  was  nuich  annoyed  by  intense  pain  over  the  uterus  and 
across  the  lower  part  of  the  back,  simidating  after-pains.  A  hypodermatic 
injection  of  ^  grain  of  morphia  was  given,  which  made  the  patient  easy.  It 
was  found  that  she  had  miscarried  the  night  previous  at  about  two  and  a  half 
months  of  gestation.  There  was  no  sign  of  puerperal  septit^  intwjtion,  but  a 
rapid  and  weak  heart  caused  the  patient  much  distress.  During  the  night 
following  she  suddenly  sprang  from  her  bed,  and  almost  immediately  expired. 

As  in  both  the  above  cases  morphia  had  been  given  by  hypodermatic  injec- 
tion, the  relation  borne  by  this  drug  to  the  phenomena  observed  is  of  interest. 
It  would  seem  from  these  cases  that  morphia  hypodermatically  is  a  dangerous 
drug  to  be  administered  to  ]>regnant  patients. 

Cerebral  thrombosis  and  hemorrhage  during  pregnancy  are  illu 
trated  in  a  case  reported  by  Horroeks,  '"^  in  which  a  patient  in  her  second  preg- 
nancy developed  stupor  and  drowsiness  with  rectal  and  vesical  incontinence 
during  the  last  month  of  gestation.  The  pupils  were  etpial  and  symptoms  of 
palsy  were  wanting.  The  urine  contained  neither  all)umin  nor  sugar.  The 
heart  seemed  normal,  and  labor  subsequently  came  on  spontaneosly.  Con- 
sciousness, however,  was  obscured,  and  derangement  in  the  motor  a]>paratus 
of  the  brain  and  nervous  system  was  evidently  present.  After  death  many 
of  the  cerebral  veins  were  found  occludeil  by  thrombi.     There  was  also  recent 


THE   PATIIOLOCY   OF  PliKaXANCV. 


21. 'J 


t'xtravasutioii  of  bloixl  al(»iij;  the  intornul  oapsiilo.  Cystitis  and  supimrativc 
iicpliritis  on  one  Hide  oxistod. 

Menineritis  duringr  preernancy  is  almost  invariably  fatal  to  tlio  niotluT, 
and  fro(|iit'ntly  to  her  child.  Cliund)rc'Iont ""  describes  7  cases  of  aente 
meningitis  dnring  pregnancy,  in  six  of  which  labor  was  terminated  artificially 
with  the  birth  of  a  living  child.  In  one  case  birth  was  spontaneous  before  the 
mother's  death.  In  view  of  the  grave  natiu'e  of  this  coniplication  labor 
should  be  indnceil  in  cases  of  meningitis  during  pregnancy  where  the  fetus  is 
viable,  in  the  hope  of  saving  the  life  of  the  infant. 

Spinal  Irritation  complicatingr  Pregnancy  and  Labor. — The  hyperemic 
and  hyperesthetic  condition  eharaeteri/ing  pregnancy  exaggerates  all  forms  of 
functional  nervous  disturbances  or  jiathological  conditions  in  the  nervous  sys- 
tem. Spinal  irritation  is  not  infrc(iuently  observed,  and  it  is  well  illustratetl 
by  cases  reported  by  Napier.""  The  symptoms  w(n'e  great  tenderness  on  pres- 
siu'c  al(»ng  the  spines  of  the  vertebrie,  and  iji  one  patient  fatal  albuminuria  grad- 
ually developed.  These  cases  followed  an  epidemic  of  diphtheria  which  pre- 
vailed four  or  five  years  prior  to  these  observations :  the  poison  of  diphtheria 
seemed  to  lose  its  activity  by  attenuation.  Cases  of  cerebro-spinal  meningitis 
(leveloi)ed  as  the  epidemic  died  away,  and  last  of  all  occurred  the  eases  of 
pregnancy  complicated  by  great  tenderness  along  the  spine,  which  tenderness 
seriously  impaired  the  patients'  strength  and  hindered  convalescence.  A  toxic 
condition  following  widespread  diffusion  of  diphtheritic  poisim  should  be  con- 
sidered as  the  cause  of  these  cases,  but  the  phenomena  of  spinal  irritation  were 
predominant. 

Maternal  impressions  are  familiar  to  all  obstetricians  of  extensive  reading 
and  experience.  It  is  not  the  writer's  purpose  to  consiiler  the  matter  in  detail, 
but  simply  to  draw  attention  to  the  fact  that  a  pregnant  patient  may  undoubt- 
edly so  profoundly  be  influenced  by  nervous  shock  as  very  markedly  to  alter 
the  development,  the  shape,  the  size,  and  the  appearance  of  her  offspring.  In 
recent  literature  on  the  subject  Mackay  ""  describes  five  cases  in  which  fright 
produced  distinct  birth-marks  nptm  the  fetus.  The  writer  may  add  a  case 
under  his  personal  observation  in  which  a  ])regnant  woman  was  informed 
that  an  intimate  friend  had  been  suddenlv  killed  bv  being  thrown  from  his 
'  trse :  the  immediate  cause  of  death  was  fracture  of  the  skull,  produced  by 
the  corner  of  a  dray  against  which  the  rider  was  thrown.  The  mother  was 
]);  f'ouudly  impressed  by  the  circumstance,  which  was  minutely  described  to 
liif  l)y  an  eye-witness.  Her  child  at  birth  i)resented  a  red  and  sensitive  area 
upon  the  scalp  exactly  corresponding  in  location  with  the  situation  of  the  fatal 
injury  in  the  rider.  The  child  is  now  an  adult  woman,  and  this  area  upon  the 
s('al[>  remains     d  and  sensitive  to  pressure,  and  is  almost  devoid  of  hair. 

Space  notnl  not  be  taken  to  discuss  the  question  of  maternal  impressions. 
There  is  certainly  more  than  coincidence  in  the  fact  of  fright  and  shock  and 
the  subsequent  malformation  or  marking  of  the  fetus.  The  well-known 
" elephant-m;;  '  "  of  England,  and  the  "turtle-man"  exhibited  in  the  United 
States,  with  other  instances,  are  familiar  evidences  of  this  statement. 


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Chorea  during  Pregnancy. — There  is  no  disorder  of  the  nervous  system 
so  nianilestly  aggravated  by  pregnancy  as  eliorea.  The  physiological  plethora 
characteristic  of  normal  pregnancy  seems  to  exaggerate  the  functional  activity 
of  the  nervous  system,  and  it  results  in  marked  exacerbation  of  all  pathologi- 
cal phenomena.  The  chara(;teristic  choreic  jnovements  occasionally  extend 
even  to  the  uterus,  as  in  a  case  reported  by  Braxton  Hicks.*""  The  patient 
was  a  young  woman  who  had  suffered  from  chorea  in  childhood  :  the  uterus, 
which  could  be  outlined  distinctly  in  the  abdomen,  presented  marked  altera- 
tions of  form,  accompanied  by  very  evident  choreic  contractions.  These 
uterine  movements  became  less  violent  as  the  patient  was  treated  by  rest  in 
bed  and  by  the  administration  of  arsenic :  she  was  subscfjuently  delivered  in 
normal  labor,  making  a  good  recovery. 

In  an  elaborate  essay  upon  the  subject  McCann'"^  divides  cases  of  chorea 
occurring  in  pregnant  patients  into  cases  of  true  chorea,  of  hysterical  chorea, 
and  a  mixed  form.  It  is  rare  to  find  chorea  occurring  in  patients  after  the 
eighteenth  year,  except  during  pregnancy.  Primigravidte  are  more  susceptible 
to  chorea  than  are  multigravida;,  especially  to  true  chorea.  In  ])atients  free 
from  rhemnatism  it  is  rare  for  true  chorea  to  occur  in  any  but  the  first  preg- 
nancy. When  the  exaggerated  reflex  condition  which  occurs  in  chorea  is 
called  to  mind,  it  is  natural  to  expect  that  the  great  majority  of  cases  will 
occur  in  the  third  and  fourth  months  of  gestation.  The  reason  for  this  occur- 
rence seems  to  be  the  irritating  effect  upon  the  nervous  system  of  fetal  move- 
ments which  begin  to  be  felt  at  about  that  time.  So  far  as  the  etiology  of 
chorea  in  pregnancy  is  concerned,  acute  rheumatism  is  the  n^  st  immediate 
cause,  and  next  comes  an  hereditary  history  of  distinct  rheumatic  taint. 
Epilepsy  and  other  disorders  of  the  nervous  system  predispose  to  chorea 
during  pregnancy.  Fright,  emotion,  and  profound  anemia  also  favor  its 
occurrence.  For  the  actual  outbreak  of  chorea,  however,  there  must  be  present 
an  hysterical  predisposition  to  nervous  excitability,  a  depreciated  condition  of 
the  blood,  and  an  actively  exciting  cause,  which  is  usually  found  in  fetal 
movements.  Post-mortem  examinations  of  patients  who  have  died  from 
chorea  during  pregnancy  show  that  in  severe  cases  the  motor  cortex,  the  intel- 
lectual centres,  and  tiie  spinal  cord  are  all  involved.  In  mild  cases  the  motor 
cortex  only  is  imj)licated,  and  the  spinal  cord  least  often. 

The  effect  which  chorea  produces  upon  ])regnancy  depends  entirely  upon  its 
severity.  In  mild  cases  am(>nable  to  treatment  the  ])regnancy  is  not  interrupted, 
while  in  severe  cases  abortion  occurs,  sometimes  followed  by  fatal  termination 
from  coma  and  high  temperature.  Severe  cases  of  chorea  which  do  not  result 
fatally  may  end  in  mania  persisting  for  a  considerable  time.  Paralysis  and 
delirium  are  also  occasionally  observed  to  follow  this  disorder.  If  the  preg- 
nancy is  at  term  when  the  mother  is  attacked  by  chorea,  the  risk  to  the  child 
is  but  very  little,  if  any,  increased.  The  earlier  in  pregnancy  that  chorea 
occurs,  the  great(>r  is  the  danger  to  the  existence  of  the  fetus.  Although  the 
physician  natiu'ally  hopes  that  choreic  movements  will  cease  after  delivery, 
.such  is  rarely  the  case ;  they  die  away  very  gradually,  and  they  have  been 


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observed  to  continue  for  five  months  after  labor,  Pregnancy  predisposes 
greatly  to  the  recnrrence  of  chorea,  so  tliat  a  girl  who  has  been  choreic  iu 
early  life  will  almost  snrely  again  become  i-horeic  should  pregnancy  occur. 
As  in  the  non-pregnant,  chorea  during  pregnancy  is  sometimes  more  severe 
than  a  former  attack,  and,  again,  ma\  be  less  violent.  Chorea  during  child- 
hood is  very  apt  to  reappear  in  subsequent  pregnancies  in  the  same  indi- 
vidual. It  is  also  interesting  to  note  that  the  younger  the  patient,  the  greater 
is  her  liability  to  u  recurrence  of  chorea. 

The  great  liability  of  pregnant  patients  to  hysterical  manifestations  restdts 
to  a  very  per|)lexing  degree  in  introducing  this  element  into  cases  of  chorea 
during  pregnancy.  The  ditt'erential  diagnosis  is  best  made  from  tiie  character 
of  the  movements,  which  in  hysteria  are  more  sudden  and  occasionally  are 
riiythmical  in  character.  Impairment  of  sensibility  is  noted  as  a  prominent 
symptom  in  cases  possessing  a  strong  hysterical  clement.  A  history  of  pre- 
vious hysteria  is  sometimes  obtainable.  In  making  a  diiferential  diagnosis 
imitation  movements  must  be  borne  in  mind,  as  they  an;  sometimes  calculated 
to  deceive  skilled  observers.  As  regards  the  jxirtion  of  the  body  most  often 
iilVccted  by  choreic  movements,  (rowers"**  out  of  64  cases  found  eleven  in 
which  the  right  sitle  oidy  wiss  alfcctcd,  and  thirteen  in  which  the  lefl  side 
alone  was  artwitcxi.  During  ])regnancy  chorea  is  most  often  bilateral,  the 
reason  for  this  being  that  as  the  disease  is  more  severe  than  in  the  non-preg- 
nant, its  manifestations  are  more  widespread.  It  is  usually  found  in  these 
cases  that  in  the  begiiming  the  movements  were  unilateral,  afterward  becoming 
biiatcM'al  as  the  disorder  increased  in  severity.  The  physiognomy  of  the  l)reg- 
nant  patient  suffering  from  chorea  is  characteristic,  being  listless  and  vacant  iu 
expression,  and  when  the  facial  muscles  are  affected  peculiar  grimaces  result- 
intr.  General  relaxation  of  the  muscular  system  often  occurs  earlv  in  the  dis- 
ease,  and  in  the  later  stages  mental  apathy  is  not  infrequent.  Dilated  pupils 
are  often  present,  and  are  thought  to  depejid  upon  a  generally  relaxed  con- 
dition of  the  muscular  system.  In  a  large  number  of  eases  the  face  is 
alfcctcd  ;  in  a  few,  however,  it  is  r  >t,  Speech  and  the  nKn'cments  of  the  tongue 
iiecome  involved  in  the  severe  case%  Sighing  and  irregular  respiration  have 
been  described  by  Iloniberg  and  others.  It  is  interesting  to  note  that  chorea 
mure  severely  involves  the  memory  of  ]>regnant  patients  than  of  non-preg- 
nant. The  cessation  of  choreic  movements  is  promptly  followed  by  improve- 
ment in  memory.  Patient.-'  who  become  maniacal  after  chorea  often  give 
utterance  to  a  ptrnliar  cry  described  by  Ilond)erg  and  others.  The  analogy 
iK'twceu  the  cry  of  chorea  and  that  of  the  patient  about  to  be  seized  by  an 
(■|)il(  ptie  ]>aroxysm  is  interesting.  The  prognosis  of  mania  or  delusions  co:m- 
plicating  chorea  in  pregnancy  is  often  unfavorable;  shoidd  the  patient  not  have 
chorea  after  her  delivery,  she  may  be  found  the  victim  of  delusions  or  of  chronic 
mental  apathy. 

Sijmjttomx  of  dmira  especially  referable  to  the  pregiiant  state  are,  first  in 
iinportunce,  tluwc  produced  by  the  (|uickening  of  th(>  fetus.  The  ])resenee  of 
II  nervous  temperament  in  a  choreic  patient,  or  its  absence,  will  (h'tcrmine  the 


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severity  of  tlie  symptoms.  As  regards  the  influence  of  chorea  upon  labor, 
choreic  movements  often  cease  when  labor-pains  set  in ;  such  movements  gen- 
erally die  away  during  the  stage  of  uterine  contraction,  often  to  recur  so  soon  as 
the  labor-pain  is  over.  The  labors  themselves  are  often  normal,  and  in  many 
cases  during  the  pains,  especially  when  the  patient  endeavors  to  assist  them, 
the  choreic  movements  become  more  than  usually  pronounced.  While  there 
is  a  temporary  lull  in  the  choreic  movements  after  the  birth  of  the  child,  the 
effort  to  expel  the  placenta  is  usually  followed  by  their  exacerbation.  It  occa- 
sionally happens  that  choreic  movements  become  more  than  usually  increased 
during  the  puerperal  state  about  the  third  or  the  fourth  day.  The  irritation 
incident  to  the  formation  of  milk  has  been  cited  to  explain  this  fact.  Abdom- 
inal pain,  which  often  accompanies  movements  of  the  bowels  at  this  time,  is 
also  thought  to  cause  increased  choreic  movements.  Pressure  on  the  uterus 
and  the  abdomen  sometimes  increases  choreic  movements  during  the  puerperal 
state.  The  irritation  of  luirsing  their  children  has  aggravated  chorea  in  some 
patients,  the  convulsions  becoming  so  violent  that  the  nipple  was  jerked  out 
of  the  child's  mouth. 

In  choreic  cases  endocarditis  is  sometimes  observed  as  a  complication,  and 
it  makes  the  prognosis  much  more  serious.  Hemic  murmurs  dependent  upon 
anemia  are  exceedingly  common  in  these  patients.  An  examination  of  the  urine 
shows  an  excess  of  urea  and  phosphates,  probably  the  result  of  the  increased 
muscular  activity  of  the  convulsive  seizures.  In  diagnosis  the  chief  difficulty 
arises  in  distinguishing  the  true  chorea  of  pregnancy  from  the  hysterical  and 
mixed  forms.  Attention  nuiv  again  be  called  to  the  fact  that  in  true  chorea 
movements  are  irregular  and  spasmodic,  and  are  increased  by  motion  and  vol- 
untary effort,  especially  if  such  effort  be  sustained.  In  the  hysterical  form 
movements  are  sudden,  isolated,  and  often  rhythmical  especially  in  the  iugers. 
Hysterical  chorea  never  becomes  so  intense  as  greatly  to  exhaust  the  patient. 
Delirium,  acute  mania,  and  delusions  may  complicate  chorea  during  pregnancy, 
as  illustrated  in  the  eases  described  by  Jones;"**  one  of  his  cases  was  com- 
])licated  by  sejitic  infection  following  jiremature  birth  of  a  decomposed  fetus 
at  seven  months.  In  another  case  ])aralysis  of  the  left  arm  occurred  as  a  com- 
})lioation.  Children  born  of  choreic  mothers  sometimes  show  marked  tendency 
to  convulsive  movements.  line""  describes  two  cases  in  which  the  chorea  of 
the  mother  reapj)eared  in  conv  ilsive  movements  of  the  child.  Maniacal 
cliorea  is  to  l)e  distinguished  from  the  mania  of  ])regnancy  and  the  jHier- 
])eral  state  by  a  jirevious  history  of  choreiform  movements.  In  defaidt 
of  such  historv  an  <>xaet  diajjuosis  is  often  difficult.  In  maniacal  chorea  the 
patients  are  less  sullen  and  are  more  garrulous  than  in  true  mania.  In  esti- 
mating the  dangers  of  chorea  in  ])regnan(y  the  violence  of  choreic  movements, 
the  amount  of  slc(>p  lost  in  conscciueuce,  and  the  intercurrent  com])lications 
must  all  be  considered.  The  jirognosis  of  maniacal  chorea  is  usually  good  as 
regards  the  menial  condition.  Occasionally  mental  defect  persists  for  a  long 
time  after  labor,  and  it  may  ultimately  become  permanent.  Sejjticeniia  and 
])yemia  very  seriously  complicate  such  cases. 


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THE  PATHOLOGY   OF  PREGNANCY. 


217 


So  fur  as  treatment  is  concerned,  sedatives  and  narcotics  liave  been  used 
extensively  with  but  indifferent  success.  The  indications  for  treatment  are  to 
secure  bodily  and  mental  rest,  to  procure  sleep,  and  to  bring  about  an  improved 
condition  of  the  patient's  blood  and  nutrition.  It  is  often  necessary  to  protect 
the  patient's  skin  from  friction  caused  by  the  severity  of  the  movements.  A 
profoundly  depressed  mind  and  nervous  sys^omcall  for  an  entire  change  of  sur- 
roundings. In  the  medicatitm  of  these  cases  arsenic,  intelligent  feeding,  and 
the  maintenance  of  proper  digestion  are  of  the  greatest  importance.  Rest  in 
bed,  freetlom  from  annoyance  and  excitement,  bathing,  and  gentle  friction  are 
also  of  value.  To  procure  sleep,  chloral  in  doses  of  30  to  40  grains  has  given 
good  results.  Gairdner '"  relates  the  case  of  a  girl,  eight  years  of  age,  who 
took  by  mistake  60  instead  of  20  grains  of  chloral  to  procure  sleep ;  she 
recovered  from  the  drug,  and  was  permanently  cured  of  her  chorea  by  the 
dose  she  had  taken.  Trousseau  and  Gowers  have  used  in  these  eases  strychnia, 
'  pushed  to  a  ])hysiological  effect.  Sodium  salicylate,  wet  packing,  and  the  appli- 
cation of  cold  to  the  spine  have  also  been  recommended.  So  far  as  the  obstet- 
ric treatment  of  these  cases  goes,  the  obstetrician  must  guard  against  hemor- 
rhage, to  which  the  anemia  so  generally  present  predisposes.  Violent  choreic 
movements  also  render  it  difficult  to  control  the  uterus  during  the  third  stage 
of  labor.  The  debilitated  condition  of  the  patients  exposes  them  to  additional 
risk  of  septic  infection.  When  chorea  persists  after  delivery  nursing  should 
be  prohibite<l,  as  it  undoubtedly  tends  to  aggravate  the  condition.  If  the 
chorea  be  slight  or  of  the  hysterical  form,  the  pregnancy  should  not  l)e  inter- 
rupted. In  all  severe  cases,  however,  labor  should  be  induced.  The  follow- 
ing conditions  may  be  cited  as  calling  decidedly  for  the  interruption  of  prog- 
nancy  in  a  choreic  ])regnant  patient :  tlireatened  exhaustion  on  the  part  of  the 
mother  from  the  intensity  of  the  movements  and  a  deficiency  of  sleep ;  when 
mania  or  fixed  and  dangerous  delusions  are  present ;  when  a  grave  physical 
complication,  such  as  endocarditis,  increases  the  gravity  of  the  case. 

Pantzer  "^  reports  the  case  of  a  woman,  aged  twenty-six  years,  pregnant  for 
the  fifth  time  and  suffering  severely  from  chorea.  In  a  previous  pregnancy 
her  movements  had  been  so  excessive  that  labor  was  induced,  after  which 
choreic  movements  persisted  for  several  weeks.  During  the  pregnancy  in 
question  she  was  obliged  to  enter  a  hospital.  Although  easily  excited,  she 
was  readily  controlled  by  morphia,  and  no  grave  condition  was  found  at  con- 
finement threatening  the  interest  of  iier  cliild  or  herself.  The  usual  treatment 
for  chorea  was  administered,  with  the  added  jirecaution  of  avoiding  large  doses 
of  bromid,  which  tend  to  favor  hemorrhage  after  labor.  The  patient's  labor 
was  normal,  and  she  made  a  good  recovery. 

Catalepsy  is  occasionally  observed  during  the  ]>regnaut  state,  as  in  a  ease 
recently  reported  by  Shoot  of  Ijunwarden."*  The  ])atient  was  a  robust 
woman,  aged  forty-four,  who  had  borne  eleven  children  ;  in  youth  slie  iiad 
suilered  from  typhus,  and  after  recovery  became  subject  to  fainting  fits,  but 
throughout  her  marrie<l  life  she  remained  strong  and  well.  Tiiere  was  no 
history  of  a  neurosis  in  her  family.     During  the  seventli  mouth  of  her  twelfth 


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prognancv  she  was  seized  with  cataleptic  fits  following  the  loss  of  a  child : 
she  was  found  stiff'  and  motionless  by  the  attending  physician.  The  forearm 
could  be  raisetl  and  bent  with  some  force,  and  reniainetl  in  the  same  position 
for  about  ten  minutes,  after  which  it  slowly  fell.  The  lower  extremities 
behavcu  in  a  similar  manner.  Consciousness  was  lost.  The  pulse  was  64, 
full  and  regular,  the  temperature  and  respiration  normal.  The  pupils  were 
somewhat  dilated,  but  reacted  to  light.  On  inhaling  chloroform  the  rigidity 
of  the  muscles  ilisapjvaicd,  and  the  patient  seemed  to  sleep  calndy  for  hours. 
On  awakening  the  patient  remen)bered  nothing  that  had  taken  place.  The 
fetal  heart-sounds,  previously  audible,  were  lost,  and  were  not  heard  until 
fourteen  days  before  labor.  No  albumin  was  found  in  the  urine  upon  exam- 
ination. Cataleptic  fits  occurred  three  or  four  tinies  daily,  occasionally  with 
an  interval  of  several  days.  Atropni  gave  the  patient  a  week's  freedom ; 
the  disorder  contimied,  however,  to  term,  when  she  was  safely  delivered  of  an 
apparently  healthy  boy.  On  the  fifth  day  after  labor  an  attack  recurred 
while  the  patient  was  nursing  her  child  ;  two  days  later  the  second  took  place, 
which  was  the  last.  Shortly  after  the  first  attack  her  child,  who  had  been 
weaned  because  of  the  cataleptic  complication,  was  seized  with  dysphagia. 
In  the  evening  of  the  same  day  the  child  had  a  cataleptic  fit,  the  symptoms 
being  precisely  those  of  the  mother.  The  rigidity  which  deveh)ped  relaxed 
during  a  warm  bath,  but  soon  afterward  returned.  Tonic  cataleptic  convul- 
sions recurred,  and  the  child  died  after  two  days'  duration  of  the  cataleptic 
fits. 

Pregnant  patients  are  exposed  to  those  poisonings  of  the  nervous  system 
from  lead,  arsenic,  dyestuffs,  tobacco,  and  other  substivnees  met  with  in  the 
arts,  and  which  commonly  act  by  producing,  among  other  complications, 
multiple  neuritis.  In  the  absence  of  specific  poisons  multiple  neuritis  is 
occasionally  observed,  as  describal  by  Sulowieff'."^  His  patient  was  three 
months  advanced  in  pregnancy  and  snifering  from  nausea  and  vomiting.  No 
cause  for  the  latter  complication  could  be  found  in  the  condition  of  the  urine 
or  of  the  genital  tract.  Her  nervous  symptoms,  however,  were  peculiar  and 
pointed  to  multiple  neuritis,  especially  well  marked  in  the  lower  extremities 
and  upon  the  back  and  neck.  The  organs  of  the  special  senses  were  in  a 
very  hyjieresthetic  condition  ;  the  blood  was  normal.  Her  history  included 
an  attack  of  scarlatina  in  childhood,  and  also  hysteria.  She  was  nourished, 
when  necessary,  by  rectal  injections,  and  was  treated  by  faradization  and 
hypnotism.  A  very  careful  study  of  her  nervous  system  showed  polyneuritis 
in  very  widesj)r('a(l  degree.  A  post-mortem  examination  showed  all  the 
viscera  free  from  marked  i)athological  change.  The  nerve-trunks,  however, 
throughout  the  body  gave  evidence  of  varying  degrees  of  degeneration  ;  this 
was  especially  true  of  the  jihrenic  nerves  :  it  had  been  noticed  during  life  that 
the  action  of  the  patient's  diaphragm  was  at  times  very  deficient. 

Diabetes. — Among  the  rare  disorders  ol'  pregnancy  in  which  the  nervous 
system  and  the  assimilation  of  the  patient  seem  equally  affected  may  be  con- 
sidered diabetes.     Its  rarity  may  be  inferred  fnim  the  statement  of  Griesinger, 


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THE  PATHOLOGY   OF  PREGNANCY. 


219 


who  found,  of  53  cases  among  women,  two  only  during  pregnancy.  In  Frerichs' 
large  experience,  in  386  cases  there  were  104  among  women,  and  only  one  of 
these  had  diabetes  during  pregnancy.  Matthews  Duncan  "''  reports  the  ease  of 
a  multigravida  who  had  a  suspicion  of  diabetes  for  a  short  time  in  a  former 
pregnancy.  At  the  eighth  month  her  fetus  perished  in  utero.  Excessive 
amniotic  liquid  was  present.  The  patient  collapsed  before  labor  began,  and 
perished  shortly  after.  During  her  first  pregnancy  she  had  suffered  from  great 
thirst,  and  passed  enormous  quantities  of  urine  during  the  first  few  days  after 
delivery.  During  the  pregnancy  which  ended  fatally  her  urine  was  examined 
two  months  before  her  confinement,  and  nothing  abnormal  was  detected.  It  was 
excessive  in  quantity.  The  patient's  tongue  was  dry  and  brown,  her  breath 
had  a  ixjculiar  sweetish  odor,  and  purplish  areas  were  detected  upon  the  skin. 
Ilcr  temperature  was  normal,  but  she  suffered  greatly  from  a  sensation  of 
oppression.  Reid  reports  a  case  very  similar  to  Duncan's.  The  amniotic 
liquid  was  very  abundant,  and  it  possessed  an  abnormally  great  amount  of 
albumin.  The  child  was  large  and  well  developed,  but  dead  before  labor. 
Xewnmn  saw  diabetes  in  two  pregnancies  in  the  same  |)atient,  the  mother 
finally  perishing  of  the  disease.  liccorchi  observed  diabetes  in  an  infant  born 
of  a  diabetic  mother.  Williams  reports  a  case,  with  autopsy,  in  which  the 
liver  and  kidneys  were  found  granular  and  in  pale  cloudy  swelling.  In 
Husband's  case  the  liquor  amnii  was  saccharine.  Bennewitz  and  Winckel 
also  rejjort  cases.  In  Duncan's  case  an  examination  of  the  eyes  revealed 
a  large  pear-shaped  clot  in  the  central  spot  of  the  retina.  The  patient  was 
suddenly  taken  with  intense  ]>ain  in  the  right  side  of  the  abdomen  in  the  fifth 
month  of  pregnancy.  Labor  was  induced,  but  the  child  was  dead  and  decom- 
posed. Tlic  patient  died,  and  no  cause  for  the  fatal  issue  could  be  found  on 
post-mortem  examination.  Frerichs  discovered  in  a  patient,  in  the  eighth 
month  of  pregnancy,  who  suffered  from  diabetes  and  who  perished  after 
delivery,  a  tumor  of  the  medulla  oblongata.  Diabetes  may  occur  during 
pregnancy  only,  being  absent  at  other  times.  It  may  cease  with  the  termi- 
nation of  pregnancy  and  may  recur  afterward.  The  ]>rognosis  fi)r  subsecjuent 
pregnancies  is  not  invariably  bad,  as  a  patient,  if  cured  of  diabetes,  may  in 
subsequent  pregnancy  escape  its  return.  The  existence  of  dialwtes  does  not 
militate  against  conception. 

A  possible  explanation  of  the  occurrence  of  diabetes  during  pregnancy 
is  found  in  the  results  of  the  study  made  by  Oddi  and  Vicarelli : ""  these 
observers  found  that  during  pregnancy  there  is  a  largely  increased  consiuiip- 
tion  of  hydrocarbons  derived  from  the  waste  of  nitrogenous  material  resulting 
from  fetal  nutrition  and  growth.  This  was  seen  by  analyzing  the  air  respired 
by  ))regnant  patients.  It  is  rational  to  conclude  tiiat  cases  in  which  this  met- 
abolism is  seriously  disturbed  may  furnish  the  complication  of  diabetes  diu'ing 
pregnancy. 

Diabetes  seems  almost  unifi)rmly  fatal  to  the  fetus,  and  that  at  a  compara- 
tively earlv  period  of  gestation.  The  amnion  seems  to  be  the  seat  of  tlic 
diabetic  process,  tind  dropsy  of  the  anuiion  or  the  formation  of  saccharine 


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matter  in  the  amniotic  liquid  is  the  condition  most  commonly  observed. 
Fry  "^  reports  the  case  of  a  patient  in  her  second  pregnancy  who  suffered 
from  great  thirst  and  who  was  easily  fatigued.  Examination  of  the  urine 
showetl  9  per  cent,  of  sugar,  which  was  reduced  by  treatment  to  5  per  cent. 
The  child  perished  during  pregnancy.  The  mother  died  five  days  after 
delivery. 

The  treatment  of  diabetes  complicating  ])regnancy  is  that  which  the  prac- 
tice of  medicine  enjoins  in  such  cases.  The  fact  that  the  life  of  the  fetus  is 
usually  lost  shoidd  lead  the  obstetrician  to  disregard  it,  and  to  empty  the  uterus 
promptly  if  the  diabetic  condition  is  pronounced.  The  prognosis  for  the 
mother,  should  she  survive  labor  or  abortion,  is  unfavorable,  as  the  diabetic 
condition  commonly  persists  and  ultimately  proves  fatal.  The  fact  that 
diabetes  occurs  in  pregnancy,  and  that  it  is  attended  with  peculiar  fatality, 
emphasizes  the  necessity  for  the  examination  of  the  urine  in  pregnant  ])atients. 
The  presence  of  more  than  a  trace  of  sugar  should  lead  to  a  thorough  examina- 
tion of  the  patient's  processes  of  assimilation,  when  it  may  be  possible  to  avert 
further  development  of  diabetes,  and  thus  save  the  lives  of  mother  and  child. 

T/ie  patholof/y  of  diabetes  mellitus  complicating  pregnancy  is  well  illus- 
tratetl  by  a  case  reported  by  Hehir."*  The  patient,  a  ro.ultigravida,  suifered 
from  diabetes  during  pregnancy,  and  gave  birth  to  a  dead  fetus  nearly  at  term. 
Amniotic  liquid  was  turbid,  having  a  heavy,  mawkish  odor,  and  being  very 
abundant.  An  infusion  was  made  from  the  epidermis  of  tho  fetus,  and  traces 
of  sugar  found  in  this  infusion.  The  liquor  amnii  was  also  examined,  and  in  it 
sugar  was  found.  The  patient  had  been  greatly  annoyed  during  her  pregnancy 
by  excessive  corpulence,  and  had  suffered  from  polyuria  and  diabetes  mellitus. 
Hehir  also  describes  a  case  of  diabetes  in  pregnancy  in  which  abortion  occurred 
at  the  fifth  month  ;  similar  phenomena  were  observed  in  this  case. 

Idiopathic  universal  pruritus  as  a  complication  of  pregnancy  may  occa- 
sion great  distress  and  may  seriously  interfere  with  a  patient's  rest  and  nutri- 
tion. In  two  cases  reported  by  Feinberg  ""  the  disorder  became  worst  at  the 
time  when  menstruation  would  have  occurred  had  pregnancy  not  been  present. 
Palliative  treatment  mitigatwl  the  patient's  sufferings  to  some  extent,  but  it 
was  unsuccessful  in  relieving  the  disorder.  Both  patients  were  exceedingly 
nervous,  easily  excited,  and  one  of  them  aborted  under  great  excitement. 

I'ruritus  limited  to  the  vulva  and  vagina  is  frequently  observed  as  a  com- 
plication in  patients  suffering  from  diabetes  during  pregnancy.  In  such  cases 
any  form  of  treatment  whidi  lessens  the  amount  of  sugar  in  the  urine  decreases 
the  ])atient's  suffering  from  pruritus.  In  cases  not  associated  with  diabetes  local 
apjilications  are  indicated,  such  as  antiseptics,  in  strong  solution,  painted  over 
the  part.  Tims,  bichlorid  of  mercury  (1  :  1000)  followed  by  an  application 
of  salt-solution  or  ])lain  water,  carbolic  acid,  3  to  5  per  cent.,  tincture  of 
iodin,  glycerin,  and  carbolic  acid,  are  oft(!n  employed.  In  patients  not 
unduly  susceptible  cocain  is  used  to  advantage,  altiiough  the  extensive  area 
to  which  the  api)licati()n  must  be  made  renders  it  a  dangerous  one  to  patients 
readily  influenced  by  the  drug.     The  ai)plication  of  electricity  by  ])lacing  a 


THE  PATHOLOGY   OF  PREGNANCY. 


221 


moist  electrode  upon  the  inucoiis  membrane  of  the  vulva  has  been  beneficial 
in  some  cases.  The  observance  of  cleanliness  is  of  great  importance,  esjie- 
cially  where  a  vaginal  discharge  amioys  the  pregnant  patient.  Douches  of 
carbolic-a(!id  solution,  of  crcolin  and  green  soap,  of  boracic  acid,  of  alum  in 
solution,  or  of  a  hot  soluti(m  of  sodium  bicarbonate  should  be  tried  faithfully. 
Sitz-baths  of  a  warm  solution  of  boracic  acid,  of  sodium  bicarbonate,  or  bran 
sitz-baths  are  also  indicated.  The  local  application  of  starch  and  laudanum 
or  lead-water  and  laudanum  is  another  resource  of  service.  Where  extensive 
irritation  and  excoriation  are  present  the  application  of  an  ointment  contain- 
ing belLtdonna,  opium,  and  iodoform  is  often  a  source  of  great  comfort.  Pen- 
cilling the  nuicous  membrane  with  nitrate  of  silver  is  occasionally  of  value. 
In  the  majority  of  cases,  however,  the  best  treatment  for  pruritus  of  the  vulva 
and  the  vagina  com])licating  pregnancy  is  to  be  found  in  careful  cleansing, 
etteoted  by  gentle  irrigation  of  the  parts  with  non-irritating,  antiseptic  fluids, 
and  by  constitutional  treatment  addressed  to  improving  the  condition  of  the 
patient's  nervous  system  and  assimilation. 

Hysteria  during  pregnancy  furnishes  an  interesting  illustration  of  the  fact 
that  the  pregnant  condition  exaggerates  any  previous  defect  or  susceptible  point 
in  the  patient's  mental  and  physical  organization.  The  belief  once  entertained 
that  pregnancy  exercises  a  favorable  influence  upon  women  already  hysterical 
is  certainly  erroneous.  It  occasionally  hap})ens  that  a  pregnan  ,  greatly 
desired  and  occurring  amid  the  most  favorable  circumstances,  furnishes  a 
healthy  stimulus  and  assists  a  patient  in  cultivating  self-control,  but  such 
cases  are  the  exception  and  not  the  rule.  Mild  forms  of  hysteria  during 
pregnancy  often  take  the  shape  of  melancholia  and  fear  of  approaching  con- 
finement. Such  cases  require  ])atient  encouragement  on  the  part  of  friends 
and  physician,  and  should  stimulate  the  obstetrician  to  take  every  precaution 
that  he  be  surprised  by  no  unforeseen  complication  during  the  labor.  If  the 
physician  makes  a  thorougli  study  of  his  patient  before  labor,  and  demon- 
strates to  her  that  he  has  exercised  every  precaution  in  her  behalf,  it  will  go 
far  in  allaying  her  ap])rehensions.  In  the  experience  of  the  writer  prelimi- 
nary examination  of  pregnant  patients  by  ))alpation,  auscultation,  and  pel- 
vimetry often  exercises  a  very  favorable  influence  in  such  cases.  Hysteria  com- 
plicating pregnancy  becomes  dangerous  when  it  ])asses  into  a  condition  of 
maniacal  excitement.  While  the  ju'ognosis  in  such  cases  is  not  unfavorable  so 
far  as  the  recovery  of  the  mother  goes,  yet  these  patients  require  prolonged  and 
careful  treatment,  and  sh,  iild  labor  occur  during  mania  injury  to  the  fetus  or 
to  the  mother  may  result.  Such  cases  require  constant  watchfulness,  kind  and 
systematic  restraint,  and  when  any  obstetric  manipulation  is  required  the  use 
of  anesthetics  is  usually  a  necessity.  As  one  of  the  dangers  that  threaten  in 
these  eases  is  exhaustion  through  a  refusal  to  take  food,  feeding  of  such 
patients  is  a  cardinal  point  in  their  treatment.  As  is  so  often  seen  in  deal- 
ing with  the  insane,  it  is  better  to  attemjit  no  deceit  in  tluir  management,  but 
to  win  the  patient's  confidence  by  faithful  and  patient  attention  without  dis- 
simulation. 


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AMERICAN  TEXT- BOOK  OF  OBSTETllICS. 


Mania  complicating  pregnancy  is  of  importance  chiefly  as  influencing  the 
course  of  labor  and  the  puerperal  state.  Mania  is  observed  during  pregnancy 
in  patients  of  very  neurotic  organization,  in  those  having  a  heredity  of  insanity, 
in  women  who  have  been  alcoholic,  hysterical,  or  in  other  ways  neurotic,  and 
in  women  who  sutter  some  great  mental  shock  while  in  the  pregnant  condition. 
Unhappy  marriages  form  a  considerable  element  in  the  causation  of  mania 
during  pregnancy.  The  diagnosis  in  these  cases  is  to  be  made  by  eliminating 
hysteria,  delirium  tremens,  hystero-epilepsy,  and  the  temporary  delusions  and 
hallucinations  whit.-h  sometimes  accompany  toxemia  from  deficient  excretion. 
In  the  former,  observation  will  usually  make  diflerential  diagnosis  a  matter  of 
ready  accomplishment.  In  cases  of  toxemia  a  study  of  the  patient's  exci'e- 
tions  is  required  to  arrive  at  a  correct  result.  The  prognosis  in  these  cases 
depends  upon  the  underlying  condition  which  is  the  exciting  cause  of  the 
mania.  In  those  of  highly  neurotic  organization,  but  whose  physical  con- 
dition is  goo<l,  the  prognosis  for  life  is  good,  but  the  outlook  for  mental 
soundness  is  not  brilliant.  In  cases  where  mania  has  followed  a  profound 
shock,  as  by  sudden  bereavement,  an  accident,  or  a  calamity,  if  the  patient's 
physical  condition  is  go<xl  the  prognosis  for  a  complete  recovery  is  also  good  ; 
this  is  especially  true  if  the  child  is  carrietl  to  terra  and  survives  its  birth.  If, 
however,  mania  is  grafted  upon  a  background  of  serious  physical  disability 
where  some  well-marked  pathological  condition  is  present,  it  may  be  the  fore- 
rinmer  of  a  fatal  issue — if  not  at  labor,  within  a  short  time  afterward.  This 
is  especially  true  in  those  cases  where  toxemia  and  interstitial  nephritis  are 
b{>ginning,  and  where  the  patient,  if  she  escapes  eclampsia,  passes  ii.to  a  con- 
dition of  pronounced  and  fatal  nephritis  after  labor. 

The  trcdtment  of  mania  during  pregnancy  varies  with  the  condition  which 
excites  the  mania.  What  has  been  said  regarding  the  treatment  of  hysterical 
mania  applies  to  cases  where  the  patient  is  neurotic,  but  is  physically  in  good 
condition.  In  women  who  become  maniacal  in  the  presence  of  calamities  or  of 
sudden  bereavement  the  free  use  of  narcotics  for  a  time  is  often  indicatcfl  to  se- 
cure sleep.  If  the  life  of  the  child  continues,  the  hope  of  its  birth  and  maternal 
affection  should  be  used  as  jwwerfid  mental  tonics  in  dealing  with  the  mother. 
Perfect  seclusion  and  protection  from  all  intrusion  are  absolutely  essential. 
When  tlie  first  sluK'k  t(j  the  mind  and  the  nervous  system  has  passed,  all  the 
resources  of  the  therapeutic  art  are  required  in  promoting  the  nutrition  of  the 
brain  and  nervous  system.  The  treatment  of  mania  complicated  by  toxemia 
through  deficient  excretion  calls  for  the  avoidance  of  narcotics  and  sedatives 
and  the  prompt  securing  of  active  elimination.  As  soon  as  the  patient  is  freed 
from  the  poisons  which  an;  irritating  the  brain  her  condition  usually  is  marked- 
ly improved. 

Nausea  and  Vomiting  of  Pregnancy. — On  the  border-line  between  the 
physiology  and  the  pathology  of  pregnancy,  nausea  and  vomiting  have  been  con- 
sidered by  some  as  an  inevitable  result  from  the  irritation  occasioned  by  the 
development  of  the  pregnant  uterus,  and  by  others  as  purely  a  pathological 
phenomenon.     Like  the  kidney  of  pregnancy,  the  pregnant  uterus  and  its 


THE   PATHOLOGY  OF  PREGNANCY. 


22.} 


nervous  supply  are  in  a  condition  of  plethora  which  borders  upon  an  actual 
pathological  change.  The  progress  of  our  knowledge  in  the  pathology  of 
pregnancy  gives  good  reason  at  present  for  the  belief  that  nausea  and  vomiting 
are  not  a  physiological,  but  a  pathological,  accompaniment  of  the  pregnant  con- 
dition. As  many  patients  pass  through  pregnancy  with  no  pathological  lesion 
of  the  kidneys,  so  many  women  bear  children  without  the  nervous  irritation 
and  the  anemia,  slight  or  profound,  that  accompany  nausea  and  vo'  iting. 

The  predisposing  causes  for  th<!  emesis  of  pregnancy  are  to  bi:  'i  d  in 
a  congenital  irritability  of  the  nervous  system,  that  produces  •A.,ggerated 
response  to  normal  reflex  stimuli.  The  predisposing  causes  for  this  af!'ecti(tn 
are  anatomical  lesions  in  the  generative  tract,  notably  congenital  malforma- 
tion of  the  uterus  or  dislocation  of  the  pregnant  womb.  The  exciting  causes 
for  this  complication  are  sudden  shocks  to  the  nervous  system  that  power- 
fully exaggerate  its  reflex  susceptibility.  An  infective  j)rocess  producing 
hyperemia  and  irritability  of  the  cerebro-spinal  axis  may  also  be  an  exciting 
cause  for  the  nausea  and  vomiting  of  pregnancy.  A  pathological  process 
which  affects  the  constitution  of  the  blood  is  also  a  frequent  exciting  cause 
in  these  cases.  Direct  mechanical  injury  or  violence  to  the  pregnant  womb 
often  begins  and  maintains  this  condition  ;  thus,  a  patient  in  early  ])regnancy, 
while  straining  or  lifting,  suddenly  retroverts  the  uterus,  and  obstinate  emesis 
follows.  Metallic  and  irritant  poisons  absorbed  into  the  system,  vitiating  the 
blood  and  irritating  the  nervous  centres,  produce  nausea  and  vomiting. 
Among  the  most  frequent  of  the  exciting  causes  are  the  movements  of  the 
fetus  in  utero  and  excessive  peristalsis  in  the  mother's  intestine.  Distention 
of  the  bladder  and  the  rectum  is  frequently  present  in  these  cases. 

The  diagnosis  of  this  condition  must  usually  be  made  in  large  part  from 
the  statements  of  the  j)atient  or  from  those  of  her  attendant.  As  such  vomit- 
ing is  most  frequent  in  early  morning,  unless  in  severe  cases  the  physician 
rarely  has  an  opportunity  actually  to  observe  the  ])henomenon.  In  mild  cases 
nausea  begins  as  soon  as  the  patient  raises  her  head  from  the  j)illow.  The 
desire  is  for  instant  emesis,  which  is  usually  accomplished  without  straining, 
and  is  often  repeated.  Following  this  emesis  the  patient  may  take  food  with 
appetite,  and  the  ]>lienomenon  may  not  recur  until  the  next  morning.  In 
such  cases  the  matter  vomited  is  mucus,  sometimes  of  strongly  acid  reaction, 
sometimes  of  Heutral  reaction.  In  more  severe  cases  the  sensation  of  nausea 
begins  as  soon  as  the  patient  awakes ;  assuming  the  u])right  posture  is  followed 
by  vomiting  but  little  relieved  by  emesis.  The  material  ejected  is  mucus,  often 
burm'ng  and  bitter  to  the  taste,  frequently  excessively  sour.  Although  the 
l):itieut  may  succeed  in  retaining  food,  the  sensation  of  nausea  persists  often 
iMitil  mid-(l,iy  or  even  later:  the  sight  or  the  presence  of  certain  articles  of 
food  greatly  increases  her  distress.  Perturbation  of  any  kind  exaggerates  the 
sensation  of  nausea.  If  vomiting  is  repeated,  it  is  accompanied  by  straining 
and  retching.  After  mid-day  the  patient  is  better,  and  may  eat  heartily  at 
evening.  Such  eases  are  accompanied  by  anemia  and  often  by  considerable 
loss  of  weight.     A  third  class  of  cases  is  well  characterized  by  the  term  per- 


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AMERIVAN    TEXT-BOOK    OF   OliSTiyTRICS. 


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nicioun ;  in  thorn  the  sensation  of  nansea  is  present  at  intervals  during  the 
])atient's  waking  hours.     Hor  cravings  are  lor   varied  articles  of  food  and 
drink,  and  they  are  no  sooner  satisfied  than  a  new  craving  arises.     Vomiting 
is  accompanied  by  straining  and  ret(!iiing,  by  dryness  of  the  fauces,  or  by  pro- 
fuse salivation.     The  matter  ejected  is,  first,  mucus  and  the  UkkI  taken,  bile, 
and,  in  severe  cases,  niiufus  stained  with  blood  or  with  coffee-ground  material. 
Food  is  no  sooner  swallowed  than  it  is  ejected,  although  there  occur  surprising 
periods  of  tolerance  in  which  the  patient  eats  greedily,  and  which  occasion 
hope  in  the  mind  of  the  physician  that  substantial  improvement  has  taken 
place.     As  the  case  proceeds  distress  and  pain  are  felt  beneath  the  stermim, 
not  located  at  any  fixed  point.     The  sensation  is  described  sometimes  as  that 
of  smothering,  but  more  often  as  that  of  distress  which  has  nothing  to  do  with 
breathing.     In  dangerous  cases  it  is  worst  at  night.     Emaciation  is  progressive 
— in  some  cases  rapid,  in  other  cases  slow.     A  more  deceptive  phenomenon  in 
these  patients  is  acute  fatty  degeneration  of  the  tissues,  that  gives  to  the  pa- 
tient a  plump  ap|)earauee  which  may  deceive  the  physician.     As  the  case  pro- 
gresses the  clinical    picture  of  pernicious  anemia  becomes   more  and   more 
apparent.     Signs  are  present  of  disintegration  of  the  blood  in  the  vomit,  in 
hematogenic  jaundice,  in  sordes,  and  in  pur{)uric  extravasations.     The  urine 
contains  the  debrifs  of  broken-down  corpuscles,  the  feces  are  dark  in  color,  the 
mucous  membranes  dark  and  reddish  in  appearance,  and  the  nujutal  condition 
is  one  of  apathy  or  of  delusion  so  often   seen    in    these   cases.     A  further 
explanation  of  the  process  is  observed    in    the  condition  of  the  eyes  by  a 
necrosis  of  the  cornea,  and  dimness  of  vision  may  be  noted.     The  j)ulse  and 
the  cardiac  action  of  the  patient  in  severe  cases  of  nausea  and  vomiting  of 
pregnancy  show  the  effect  upon  the  heart  and  the  arteries  of  the  gradually 
developing  anemia.     The  pulse  is  rapid,  soft,  and  weak.     Arterial  tension  is 
usually  diminished,  the  first  sound  of  the  heart  grows  less  and  less  distinct 
and  forcible,  and  in  fatal  cases  cardiac  syncope  develops.     The  temperature  is 
subnormal  at  first ;  later  in  severe  cases  it  increases  as  a  fatal  issue  a])proaches. 
In  other  cases  the  temperature  varies  slightly  from  the  normal,  and  in  all  cases 
it  is  not  an  important  factor  in  diagnosis  or  in  prognosis.     The  ])ulmonary 
signs  are  usually  negative  :  the  patient  occasionally  complains  of  an  irritable 
cough  which  accompanies  a  dry  condition  of  the  fauces,  or  in  others  of  the 
accumulation  of  an  excessive  amount  of  mucus.     Palpation  of  tiie  abdomen 
may  detect  a  dislocation,  of  the  uterus,  and  in  the  early  stages  of  the  more 
severe  cases  the  abdominal  walls  are  often  excessively  irritable,  the  practice  of 
palpatitm  increasing  the  nausea.    Liver-dulness  is  usually  slightly  increased  in 
area  as  the  liver  becomes  the  seat  of  acute  parenchymatous,  fatty  degeneration. 
The  patient's  reflexes  are  much  increased,  although  ])aralysis  or  atrophy,  otiicr 
than   that  attending  emaciation,  is  seldom   observed.     The  nutrition  of  the 
skin,  except  in  purpuric  (^ases,  is  usually  fairly  maintained ;  bed-sores  in  cases 
well  cared  for  are  of  rare  occurrence.     A  clammy  sweat  is  frequently  seen, 
especially  upon  the  face. 

The  symptoms  of  an  improvement  in  the  condition  of  the  patient  suffering 


THE  PAriroLoav  of  PUKayANVY. 


225 


from  nausea  ami  vomiting  of  pregnancy  arc  a  dimiiuition  in  the  uansoa  and 
the  eniesis ;  tlie  ability  to  take  anil  to  retain  food  ;  a  normal  eondition  of  the 
excretions,  especially  of  the  urine;  the  absence  or  the  diminution  of  excessive 
perspiration  ;  considerable  periods  of  sleep  without  emesis,  and  the  absence  of 
substernal  distress,  especially  at  night.  The  pulse  falls  gradually  to  100,  and 
the  temperature  reujains  normal.  Symptoms  of  danger  in  these  cases  are  the 
continuance  of  the  nausea  and  vomiting  and  the  gradual  dev('k)pment  of  the 
signs  and  symptoms  of  pernicious  anemia.  Among  the  most  important  of 
these  are  a  persistently  rai)id,  feeble  pulse,  substernal  pain  and  distress,  and 
colfee-ground  vomit. 

The  pailiohf/icdl  anafomy  of  tliese  eases  may  be  dividi'd  into — first, 
those  of  the  organs  of  the  body  other  than  the  generative  organs  ;  and, 
second,  tlutse  of  the  uterus  and  its  ai)pendages.  In  the  first  class  of  cases  it 
is  evident  that  lesions  which  may  produce  obstinate  nausea  and  vomiting  in 
the  non-pregnant  may  also  by  coincidence  be  present  in  gravid  women. 
Thus,  cancer  of  the  stomach ;  chronic  gastritis,  whether  gouty,  alcoholic,  or 
caused  by  arterio-sclerosis ;  nephritis  in  its  various  forms;  brain-tumor; 
chronic  displacement  of  the  stomach  by  the  pathological  condition  of  adjacent 
viscera ;  hysteria  producing  emesis ;  emaciation,  vomiting,  and  acute  yellow 
atrophy  of  the  liver, — may  be  present 
and  cause  vomiting  in  pregnant  patients. 
( )f  these  conditions  but  one  stands  in  a 
possible  causal  relationship,  and  is  by 
some  considered  dependent  upon  the 
condition  of  pregnancy.  It  has  been 
shown  by  Lomer  and  by  Frerichs  that 
tliis  disorder  nniy  atfect  pregnant  women 
in  fiu'ms  of  varying  severity,  and  that 
the  milder  cases  of  acute  yellow  atro})hy 
of  the  liver,  in  which  death  does  not 
occur  from  this  complication,  often  show 
themselves  through  nausea  and  vomiting 
only. 

As  regards  the  changes  to  be  met 
with  in  the  genital  organs  in  these 
cases,  they  are,  first,  those  of  jiosition  ; 
and,  second,  those  of  structure.  In  the 
former  we  have  acute  and  chronic 
dislocations  of  the  uterus.  Couimoncst 
among  these  dislocations  is  retroversicm, 
which  generally  follows  straining  or 
lifting,  and  in  which  the  relation  be- 
tween the  dislocation  and  the  nausea  and 
vomiting  is  that  of  evident  cause  and  effect.  This  complication  is  serious  in 
proportion  to  the  condition  of  the  surrounding  parts :  if  no  adhesions  bind 


1 11— Voiiiitinir  nf  preRixiiK'y-    Cyst  in 
iiuti'vinr  wall  (if  eorvix  ^Davls). 


•  \ 
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M, 


rft[7    ^  ^X^^ 


1/ 


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226 


j.v/;/i'/r.LV  Ti:xT-Booh'  of  oiisrF/rnrcs. 


ihe  utiTiis  in  its  abiiuriiial  position,  tiio  reduction  of  the  dislopution  is  readily 
ellectcd  and  tiio  excitinj;  cause  is  at  once  removed.  Wiierc,  however,  the 
prcjfnant  womb  hccomcs  retroverted  and  bonnd  down  by  adliesions  in  the 
process  of  pelvic  inthunmation,  the  patholofjical  condition  is  far  more  compli- 
cated and  jjrave.  Chronic  «lislocations  of  the  prej^nant  womb  are  those  in 
which  that  organ  as  a  whole  is  forced  downward  in  the  pelvis  and  impacted 
with  its  fnndns  against  the  symphysis  pubis.  This  condition  of  the  womb  is 
the  result  of  persistent  wearing  of  tight  clothing  before  and  after  the  occur- 
rence of  pregnancy,  and  it  has  been  well  described  and  its  imi)ortance  has 
been  urged  by  (Jrailey  Hewitt  in  a  brochure  entitled  Severe  Vomiiiitg  ilitriii;/ 
Pre()H(tncji,  published  in  London  in  1800.  This  condition  of  impaction  is 
not  infreciuently  accompanied  by  congenital  malformatit)n  of  the  pregnant 
uterus,  evidenced  by  extreme  anteHexion,  with  a  patlutlogical  condition  of  great 
importance  in  the  cervix.  It  has  repeatedly  been  observed  in  such  cases  that 
tlie  cervical  canal  was  tightly  closed  and  that  the  tissues  of  the  cervix  were 
excessively  dense  and  resistant.  Attention  has  recently  been  called  by 
Davis,'^"  in  a  case  of  this  sort,  to  a  condition  of  excessive  development  of 
connective  tissue  in  the  cervix  accomjianied  by  the  presence  of  a  retention- 
cyst  of  considerable  size  in  the  anterior  wall  of  the  cervix  (Figs.  144, 145). 


Fiii.  1  l."i.— Vomitiiif,'  iif  pri'Kiiuiicy.     Delist'  coiiiRTtivi;  tissuo  In  cervix  (Diivis). 


In  addition  to  these  gross  chaiige:^  in  the  uterus,  tumors  of  the  ovary  and 
enlaro-ement  of  the  tid)es  have  been  observed  in  cases  of  nausea  and  vomiting 
of  pregnancy.  Microscopic  examination  of  the  endometrium  in  many  oi' 
these  cases  lias  demonstrated  the  presence  of  endometritis  of  various  forms : 
that  this  of  itself  is  a  cause  of  the  nausea  and  vomiting  is  not  demonstrated  ; 
the  condition  is  apparently  the  accompaniment  and  the  result  of  the  congenital 
malformations  or  dislocations  already  described. 

Through  the  researches  of  Lindenmann  of  Moscow'-'  we  are  in  possession 
of  the  interesting  restdts  of  microscopic  examinations  upon  the  tissues  of  a 
mother  and  her  fetus  perishing  from  pernicious  vomiting  complicated  by 
polyneuritis.  A  gross  examination  revealed  enlargement  of  the  spleen  with 
the  appearance  usual  in  inanition,  with  cirrhotic  kidneys  and  liver.     Micro- 


TIIK  PATJIOLOaV   OF   PliEaXAMT. 


227 


s('(»pic  examination  rpvoaknl  noiiritis  of  the  jjlircnio,  piK'nnioijastrit',  inoilian, 
and  pcronwil  nerves,  bcinj^  espoeially  well  marked  in  the  phrenic.  Tho 
liver  siiowed  fatty  degeneration  and  elondy  swelling.  The  blood-vessels  of 
the  spleen  were  dilate«l,  and  the  bhx^l-eorpnseles  could  not  be  stained  by 
coloring  agents.  The  epitheliiun  of  the  kidneys  showed  fatty  degeneration. 
The  organs  of  the  fctns  exhibited  fatty  degeneration  of  the  liver  and  necrosis 
of  the  kidney.  The  entire  pathological  |)icture  was  that  of  infection  by  a 
toxine,  and  Tiindenmann  considers  the  infection  as  anto-intoxication,  In  his 
control-experiments  upon  this  case  he  describes  interesting  observation,'  on  the 
pathology  of  inanition  in  animals,  and  from  these  comparative  studie.-  he 
excludes  simple  inanition  as  a  cause  for  the  lesit)ns  in  j)ernicious  nausea. 

The  rational  lirahnvnt  of  the  nausea  and  vomiting  of  pregnancy  is  im- 
possible without  a  thorough  knowledge  of  the  co'idition,  first,  of  the  patient's 
])roccsses  of  assimilation,  and,  second,  of  the  condition  of  the  genital  tract. 
The  patient  nuist  be  examined  thoroughly  to  exclude  any  cause  tor  the  malady 
that  lies  outside  the  genital  tract.  This  examination  will  eliminate  the  rarer 
complications  of  this  disorder.  A  thorough  and  painstaking  examination  of 
the  uterus,  its  si7,e,  shape,  consistence,  position,  and  the  condition  of  the  pelvic 
tissues  surrounding  it,  is  then  imperative.  In  cases  where  the  sensitiveness 
of  the  j)atient  is  so  great  that  an  examination  aggravates  the  vomiting,  anes- 
thesia by  chloroform  or  by  bromid  of  ethyl  is  indicated.  The  i)hysician  in 
tills  examination  nuist  broadly  ditfereutiate  between  two  conditions:  he  may 
tind  a  simple  dislocation  of  the  uterus  in  retr('V»»rsion  or  prolapse  of  the 
uterus,  and  partial  impaction  anteriorly  ;  or  he  may  detect  a  congenital  mal- 
t'ormation  manifested  in  sharp  anteflexion  with  thick  and  resisting  cervix,  or 
a  retroversion  bound  down  by  pelvic  adhesions.  In  the  first  and  simplest  of 
tlieso  conditions  the  restoration  of  the  uterus  to  its  normal  position  is  indi- 
cated, and  is  almost  invariably  successful  in  relieving  the  condition.  The 
explanation  of  this  relief  seems  to  be  that  the  constant  irritation  to  the  reflex 
nervous  system  which  pressure  upon  the  pelvic  nerves  maintains  is  relieved  by 
replacing  the  uterus,  hence  the  pathological  jihcnomenon  ceases.  If  retrover- 
sion be  present,  the  bladder  and  the  rectum  should  be  emi)tied  thoroughly,  the 
patient  ]ilaced  preferably  in  Sims'  position,  when,  under  anesthesia  if  neces- 
sary, the  perineum  shoidd  be  retracted  and  the  cervix  drawn  downward  and 
backward  with  one  hand,  while  with  the  fingers  of  the  other  hand  the  fundus 
should  be  directed  gently  u]>ward  and  forward.  Reposition  having  thus  been 
elTcctcd,  it  is  well  to  sustain  the  uterus  in  its  position,  at  first  by  a  jMicking  of 
antiseptic  gauze,  then  by  tampons  of  carded  wool.  If  the  pregnancy  be  an 
(arly  one  and  no  pathological  condition  in  the  ])elvis  be  present,  a  Ilodge 
pessary  may  be  worn  to  advantage.  In  prolapse  and  anterior  imi>action  of 
the  gravid  uterus  a  thorough  cmjitying  of  the  bowel  is  of  great  importance 
before  attempting  replacement.  The  uterus  should  then  bo  raised  gently  upon 
the  fingers  of  the  physician,  and  if  difficulty  and  resistance  be  experienced, 
tiie  knee-chest  jiosition  should  I)e  tried.  It  is  often  observed  in  these  cases 
that  but  slight  change  in  position  is  sufficient  to  relieve  the  patient,  and  this 


I  UA 


2-2S 


^^^E^rcAN  text-book  of  obstktrtcs. 


I    ;- 


(7 


gain,  liowovor  small,  is  to  hv  inaintaiiu'd  by  tamponing  the  vagina  with  anti- 
septic soft  material.  As  soon  as  tlic  patient's  strength  permits,  it"  the  uterus 
is  not  in  its  normal  position,  it  siionhl  again  be  raised  by  gentle  manipniation 
and  the  tampon  be  replaeed.  In  this  manner,  under  thorough  antiseptic  ])rc- 
eautions,  it  is  possible  by  gentle  manipulation  to  restore  vi'ry  nearly  to  its 
normal  position  a  uterus  prolaj)sed  and  anteriorly  impacted. 

In  cases  where  the  ])hysician  detects  an  abnormal  c«)ndition  of  the  cervix, 
the  result  of  congenital  nialformatii>n  anil  pathological  processes,  the  case  is 
far  more  serious  and  the  treatment  is  more  ditlieult.  It  is  here  that  dilatation 
of  the  cervix,  found  by  (.'opeman,'"  by  a  fortunate  accident,  to  be  cllicient,  is 
the  method  of  treatment  to  be  employed.  The  proil'ssion  is  huniliar  with 
Copeman's  I'lfort  to  induce  labor  in  a  jiaticnt  pregnant  six  months  and  almost 
dead  from  nausea  and  vomiting.  Having  dilated  the  cervix  as  much  as  he 
(H)uld  with  his  lingei's,  he  attempted  to  rupture  the  nien)branes  and  failed.  The 
improvement  caused  by  the  dilatation  was  so  great  that  no  fmllier  interference 
was  practised,  and  the  patient  recovered.  Tiiere  can  be  no  (piestion  but  that 
in  cases  where  a  patlu)logit'al  condition  of  the  cervix  is  present,  dilatation  is 
demandeil,  anil  without  delay.     The  physician  shoidd  not  be  misled  by  a  soft 

lition  of  the  external  os,  for  oftentimes  a  chronically  congested  mucous 

f  the  o'lands  of  the  cervix  give  to  the  casual 


cun( 

membrane  and  liypersecretion  o 


d  h 


tl 


(il)server  tlie  nnj)ress 


ion 


that  tl 


le  cervix  is  so 


ftenec 


w 


lile  this  mav  be  true 


of  its  external  portion,  the  internal  os  will  be  found  tightly  contrattol  and  its 
walls  in  a  condition  of  dense  resistance.  Dilatation  should  be  jiraetised  under 
anesthesia,  preferably  by  chloroform  or  by  bromid  of  ethyl.  The  finger  is  a 
safe  instrument,  but  in  cases  where  the  tissue  resists  the  linger  it  is  necessary 
t(»  use,  first,  stei'l-bladed  dilators,  as  is  done  by  Wiley  and  others,  and  then 
complete  the  dilatation  to  the  j)oint  of  admitting  the  finger  by  solid  metal 
bougies.  This  procedure  of  course  exposes  the  pregnancy  to  danger  of  inter- 
ruption, and  rupture  of  the  membranes  may  occur  during  the  dilatation.  Tin; 
l)hysician  should  be  prepared  for  this  coni])lication  by  having  ready  a  suitable 
curette  and  douche-tube  with  which  to  thoroughly  curette  and  douche  iIk^ 
uterus.  Following  the  complete  removal  of  the  ovum  by  the  curette  and 
douche,  the  uterus  should  be  packed  with  iodoform  gauze  and  be  carried  well 


"1 


)  into  the  pelv 


I 


n  uiu 


lertaliing  to  treat  a  case  of  the  nausea  and  voinitiii 


of  pregnancy  it  is  impossible  for  the  physician  to  do  his  duty  without  making 
a  thorough  examination,  and  without  |)ractising  interference  such  as  his  judg- 
ment may  dictate.  If  he  is  hampered  in  this  examination  by  the  pn'judiccs 
of  his  patient,  he  must  decide  whether  to  place  the  responsibility  upon  her 
and  her  frieiuls  or  to  retire  from  the  case. 

In  milder  cases,  where  a  condition  of  simple  irritability  and  hypersecretinn 
ill  the  OS  and  cervix  are  dett'cted,  local  applications  to  these  parts  are  of  great 
value.  Where  the  mucous  meml)rant'  is  angry  and  red,  following  a  cleansing; 
douche  of  creolin  and  green  soap,  the  ])hysiciaii  may  apply  nitrati-  of  silver  1)\ 
jiencil  with  advantage.  In  raising  a  simply  dislocated  uterus  in  the  pelvis  anti- 
septic and  analgesic  ointments  may  be  incorporated  with  the  tampons  employed. 


IS 


THE   PATJIOLOdY    OF   PRFAiyAyVY 


229 


Irctioii 

kiisiiKj; 

[•or  l)v 

aiili- 

iovi'il. 


TiiiKS  an  ointmout  of"  bollailoiniM,  iodot'onii,  and  morphia  is  somotimos  of  use 
in  tliose  cast's.  If  oxcossivo  secretion  he  present,  io(K)fonn,  belhulonna,  and 
glycerol  of  tannin   form  a  useful  mixture. 

The.  mt'dh'inal  (rcdfinoit  of  the  nausea  and  vomiting";  of  preixnaney  consists, 
first,  in  eliminatinji;  hy  examination  the  necessity  for  operative  interference,  or 
in  promptly  rcmedyinu;  a  pathological  condition  of  the  uterus.  A  strict  con- 
trol of  the  patient  is  then  an  absolute  necessity,  and  here  the  services  of  a 
skilled  and  competent  attendant  arc  of  the  greatest  value.  The  patient  should 
he  j)Ut  to  bed  and  her  strength  preserved  in  every  possible  way.  Tlie  subject 
of  nausea  and  vomiting  should  not  be  dwelt  upon  with  iier.  Siie  slioidd  bo 
fed  by  carefully-prepared  nutriment — if  possible,  '>y  th(>  mouth — at  r(>gular 
intervals,  [f  the  stomach  is  non-retentive,  rectal  !;),ections  of  nutritive  sub- 
stances are  demanded.  Among  these  substances  are  various  j)rcparations  of 
beef  in  the  form  of  peptonoids,  peptonized  beef,  beef-juice  combined  with 
brandy,  with  milk  peptonized  and  pancreatized.  If  it  is  desired  to  adminis- 
ter alcohol  and  the  stomach  cannot  tolerate  dry  champagne  or  brandy  and 
soda,  brandy  may  he  given  by  rectal  injection.  The  list  of  remedies  which 
have  been  employed  by  administration  in  the  stomach  in  these  cases  is  exces- 
sively great,  and  it  shows  how  eomparativt'ly  niiimportiuit  all  have  been  in 
radically  relieving  the  disorder.  Where  evidence  of  chronic  catarrh  of  the 
stomach  was  present,  lavage  of  the  stomach  has  been  found  of  the  greatest 
value.  The  soft-rid)ber  stomach-tube  should  be  ])assed,  and  a  solution  of 
sodium  chliirid,  sodium  salicylate,  or  a  dihit(>  solution  of  bicarbonate  of 
sodium  should  be  employed.  The  administration  of  animal  ferments  In  con- 
nection with  food  is  also  of  great  valiu\  Thus,  ingluvin,  pancreatin  witii 
sodium  bicarbonate,  with  nux  vomica,  or  strychnia  and  pepsin,  are  of  decided 
v;ilue.  Solid  food  must  not  be  attempted  until  the  patient's  strength  has  con- 
siderably improved  and  the  condition  of  the  tongue  warrants  its  trial.  It  is 
well  at  times  to  consult  tl>',  j..v-  nt's  appetite  and  craving  when  solid  food  is 
given,  if  this  craving  does  M.)t  call  for  articles  of  an  injurious  character. 
When  solid  food  is  tai.<  n,  scraped  raw-beef  sandwiches,  oysters,  junlwt,  milk 
with  lime-water  or  with  '  iehy,  and  freshly  made  broth  in  which  bread  is 
dipped,  are  usually  of  value. 

Prugs  are  of  use  in  the  tn>atment  of  this  complication  only  in  so  far  as 
they  iissist  in  ])reserving  the  ])atient's  strength.  It  is  folly  to  drug  a  patient 
with  narcotics  while  the  ])hysician  is  ignorant  of  th(>  position  and  condition 
!»f  the  pelvic  organs,  and  the  prolonged  administration  of  iHor])hia  is  often 
sim])ly  a  mask  <br  negligence  or  for  incompetence.  It  is  much  better  to  pro- 
cure sleep  by  the  administration  of  alcohol  j)er  rcctinn  by  night,  by  sponging 
with  warm  water  and  bathing  whiskey,  ami  by  sccui'iiig  for  the  patient  perfect 
repose,  ihan  by  the  administration  of  depressing  i-emedies.  Where  narcotics 
are  indispensable.  nu)rphia  and  atropia  or  codeia  are  undoubtedly  the  best. 
In  exlrenu' cases  prompt  and  vigorous  stinudation  nuist  be  brought  into  play 
til  tide  the  patient  over  a  collapse  which  may  follow  the  dilatation  of  the 
ci'rvix  or  the  em|)tying  of"  the  uterus.     Here  the  hypodermic  use  of  strychnia, 


m 


\\\ 


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! 


fin 

.■'  --if/-  ■• 

i 

1.! 

1 

'! 

I    ' 


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280 


^IJ/Ti-iJ/CliV    TEXT-BOOK    OF   OBSTETRICS. 


digitalis*,  atropia,  and  alcohol,  iho  transfusion  of  saline  solution,  the  aj)pllcation 
of  electricity  to  the  spine,  the  aiiplieation  of  heat  to  the  base  of  the  brain  and 
about  tiie  trunk  of  the  IkkIv,  are  iill  of  value. 

The  explanation  of  those  eases  in  which  spontaneous  cure  of  this  condition 
occurs  is  to  be  found  most  reasonably  in  spontaneous  reduction  of  dislocations 
of  the  uterus.  Experience  has  shown  that  it  requires  but  a  slij^ht  change  in 
the  position  of  this  organ  to  alter  a  state  of  irritant  pressure  to  a  condition 
in  which  no  irritation,  or  but  little,  is  produced.  There  is  certainly  no  other 
rational  ex])lanation,  from  our  knowledge  of  pathology,  for  these  cases.  The 
folly  of  waiting  for  such  a  change  to  occur  without  using  every  effort  to  place 
the  uterus  in  proper  position  is  self-evident.  It  is  remarkable  that  this  most 
important  point  in  treatment — namely,  the  securing  of  a  proper  jiosition  of 
the  uterus — should  have  been  considered  as  a  last  resort.  That  such  a  change 
may  often  be  produced  by  the  posture  of  the  jiatient  only  is  illustrated  in  a 
case  reported  by  (Jrant,'^  who  as  a  last  resort  elevated  the  hips  of  a  patient 
upon  pillows,  whereupon  her  vomiting  ceased.  The  fact  that  curetting  the 
uterus  in  urgent  eases  is  followed  by  immediate  relief  is  well  illustrated  bv 
Roland '-'  and  by  Blanc.'-'     The  excellent  results  following  the  reduction  of 


Flii.  1  liV— Air-liiill  |ics-nry  in  |i(i»iticiii  Mini  rnisiim  tlic  uterus. 

dislocations  of  the  uterus  fiii<l  abundant  illustration  in  Hewitt's  Jfcpnrtu,  in 
which  the  nsi  of  tli.-  Uariel  air-ball  pessary  is  (leserii)ed  and  fully  illustrated. 
T'  is  instrument  is  of  value  when  the  linger  has  dislodge<l  the  anteriorly-im- 
pacted uterus,  and  under  antiseptic  precautions  its  u>ii>  has  been  attended  witli 


THE   PATHOLOGY   OF  PREGNANCY. 


231 


excellent  results.  The  accompanying  illustration  (Fig.  146)  sliows  the  air-ball 
pessary  in  position  and  raising  the  uterus  in  the  pelvis.  Kingman  '^®  also 
describes  cases  in  which  the  reduction  of  uterine  dislocations  has  terminated 
nausea  and  vomiting. 

Ptyalism  complicating  this  condition  has  been  well  described  by  Ahlfeld/^ 
Avho  believes  that  these  cases  are  primarily  neurotic  in  origin,  and  treats  them 
accordingly.  With  the  same  view  of  the  causation  of  vomiting,  Gunther  '^ 
treats  these  cases  by  galvanism,  the  positive  jiole  being  placed  against  the  cer- 
vix, the  negative  between  the  eighth  and  twelfth  doi'sal  vertebrae.  From  2i  to 
5  milliampcres  were  emi)loyed  for  from  seven  to  ten  minutes  ;  so  long  as  the 
current  was  uninterrupteil  he  did  not  observe  danger  of  disturbing  the  preg- 
nancy. Siinger  and  Hcnnig  '^  describe  cases  in  wliich  the  exciting  cause  of 
vomiting  was  a  pathological  condition,  either  in  the  uterus  or  some  abdominal 
organ. 

Ascites  complicating  pregnancy  may  arise  from  a  lesion  of  the  abdominal 
viscera  interfering  with  the  return  circulation  and  also  with  the  lymphatic 
circulation  of  the  peritoneum.  l*rcgnancy  itself  sometimes  occasions  ascites 
through  a  pathological  condition  which  atfects  the  peritoneum  of  the  mother 
and  the  amnion  of  the  fetus  by  a  similar  jirocess.  An  interesting  case  illus- 
tr;iti!\g  this  condition  is  reported  by  Florentine.'*'  The  patient  was  a  young 
v(yn:,n  married  three  years  who  had  borne  one  living  child  and  had  one 
abortion.  The  cessat'on  of  menstruation  was  followed  by  obscure  pain  in 
the  abdomen,  increase  in  size,  and  the  evident  presence  of  fluid.  Pressui'e- 
symptoms  became  so  pronounced  tliat  suffocation  was  threatened  and  pains 
like  those  of  lal)or  supervened.  The  membranes  were  ruptured,  when  the 
entire  fetus  with  a  large  amount  of  amniotic  liquid  was  sudd  'uly  expelled. 
Distention  of  the  alidomen  was  relieved  by  paracentesis.  The  presence  of 
an  ovarian  cyst  was  then  diagnosticated  and  the  tumor  removed  a  month  later. 
Recovery  ensued. 

Tubercular  peritonitis  complicating  pregnancy  is  also  a  cause  of  ascites, 
and  it  may  develop  gradually  as  gestatioii  advances.  The  treatment  of  al)- 
(loniinal  dr()])sy  complicating  pregnancy  is,  j)referably,  by  exploratory  incision. 
If  a  tubercular  process  be  ])reseiit,  the  prognosis  for  very  great  imjirovcment, 
if  not  recovery,  is  excellent.  If  a  [)athol()gical  condition  of  tlie  lymphatic 
system  of  the  peritoneum  is  the  cause  of  tiie  condition,  free  drainage  by 
incision  is  much  the  safer  treatment.  The  immunity  displaytnl  by  jircgnant 
]>aticnts  to  operative  jirocedures  when  ])ropcrly  conducted  renders  such  inter- 
ference safe  and  highly  appropriate. 

Phantom  pregnancy,  or  pseudo-cyesis,  may  result  from  a  strong  desire 
for  pregnancy  in  a  ]>atient  sutfering  from  ascites.  An  illustrative  ease  is 
reported  by  (May.''"  Phantom  jiregnniu-v  without  |>alliological  lesion  is  not  a 
rare  condition.  ()i)served  in  nervous  pat'<  :<ts  who  strongly  desire  preguiuicy, 
and  wiio  are  usually  i)ast  the  time  of  greatest  reproductive  activity,  it-  ,-ynip- 
tnms  are  the  subjective  symptoms  of  normal  gestation.  The  diaipioxiH  and 
Ircdiinciif  of  il.is  condition  are  completed   i)y  a  thorough   examination,  and 


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AMERICAX  TEXT-BOOK  OF  OBSTETRICS. 


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whenever  the  patient  will  submit  to  examination  under  an  anesthetic  the  cure 
is  usually  complete.  It  is  well  in  such  cases  to  have  a  friend  of  the  patient 
])rcsent  at  the  examination  to  personally  witness  the  disajipearance  of  the 
abdominal  tumor  as  anesthesia  proceeds,  Illustrativo  cases  are  found  in  the 
literature  of  the  subject,  and  among  them  is  that  of  Johnston. '^^ 

Acute  yellow  atrophy  of  the  liver  in  the  pregnant  woman  is  an  infectious 
disease  of  uncertain  origin.  Out  of  143  cases  of  this  disorder  Thierfelder 
observed  thirty  during  pregnancy.  Spteth  saw  it  but  once  in  16,502  preg- 
nant women.  Epidemics  of  this  disorder  have  been  reported  by  Kerksig, 
Charpentier,  and  Bardinet.  Lonier's  excellent  jiaper  upon  the  subject,  and 
the  reports  of  Mavthews  Duncan  '^•*  describe  this  complication  fully.  Its 
s}/mptoms  are  those  of  jaundice,  hematogenic  and  hc))atogenic,  witli  evidence 
of  profound  intoxication  from  the  absorption  of  septic  material  and  toxins. 
On  palpating  the  abdomen  the  area  of  liver-dulnoss  is  diminished  ;  after  the 
stage  of  incubation,  lasting  from  three  to  five  days,  the  ])atient  has  gastric  and 
intestinal  catarrh  with  rigor,  j)ains  in  tlie  head  and  back,  and  fever.  Albu- 
minuria is  often  present ;  in  severe  cases  there  is  great  tenderness  over  the 
liver  and  abdomen.  Occasionally  the  disease  results  in  death  before  delivery. 
As  a  rule,  patients  come  into  labor  or  abort  with  a  fatal  issue.  In  a  case 
recently  observed  1,'y  the  writer  the  profotuid  jaundice  of  the  mother  was 
reproduced  in  the  bright  yellow  color  of  the  amniotic  liquid  and  the  deep 
orange  staining  of  the  fetus  and  its  appendages.  This  patient  had  high  fever 
before  delivery,  and  died  in  septic  coma  shortly  afterward.  The  cause  of 
acute  yellow  atrophy  with  malignant  jaundice  is  blood-poisoning  from  acute 
septic  infection.  Its  pro(/no.m  is  exceedingly  grave,  and  the  treatment  of 
these  cases  consists  in  the  effort  to  terminate  pregiumcy  promptly,  to  arouse 
the  secretions  of  the  intestinal  canal,  and  to  support  the  patient's  strength. 

Tlie  milder  form  of  jaundice  diirinfj  prcffnanci/  may  result  from  impaction 
of  feces,  catarrh  f)f  the  bile-ducts,  pressure  of  the  jiregnant  womb  upon  the 
liver,  and  the  physiological  hyperemia  which  the  liver  shares  in  common  with 
other  abdominal  viscera.  Failure  in  excretion  by  the  kidneys  in  greater  or 
lesser  degree  is  often  noted  in  these  cases,  and  the  development  of  gall-stones 
is  a  not  infrequcjit  accompaniment.  Where  the  disorder  is  ])romptly  recog- 
nized, and  the  gastro-intestinal  tract  is  subjected  to  proper  and  ctKcient  treat- 
ment, it  is  often  ])ossible  to  avoid  fatal  issue.  Winter  describes  an  illustrative 
case"*  in  which  a  nuiltigravida  who  had  suflTered  froui  malarial  intoxication 
was  attacked  with  jaundice.  After  a  violent  illuess  of  six  or  eight  days,  with 
great  gastric  disturbance  and  vomiting,  prematui'c  labor  occurred,  after  which 
the  mother  recovered.  Tlie  frcdimcnt  of  this  coudition  is  the  medicinal  treat- 
ment appropriate  for  these  cases  in  the  noii-])reguant.  Premature  labor  is  t(» 
be  ex})ected  in  well-marked  cases,  and  in  protecting  the  interests  of  the  mother 
no  effort  should  be  made  to  avoid  it. 

Gastric  ulcer  complicating  pregnancy  has  been  observed  by  Robert  Koch  '*' 
ill  two  j)Mticiits,  each  of  wliom  sulVcred  from  ])rofus<'  vomiting  of  bIoo<l  accom- 
jiaiiied  l)y  alxloiniiial  distress.     In  one,  tlic  milder  case,  pregnancy  was  '\\\in'- 


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THE   PATHOLOGY   OF  PREGXANCV. 


233 


rtipted  and  a  living  child  was  born.  In  the  other  the  patient  collapsed  after 
vomiting  blood  freelv,  and,  although  she  rallied  and  ultimately  recovered,  her 
child  was  stillborn. 

Appendicitis  in  jiregnancy  has  been  well  described  by  Mixter.'^^  Prema- 
ture labor  followed  the  attack,  and  an  abdominal  tumor  demanded  operation. 
The  appendix  was  found  at  the  lower  end  of  the  kidney,  its  position  having 
possibly  been  altered  by  the  pregnant  uterus.  Fecal  concretions  were  present. 
Tiie  patient  recovered  after  ojjeration. 

Albuminuria  and  peptonuria  are  variations  in  the  metabolism  of  the 
pregnant  i)atient,  and  are  of  interest  and  importance  to  the  oi^stetrician.  Tiie 
clinical  importance  of  the  presence  of  serum-albumin  in  the  urine  in  ])regnancy 
has  been  greatly  exaggerated,  and  a  closer  study  of  the  excretions  has  demon- 
strated its  very  limited  significance.  In  accordance  with  tlie  preciseness  and  the 
delicacy  of  the  tests  employed  serum-albumin  has  be(;n  found  to  be  present  by 
Schroeder  in  from  3  to  5  per  cent. ;  Iiigersiev,  4.8  percent. ;  Flaischleii,  2.6  per 
cent. ;  Meyer,  5.4  per  cent. ;  while  Lantos,  in  an  interesting  series  of  observa- 
tions at  Budapest,'^  found  albumin  in  18  per  cent,  of  pregnant  women  and  in  60 
])er  cent,  of  tliose  recently  delivered.  In  thirty-nine-  fatal  cases,  in  whicli  tlio 
urine  had  contained  albumin,  the  patients  had  suilercd  neither  from  eclamjjsia 
nor  from  nephritis.  The  kidneys  in  these  cases  were  very  pale  and  anemic. 
Lantos  is  convinced  that  albuminuria  is  very  common  among  pregnant  women, 
that  it  results  from  reflex  irritation  of  the  vaso-motor  nerves  of  the  renal  vessels, 
and  that  it  has  no  patiiological  significance;  it  may,  however,  be  of  value  as  a 
sign  of  pregnancy  in  making  a  ditt'erential  diagnosis.  Peptone  has  been  found 
in  the  urine  of  pregnant  women,  and  it  is  thought  by  some  to  be  an  evidence  of 
the  death  of  the  fetus.  Thomson  '**  could  not  observe  that  peptone  was  cha- 
racteristic of  the  pregnant  condition,  nor  that  it  is  a  symptom  of  a  macerated 
or  a  dead  fetus.  According  to  his  researches,  peptone  appears  intermittently 
witiiout  a|)preciable  cause  in  the  urine  during  pregnancy  and  after  lal)()r. 
Vwnn  the  researches  of  Koettnitz,'^"  who  examined  the  urine  in  31  cases  of 
pregnancy,  we  may  believe  that  peptone  is  not  a  sign  of  fetal  death.  Its 
presence  seems  a  |)hysiological  phenomenon,  only  becitming  jiathologieal  when 
this  su))stance  is  found  in  excess.  In  I'omplicated  labor  where  maceration  of 
the  fetus  and  severe  visceral  disease  of  the  motlier  are  present  it  has  been 
found. 

Tlie  treatment  of  albumiiuu'ia  and  peptonuria  during  pregnancy  consists 
in  interference  and  lational  iiygieiie.  As  most  ]tregnant  ]vitients  eliminate 
insuttieieiitly,  such  forms  of  diet  as  agree  best  with  the  individual  case  should 
he  enjoined.  The  peculiarities  of  the  individual  should  be  stiidicvl  chwly,  and 
tile  whole  range  of  tiierapiMitie  and  medical  art  will  tre(|ueiitly  be  taxed  to  aid 
the  patient  in  solving  the  diilieult  problem  of  nourishing  herself  and  her 
unborn  ehihl.  Many  specifi(!  treatments  have  been  urged  i'or  albumimwia  ; 
among  them  is  the  benzoic-acid  treatment,  sometimes  eond)ined  with  bicarbon- 
ate of  ])otassium.  Various  ]  \ugatives  have  been  giv(  ii  in  these  eases,  the  best 
purgatives  being  those  that  do  not   introduce  into  the  blood  of  the  |)alieut  a 


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AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


largo  amount  of  potassium  salts.  In  general  it  may  be  said  that  the  presence 
of  albumin  or  of  peptone  in  the  urine  of  a  pregnant  patient  is  not  of  itself  a 
l)athologieal  phenomenon,  and  it  is  only  when  the  presence  of  albumin  is  asso- 
ciated with  casts  and  deficient  excretion,  as  indicated  by  deficient  urea,  that 
albumin  becomes  an  indication  of  disease. 

Abnormal  conditions  of  the  mouth  and  teeth  during  pregnancy  may 
occasion  cousideraljle  distress  and  inconvenience  to  the  patient.  The  gums 
fre(piently  become  abnormally  soft,  and  a  condition  known  as  "  white  caries" 
is  often  seen  in  the  teeth.  The  edges  of  the  gums  are  thin,  pale,  somewhat 
shrivelled  in  appearance,  and  retracted  from  about  the  teeth.  A  jirominent 
ridge  along  the  free  border,  often  of  deeper  tint  than  the  surrounding  mem- 
brane, is  sometimes  observed.  In  other  cases  the  gums  are  reddish  and  are 
apparently  softened,  exuding  a  thin  fluid  or  pus  from  around  the  neck  of  the 
tooth.  Such  a  condition  does  not  imply  neglect  of  cleanliness,  but  it  seems  a 
passive  congestion  and  transudation  from  the  tissues.  It  has  been  shown  by 
Elliott  '^°  and  others  that  this  condition  of  caries  in  the  teeth  results  from  the 
altered  secretions  in  the  oral  and  buccal  cavities.  The  secretion  of  saliva  is 
much  increased,  ptyalin  being  often  absent.  The  saliva  early  in  the  day  is 
often  of  acid  reaction,  and  this  is  thought  to  have  a  potent  influence  upon  the 
development  of  curies  of  the  teetli.  This  disorder  is  sometimes  known  as 
"brown  caries"  when  extensive  discoloration  of  the  teeth  is  ])rcsent.  The 
margins  of  cavities  in  these  cases  are  black.  A  line  of  brownish  discolora- 
tion sometimes  occurs  upon  the  upper  incisors  or  the  canines.  The  enamel  is 
opacjue.  This  form  of  caries  generally  begins  in  the  region  of  the  bicuspids 
of  the  upper  or  lower  jaw,  and  is  usually  found  among  ])atients  of  the  lower 
classes.  Softening  of  the  dentine  of  the  upper  bicuspids  and  molars  is  some- 
times observed,  apparently  liecause  the  bicuspids  are  those  teeth  against  which 
fluid  is  most  forcibly  ejected  in  the  emesis  of  pregnancy  ;  tli(y  are  also  in  con- 
tact with  the  tongue  at  rest.  General  softening  of  the  teeth  without  actual 
decay,  and  loosening  of  the  teeth  in  their  sockets  from  jiartial  absorption  of 
tiie  alveolus,  are  also  observed.  White  or  soft  caries  is  often  found  in  an 
inexplicable  manner  in  patients  apparently  well  nourished,  and  in  its  j)atIiology 
resembles  osteomalacia. 

Affections  of  the  nerves  of  the  face  and  the  teeth  often  accompany  the 
structural  conditions  mentioned.  I?y  some,  altered  nervous  conditions  in  these 
])arts  are  referred  to  pathological  conditions  in  tlie  mucous  nuMnbrane  of  the 
stomach.  Occasionally  pain  in  the  mouth  and  teeth  is  purely  reflex  from  the 
utci'us,  as  in  a  case  described  by  Garrettson  in  which  pain  was  felt  about  a 
carious  tooth.  Its  removal  brought  no  relief,  l)iit  tiie  healing  of  an  ulcerated 
cervix  uteri  caused  the  pain  to  disappear. 

Tlic  frrcidiicitf  of  these  conditions  is  to  be  found  in  a  pro]U'r  attention  to 
the  general  condition  of  the  patient.  Ijoeally,  chhcate  <>l'  potassium  ami 
bromid  />{'  potassium  arc  usefid  when  the  gums  ii:e  irrital)le.  Powdered 
l)oracic  acid  may  be  brusiied  upon  the  teetii  with  a  soft  brush,  or  e(|nal  ])art> 
of  charcoal  and  preeii)itated  chalk  may  be  used   for  short  periods.      In  I'dlcv 


THJ-:  PATHOLOGY    OF  I'REGXANCY. 


2:50 


pain,  felt  in  sound  teeth,  a  i)li8tei'  over  the  fourth  or  Hfth  dorsal  vertebra  has 
been  of  use.  Absohite  alcoht)!  and  eoHodion  may  be  painted  over  a  tooth 
attacked  by  soft  caries.  AVHien  carious  cavities  require  filling,  this  should  be 
accomplished  with  as  little  distress  to  the  patient  as  possible,  and  the  filling 
should  be  of  a  non-irritating  character.  When  a  tooth  occasions  severe  sutl'er- 
ing  during  jiregnancy  there  arc  many  reasons  for  advising  its  removal,  as  preg- 
nancy has  been  interrupted  as  the  result  of  such  distress,  while  the  ])resence 
of  continued  pain  has  an  undoubted  influence  upon  the  development  of  the 
child. 

Exophthalmic  goitre  and  simple  goitre  may  develop  rapidly  during 
pregnancy,  and  by  the  associated  changes  which  occur  in  the  circulation  may 
result  disastrously  to  the  fetus.  Thus  in  a  case  reported  by  Haberlin  '^'  the 
rapid  develojjment  of  exophthalmic  goitre  was  accompanied  by  premature 
separation  of  the  placenta,  with  death  to  the  fetus  at  eight  months.  The 
termination  of  labor  was  followed  by  immediate  cessation  of  the  development  of 
the  goitre.  In  severe  cases  such  patients  become  excessively  nervous,  the  hands 
tremble  violently,  palpitation  of  the  heart  and  a  sense  of  constriction  about  the 
throat  are  present,  with  considerable  emaciation.  Vomiting  is  also  a  symptom 
in  well-marked  cases.  While  palliative  treatment  nuiy  temporarily  relieve 
these  j)atients,  if  the  symptoms  be  urgent  a  removal  of  the  goitre  should 
promptly  be  undertaken. 

Abnormal  conditions  of  the  blood  are  not  of  very  infrequent  occurrence. 
The  normal  condition  of  the  blood  during  pregnancy  in  ill-nourished  women 
is  that  of  temporary  anemia,  which  soon  gives  ])lace  to  a  development  of 
physiological  plethora  and  hyperemia.  It  has  been  shown  by  Dudner'**  and 
others  that  so  sooi  as  the  balance  of  nutrition  becomes  established  a  steady 
increase  in  the  amount  of  corpuscles  and  hemoglobin  is  to  be  observed. 
Narse"-*  found  the  specific  gravity  of  the  blood  during  pregnancy  to  be  102o. 
The  amount  of  fibrin  increases,  while  the  (|uantity  of  salts  and  hemoglobin 
diminishes.  Winckclmann '"  found  that  as  pregnancy  advances  the  quantity 
of  hemoglobin  increases.  Scliroeder '^'  considers  anemia  in  pregnancy  as  the 
exception  and  as  a  pathological  condition,  while  neither  he  nor  Meyer '^' 
observed  a  g'  at  decrease  in  hemoglobin  or  corpuscles.  The  observations 
of  Ingersletf,'"  '^""ehling,'^''  and  Meyer '^'•*  upon  the  comparative  composition 
of  the  blood  in  the  pregnant  and  the  non-pregnant  show  that  in  the  fornu>r 
the  mind)er  of  red  corpuscles  is  slightly  decreased  and  also  the  amoutit  of 
liemoglobin  during  early  pregnancy. 

Aiiriiita  in  tiie  pregnant  is  produced  by  the  same  causes  which  influence 
the  non-pregnant.  Its  recognition  is  effected  i)y  the  same  methods  of  examina- 
tion and  diagnosis  employed  in  the  study  of  internal  medicine.  The  condition 
of  anemia  complicating  pregnancy  was  early  recognized  by  American  physi- 
cians, whose  contributions  to  the  literature  of  the  subject  are  among  the  first. 
Cazeaux  and  the  I'^rench  school  ascribe  to  anemia  many  of  the  disorders  of 
]tregnancy.  A  curious  ;iversion  to  the  treatment  of  anemia  diu'ing  ]M'cgnancy 
by  methods  usually  employed  in  non-pregnancy  is  shown  in  the  records  of 


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AMERICA X    TEXT-BOOK    OF   OBSTETIUCS. 


a  malpnictice  suit  reported  in  1871  by  Woodniaii  to  the  Obstetrical  Society 
of  IjOIuIoh,  when  a  physician  was  sued  for  using  the  ainnioi)io-eitrate  of  iron 
in  the  treatment  of  this  condition.  It  was  claimed  that  he  had  thus  ]iroduced 
abortioji.  The  verdict  of  the  society  was  in  favor  of  the  physician.  Gus- 
serow  '•''*'  reports  five  cases  of  extreme  anemia  in  tl>e  prcj^nant  state.  The 
eiglith  month  seemed  the  perio<l  most  favorable  for  the  development  of  this 
complication.  Bischoff  and  liiermcr  report  cases  of  oligemia  and  anemia 
with  cachexia  at  about  this  period.'"  Cameron's  excellent  descri])tion  of 
leukemia  during  pregnancy'''^  includes  a  case  with  a  marked  family  history 
of  leukemia.  Sanger  ''^  reports  the  case  of  a  leukemic  mother  who  bore  a 
healthy  child,  and  also  of  a  healthy  mother  who  gave  birth  to  a  leukemic 
chihl.  Davis'**  rejwrts  the  case  of  a  multigravida  seized  with  hematogenic 
jaundice.  Examination  of  the  patient's  blood  showed  the  condition  of  per- 
nicious anemia.  The  blood  of  her  fetus  was  found  to  be  normal.  UndcT 
treatment  her  condition  greatly  improved  after  delivery. 

While  it  is  possible  for  these  patients  to  bear  healthy  children,  still  preg- 
nant women  suffering  from  various  forms  of  anemia  and  leid<emia  are  subject 
to  dangerous  symptoms  as  pregnancy  advances  and  as  the  pathological  condition 
of  the  blood  becomes  pronounced.  Important  symptoms  are  epistaxis,  hema- 
temesis,  and  melanemia,  with  the  development  of  a  purpuric  condition.  Atten- 
tion has  been  drawn  by  Laid)enberg  "''  to  the  severity  of  this  comjilication 
and  to  its  almost  inevitable  interruption  of  pregnancy,  and  he  urges  the  early 
induction  of  labor  as  the  duty  of  the  physician. 

The  most  serious  condition  of  the  blood  attacking  the  pregnant  patient  is  'pur- 
pura luvmorrhagicd.  Its  occurrence  and  severity  in  pregnant  women  are  ex- 
plained by  the  sympathy  existing  between  the  utero-ovariati  and  the  tegument- 
arv  systems  of  the  bodv.  This  nervous  connection  is  often  observed  in  the  skin 
eruptions  which  accompany  disorders  of  menstruation.  As  has  been  shown  by 
Immermann,  the  complication  is  sporadic  in  pregnant  patients,  and  it  occurs 
Avithout  regard  to  family  history  or  to  previous  condition.  Phillips"^  col- 
lected cases  illustrating  the  absence  of  previous  history  of  hemophilia  in  these 
patients.  In  some  of  them  hard  work  and  insufficient  nourishment  seem  to  have 
produced  the  disorder.  Profound  mental  disturbance  has  occasionally  been  fol- 
lowed by  this  condition.  In  Phillips'  case  the  child  showed  no  symptoms  of 
])ur])ura,  and  the  mother  recovered  raj)idly  after  labor.  Kaezmarsky  ''^^  reports  a 
case  in  wliich  severe  sacral  pain  during  pregnancy  was  the  first  symptom.  The 
l)irtli  of  a  dead  fetus  followed  speedily,  and  the  mother  perished  from  hemor- 
rhage. Dolirn  reports  twin  pregnancy  with  this  complication,  with  severe  post- 
partum hemorrhage  and  death.  lioth  these  ])atients  had  ])reviously  been 
healthy.  AVernicke,  Recklinghausen,  Ilanot,  and  Luzet  offer  evidence  which 
seems  to  prove,  on  the  one  hand,  that  the  disorder  is  a  form  of  infection  by  bacilli ; 
on  the  other  hand,  the  cases  described  by  Dohru  ''^^  do  not  point  to  this  con- 
dition as  causative.  The  immunity  of  the  fetus  in  these  cases  is  inexplicable 
and  of  interest.  Microscopic  study  made;  of  the  l)loo<l  in  this  complication  by 
(iibbon  during  the  height  of  an  attack  of  purpura  showed  that  the  red  cor- 


THE   PATHOLOGY   OF  PREGNANCY. 


237 


pn.sples  contaiuod  muubcrs  of  hlm-k  granules  massed  togotlicr  in  some  of  the 
coll.s.  Tlu'se  bodies  increased  as  the  (hsorder  became  severe,  and  diminished 
in  convalescence.  The  nnmbei'  of  corpuscles  early  in  the  disease  was  over 
5,000,000  per  cubic  millimeter,  this  number  being  greatly  diminished  as  the 
disorder  made  progress.  The  white  corpuscles  became  excessive,  and  the 
hemoglobin  fell  to  30  per  cent.,  afterward  rising  to  60  per  cent. 

The  irmtinvnt  of  anemia  and  Ictdcemia  complicatii.;,  pregnancy  consists  in 
securing  thorough  elimination,  and  in  the  employment  of  those  forms  of  treat- 
ment found  usefid  in  the  non-pregnant  ])ationt.  Osier'*'  obtained  good 
results  from  the  persistent  use  of  arsenic,  the  free  use  of  iron,  the  inhalation 
of  oxygen,  systematic  and  forced  feeding,  and,  of  great  importance,  the  correc- 
tion of  the  condition  of  gastro-intestinal  catarrh  so  often  found  in  these  cases. 
The  patient's  strength  should  be  conserved  in  every  possible  manner.  Should 
purpuric  eru|)tion  devclo}),  with  hemorrhages,  antiseptic  dressings  must  be 
applied  over  these  areas,  and  care  should  be  taken  that  bichlorid  of  mercury 
is  not  employed,  the  susceptibility  of  anemic  pregnant  j)atients  to  mercurial 
poisoning  being  a  contra-indication  to  its  use.  Bichlorid  of  mercury  in 
minute  doses  should  be  given  when  a  possible  sy])hilitic  taint  is  suspected 
as  a  complication.  The  j)rompt  induction  of  labor  is  required  in  cases  where 
the  disorder  steadily  increases  in  severity,  although  this  procedure  when  the 
])atient  has  reached  a  critical  condition  is  useless  and  unjustifiable.  If  done  at 
all,  labor  should  be  induced  promptly  and  while  there  yet  remains  sufficient 
strength  to  justify  a  hope  that  the  patient  will  rally. 

Cardiac  disease  complicating  pregnancy  is  not  infrequently  observed. 
In  those  patients  who  are  well  nourished  slight  cardiac  lesions  are  frequently 
undete(!ted  during  ])regnancy  and  cause  no  embarrassment  at  labor.  A 
])hysiological  hy))ertrophy  of  the  heart  occiu'ring  during  pregnancy  is  well 
described  by  Larchcr,  who  found  hyjiertrophy  of  the  left  ventricle  in  preg- 
nant women.  Other  observers  assert  that  this  hypertrophy  is  associated 
with  dilatation  of  the  right  heart.  Istria'^  and  others  maintain  that  preg- 
nancy often  induces  endocarditis,  and  other  observers  have  noted  the  devel- 
opment of  endocarditis  after  repeated  parturition.  The  most  fatal  of  these 
lesions  in  the  pregnant  patient  is  mitral  stenosis.  Marshall""  and  Duck- 
worth demonstrated  the  remarkable  ])reponderance  of  this  form  of  heart 
disease  in  women.  Direct  cardiac  symptoms  are  comparatively  few,  con- 
sisting of  ])alpitati()n,  sometimes  i)ain  and  depression.  Bronchial  catarrh 
is  generally  obsei'ved.  The  want  of  concMirrcnce  between  the  cardiac  sys- 
tole and  the  impulse  given  by  the  pulse-wave  is  an  interesting  and 
important  diagnostic  point  in  these  cases.  Cases  reported  by  Fritscli, 
Budin,  Macdonald,  and  Malherbe  illustrate  the  occurrence  and  fatal  termi- 
nation of  this  disorder.  The  results  of  this  lesion  in  14  cases  given  bv 
Macdonald  were  death  in  nine.  Porak  saw  eight  fatal  cases  out  of  13.  Remy 
in  19  cases  found  el(>ven  fatal.  In  double  n\itral  lesion  seven  out  of  Hart's  8 
cases  perished.  In  one-half  of  the  cases  recorded  pregnancy  has  been  inter- 
rupted without  interference.     Half  of  these  patients  died  and  half  of  them 


rm 


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238 


.  I  .}fEIf  /( 'A  X  TKXT-  li  O  OK  OF  O  liSTETn  K  'S. 


recovered.  The  pretloiuiiiaiiee  of  piilinoiiiirv  syin|»t(»ms  in  mitral  stenosis 
sliould  l)c  borne  in  mind  in  makinj^  a  diagnosis  and  in  instituting  treatment. 

Wliile  tlie  mortality  ol"  pregnaney  eomplicated  by  mitral  stenosis  is  more 
than  ')()  por  cent.,  aortic  lesions  give  u  mortality  of  'J.']  per  cent.  Mitral 
insnllieieney  is  aci  redited  with  1.3  per  cent.,  wliile  in  complex  lesions  (»f  tin; 
heart  a  mortality  of  50  per  cent,  is  a  conservative  estimate.  The  prognosis 
for  the  continuance  of  pregnancy  and  for  the  life  of  the  chihl  is  distinctly 
tinfavorable.  Mack ness '"^  reports  a  case  of  pregnancy  complicated  by  aortic 
and  mitral  disease  in  which  labor  was  indiiccil.  Partial  reeoverv  ensned. 
The  patient's  condition  of  prostration  became  so  excessive  (hiring  the  latter 
})ortion  of  her  pregnancy  as  to  require  vigorous  stiinnlation.  She  was  greatly 
prostrated  by  ])ersistent  emesis  and  ))aroxysnis  of  oppression,  which  were 
relieved  by  the  administration  of  nitrite  of  aniyl. 

Mcrklen  "'*  reports  an  illustrative  case  in  which  pulmonary  tuberculosis 
■was  associated  with  stenosis  at  the  mitral  orifice.  Dilatation  of  both  sides  of 
the  heart  was  present,  with  general  anasarca  and  exaggerated  pulmonary  con- 
gestion. Venous  stasis  in  the  kidneys  was  well  pronounced.  I'ulmonary 
liemorrhage  occurred,  and  it  was  a  temporary  relief  to  the  patient. 

Hemoptysis  complicating  pregnancy  may  occur  from  simple  pulmonary 
congestion  in  eases  of  valvular  heart  disease,  or  may  result  from  disease  of 
the  parenchyma  of  the  lung,  most  commonly  tubercular.  ^Cartin'®^  describes 
the  case  of  a  patient  four  months  pregnant  who  sutt'ered  from  obstinate  and 
j)ersistent  hemoptysis.  There  were  jiulmonary  signs  of  consolidation  an- 
teriorly below  the  right  clavicle.  Bleeding  occurred  at  about  the  time  when 
the  patient  would  have  nnnistruated  had  she  not  been  pregnant.  Kjjistaxis 
subsequently  develoi)ed,  and  later  a  profuse  red  rash,  resembling  that  of 
scarlatina,  covered  the  body.  This  rash  gradually  faded,  and  was  not  attended 
by  fever  or  any  signs  of  other  complication.  I'ulmonary  signs  gradually 
improved,  especially  under  treatment  by  a  succession  of  blisters  upon  the 
ch(>st,  that  gave  marked  relief.  The  j)aticnt  entirely  recovered  and  went  to 
the  usual  termination  of  pregnancy. 

Hemorrhage  from  the  Uterus. — The  fact  that  ])rofuse  hemorrhage  from 
the  uterus  may  occur  during  pregnancy  and  still  the  ])atient  go  cm  to  the  end 
of  gestation  is  well  illustrated  in  a  case  descriljcd  by  llobertson.'^''  His  patient 
was  a  multiy-ravida  who  had  several  liemorrhaues  so  severe  as  on  each  occasion 
to  cause  the  supposition  that  abortion  had  occurred.  Her  pregnancy  continued 
to  a  successful  termination. 

Internal  hemorrhage  is  observed  asacom])lication  in  patients  sufl'ering  from 
nephritis  during  ])regnancy.  To  such  an  extent  may  syni])toms  of  shock  and 
acute  anemia  l)e  ]>resent  that  placenta  prfevia  has  been  susjiccted  in  these  cases. 
Schauta"'®  reports  the  ease  of  a  \vonian,  aged  forty-ibur,  who  had  borne  nine 
children,  and  in  whom  profuse  hemorrhage  caused  a  diagnosis  of  placenta  pra3via. 
Although  the  jiatient  was  not  in  lalxjr,  the  os  was  sufficiently  dilated  to  permit 
a  diagnosis  to  be  made  that  placenta  i>ncvia  was  not  present.  Transfusion  by 
normal  salt-solution  was  iminetliately  performed,  and  when  the  patient  rallied. 


i'. 


THE   PATHOLOGY   OF  PliEGNANCY. 


2:50 


as  tho  diild  was  (load,  it  was  extracted  by  craniotomy.  A  larj;c  amount  of 
clotted  blood  was  found  in  the  uterus  and  vaj-ina.  Tin-  patient  siiecuinbed 
from  tiie  hemorrhage  shortly  after  delivery.  The  post-mortem  examination 
revealed  chronic  nephritis  as  the  only  complication  accounting  for  the  con- 
dition.    Winter  observed  three  similar  cases  in  Schroeder's  clinic. 

3.  Acute  Infections  during  Pregnancy. 

The  condition  of  pregnancy  renders  the  patient  peculiarly  liable  to  the 
rapid  development  of  infective  germs.  The  body  of  the  pregnant  woman 
presents  that  condition  of  plethora  and  hyperemia  in  the  viscera  that  invites 
the  growth  of  bacteria.  It  is  not,  then,  difficult  to  understand  why  these 
complications  of  pregnancy  are  among  the  most  severe.  First  among  these 
disorders  may  be  considered  those  in  which  the  infection  usually  gains  access 
to  the  body  through  the  genital  tract.  Such  disorders  are  gonorrhea,  syphilis, 
and  cancer. 

Gonorrhea  is  by  no  means  an  uncommon  complication  of  pregnancy,  and 
in  an  ignorant  woman  no  intelligent  history  attracting  the  attention  of  the 
physician  to  the  condition  present  may  be  afforded.  The  complaint,  howes'cr, 
of  difKcidty  in  micturition  and  of  burning  and  irritant  discharge  should 
occasion  an  examination,  when  specific  vaginitis  may  be  detected.  The  symp- 
toms and  treatment  of  this  disorder  in  the  pregnant  are  essentially  those  in 
the  non-pregnant,  but  the  pathology  of  the  condition  is  more  complex  and  of 
greater  import.  Not  (july  may  the  gonococci  infect  the  nuicous  membrane 
of  the  vagina,  and  possibly  cause  abscess  of  JJartholini's  glands,  with  oc- 
casional acute  inflammation  of  the  rectum  and  the  surrounding  tissues,  but 
the  endometrium  also  may  be  attacked,  and  even  the  fetus  may  be  infected 
in  ntero,  by  the  gonorrheal  virus.  Children  have  been  born  with  gonorrheal 
o])hthalmia  and  under  circumstances  which  precluded  the  possibility  of  in- 
fection during  birth.  Such  infection,  however,  is  of  comparatively  little 
importance  when  compared  with  the  dangers  arising  to  the  mother  from  the 
development  and  retention  of  gonorrheal  infection  in  the  tissues  about  the 
uterus  and  in  the  tubes  and  t)varies.  The  entire  genito-urinary  tract  of  the 
mother  is  liabU?  to  such  infection,  the  consequences  of  which  may  not  become 
apparent  until  some  time  after  delivery.  Thus,  in  the  writer's  observation  a 
patient  })erished  from  the  sudden  and  acute  septic  inf(L>ction  occasioned  by  the 
spontaneous  rupture  of  a  small  gonorrheal  ovarian  abscess  occurring  two 
weeks  after  delivery.  This  ))aticnt's  puer[)eral  period  had  apparently  been  nor- 
mal, and  the  infection  n'ust  have  l)een  received  before  or  during  pregnancy.  The 
same  observer  witnes  d  death  from  nephritis  in  which  the  genito-urinary 
tract  had  been  the  cat  during  jircgnancy  of  gonorrheal  infection.  In  this 
case  the  tubes  and  ovaries  escaped,  but  the  bladder  and  ki<]neys  showed 
abundant  infective  germs.  The  presence  of  gonorrhea  as  a  complication  of 
pregnancy  should  lead  to  prompt  antise])sis  of  so  nuich  of  the  genital  tract 
as  is  accessible.  If  the  bladder  is  invaded,  it  should  also  be  subjected  to  the 
same  thorough   antisepsis.      At  the  time  of  labor  all  possible   precautions 


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should  be  taken  to  avoid  violence  to  the  uterus  or  its  appendages  that  may 
set  free  retained  gonorrheal  poison.  During  the  puerperal  period  the  occur- 
rence of  septic  inHaniiuation  in  and  about  the  uterus  should  be  treatetl 
])r()niptly  by  intra-utcrine  antisepsis,  or  so  soon  as  possible  by  abdominal 
incision.  It  is  folly  to  treat  the  insidious  ravages  of  gonoi*rhea  in  the  con- 
nective tissue,  the  peritoneum,  and  contents  of  the  pelvis  occurring  after 
labor  by  any  but  prompt  surgical  measures.  Hxploratory  abdominal  incision 
is  far  more  conservative  in  these  cases  than  delay. 

Syphilitic  infection  during  pregnancy  in  many  cases  runs  the  usual  course 
of  this  tlisorder,  and  in  others  it  assumes  peculiar  malignancy.  Patho- 
logically speaking,  the  viridence  of  syphilitic  infection  in  pregnancy  depends 
n(;t  only  upon  the  patient's  powers  of  resistance,  but  also  upon  septic  germs 
vvhich  may  be  associated  with  the  bacillus  of  syphilis.  Some  of  the  most 
malignant  types  of  puerperal  sepsis  are  observed  in  patients  who  become 
syphilitic  at  conception  or  during  pregnancy.  In  these  patients  the  syphilitic 
eruption  is  so  masked  and  exaggerated  by  the  septic  element  present  as  to 
occasion  great  difficulty  in  diagnosis.  The  writer  recalls  a  case  of  this 
sort  where  close  study  by  Kaposi  was  necessary  to  differentiate  between  an 
acute  syphilitic  exanthem  and  septic  infection.  Hirigoyen'*^  describes 
the  occurrence  of  syphilis  in  34  patients,  who  corajn-ised  5  per  cent,  of  the 
total  number  of  pregnancies  under  observation.  Other  statistics  seem  to 
indicate  that  this  percentage  is  the  usual  one  in  pregnancy  occurring  in  large 
cities. 

The  influence  which  pregnancy  exerts  upon  women  already  syphilitic  has 
been  described  by  Fournier,  who  laid  down  the  maxim  that  a  syphilitic 
woman  who  becomes  pregnant  is  much  more  likely  to  abort  than  is  a  preg- 
nant woman  who  becomes  syphilitic.  The  percentage  also  of  fetal  death  in 
syphilitic  women  who  become  pregnant  is  much  greater  than  among  pregnant 
women  who  become  syphilitic.  The  age  of  the  syj>hilis  exercises  a  very  dis- 
tinct influence  upon  the  prognosis  of  the  pregnancy  :  the  longer  the  woman 
has  been  syphilitic  before  pregnancy  occurs,  provided  she  has  not  been  sub- 
jected to  efficient  treatment,  the  worse  is  the  prognosis  for  the  eontimiance  of 
the  pregnancy  and  the  life  of  the  fetus.  The  prognosis  of  pregnancy  is  also 
very  serious  the  earlier  in  the  pregnancy  the  infection  occurs  ;  thus,  the 
majority  of  pregnancies  complicated  by  syphilitic  infection  occurring  during 
the  flrst  four  months  result  in  the  death  of  the  fetus.  When  infection  occurs 
from  the  fourth  to  the  sixth  month  of  pregnancy  50  per  cent,  of  children  are 
lost.  During  the  last  three  months  of  pregnancy  the  comnlication  of  syphilis 
results  in  the  death  of  less  than  half  of  the  children.  General  fetal  mortality 
in  ayj)hilis  is  under  the  best  circumstances  75  per  cent. 

The  mother's  iiealtli  in  pregnancy  complicatwl  by  syphilis  is  liable  to 
rapid  deterioration  if  tin'  syphilitic  process  be  acute.  The  stimulus  of  j^reg- 
nancy  seems  to  exaggerate  the  sj)read  of  the  poison  and  the  various  lesions 
which  it  causes.  To  l)e  efficient,  aiitisyphilitic  treatment  should  begin  as  soon 
as  the  infection  occurs,  anil  the  earlier  in  the  pregnancy  such  treatment  is 


THE  PATHOLOGY   OF  PBEGNANCY. 


241 


begun  the  better  are  the  results  obtaineil.  Local  treatment  of  syphilitic 
lesions  complicating  pregnancy  consists  in  thorough  cleanliness  and  in  the 
maintenance  so  far  as  possible  of  local  antisepsis.  Ulcers  should  be  dusted 
with  calomel  and  iodoform ;  the  parts  should  be  kei)t  thoroughly  clean  with 
antiseptic  douches,  and  the  discharges  from  syphilitic  patients  should  be 
received  upon  absorbent  material,  which  is  then  burned.  Antisyphilitic 
medication  is  to  be  conductetl  in  accordance  with  the  therapeutics  of  this 
disorder  in  the  non-pregnant.  The  biniodid  of  mercury,  the  bichlorid  of 
mercury,  calomel,  gray  powder,  and  the  bichlorid  hypodermatically  are  all  of 
use.  Inunctions  with  mercurial  ointment  are  found  advantageous  in  many 
cases.  In  those  patients  with  whom  mercury  does  not  agree  iodid  of  potas- 
sium in  combination  with  iodin  may  be  used  to  advantage.  The  following 
mixture  has  proved  efficacious  in  a  number  of  cases : 


Iodin, 

Iodid  of  potassium, 
Compound  syrup  sarsaparilla. 
Dose,  one  tcaspoonful  after  meals. 


gr.  IV ; 
.^iv ; 
.Siv. 


Besnier'*®  obtained  good  results  with  a  pill  containing  ^  of  a  grain 
of  bichlorid  of  mercury  with  y^  of  a  grain  of  extract  of  opium  and  ^Jj  of  a 
grain  of  extract  of  gentian,  rubbed  up  with  glycerin. 

Equally  important  with  the  specific  treatment  of  syphilis  in  pregnancy  is 
the  tonic  treatment  wliich  these  cases  demand.  Well-ordere<.l  feeding,  in 
which  an  abundance  of  fat  in  cod-liver  oil  or  other  forms  is  includetl,  and 
tiie  persistent  administration  of  iron,  arsenic,  nux  vomica,  and  such  substances 
as  stimulate  digestion,  are  of  the  greatest  importance.  The  aim  of  the  physi- 
(jian  must  be  not  simply  to  tear  down  diseased  tissue,  but  to  build  up  that 
which  is  sound.  The  results  of  such  treatment  are  often  most  gratifying. 
The  characteristic  lesions  of  syphilis  fade  with  great  rapidity  in  these  cases  ;  the 
l)aticnt  who  may  have  repeatedly  aborted  goes  on  nearly  or  quite  to  term,  and 
a  fairly-devoloped  and  healthy  child  is  born.  Neglect,  however,  or  inadequate 
treatment  for  these  patients  often  resjilts  in  sad  ravages  in  the  mother's  tissues, 
resulting  very  frequently  in  fetal  death. 

Oincer  complicating  pregnancy  affects  the  course  of  gestation  chiefly  in 
its  local  manifestations  in  the  genital  tract.  In  rare  instances  multiple  sar- 
comata develop  with  great  rapidity  in  various  portions  of  the  body,  causing 
(loath  by  constitutional  infection.  In  otiier  instances  cancer  of  the  uterus  by 
metastasis  sjieedily  retluces  the  patient  to  a  condition  of  threatened  collapse, 
often  resulting  in  constitutional  septic  infection.  In  such  cases  the  interruption 
of  pregnancy  seems  of  very  little  avail  for  the  patient,  except  i  »  so  far  that 
tlio  malignancy  of  the  cancerous  process  seems  less  acute  if  the  uterus  is 
emptied. 

Ti/phoid  infection  during  ])regnancy  seriously  complicates  the  mother's 
chance  of  convalescence  from  labor,  and  frequently  results  in  tiie  deatii  of 
16 


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242 


AMERICAN   TEXT-BOOK  OF   OBSTETRICS. 


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the  fetus.  In  a  case  clcscribcd  by  Findlay  "'  the  hnsbaiul  had  been  ill  for 
8otue  time  w'th  typhoid  infection.  The  patient's  pregnancy  was  terminated  at 
about  the  expected  time,  labor  occurring  with  a  temperature  of  103°  F.  and 
the  pulse  I-IO.  The  uterus  contracted  well,  although  during  labor  intestinal 
jMjristalsis  was  active  and  the  patient  had  diarrhea,  M-hich  subsided  after 
delivery.  The  secretion  of  milk  did  not  occur,  the  breasts  remaining  without 
signs  of  activity.  The  skin  of  the  child  was  shrivelled,  and  after  a  few  days 
it  showed  an  eruj)tion  with  bullous  spots,  the  scars  of  which  persisted  when 
the  child  had  reachetl  adult  life.  Pregnancy  is  interrupted  in  these  cases  by 
continuetl  high  temperature,  by  hemorrhage  in  the  endometrium  or  in  the 
membranes  of  the  ovum  itself,  and  by  a  depi-essed  condition  of  the  maternal 
circulation,  with  asphyxiation  of  the  child.  Kaminski,  Zulzer,  and  Scanzoni 
observed  in  two-thirds  of  their  cases  the  interruption  of  pregnancy.  The 
fact  that  the  fetus  may  become  infccteil  by  the  transmission  of  the  germs  of 
typhoid  through  the  ])lacenta  has  been  demonstrated  by  Giglio.""  The  latter 
examinwl  carefully  a  fetus  and  its  appendages  born  from  a  mother  suffering 
with  typhoid  fever  in  an  epiden)ic  at  Palermo.  Pregnancy  terminated  forty- 
six  days  after  the  beginning  of  the  fever.  Although  the  specimen  seemed 
normal  on  casual  examination,  cultures  of  the  maternal  blood  demonstrated 
the  presence  of  the  typhoid  germ,  while  cultures  from  the  milk  revealed 
bacteria  exactly  resembling  those  obtained  from  a  typhoid  non-i>regnant  pa- 
tient. The  fetus  and  its  apjwndages  also  contained  typhoid  bacilli.  Boyd  "' 
reports  a  ease  in  which  a  week  after  the  fever  began  premature  labor  occurred. 
The  i)atient  finally  succumbed  after  continuetl  high  temperature. 

The  fUagnosis  of  typhoid  fever  complicating  pregnancy  presents  no  especial 
difficulty.  Should  the  physician  see  the  case  during  the  puerperal  pericKl,  it 
must  not  be  mistaken  for  puerperal  sepsis,  nor  should  puerperal  sepsis  com- 
plicated by  diarrhea  be  mistaken  for  typhoid  fever.  It  will  be  remembered 
that  in  septic  cases  diarrhea  is  a  not  infrequent  symptom.  The  treatment 
of  typhoid  fever  during  pregnancy  should  be  addressed  to  controlling  the 
temperature  and  to  maintaining  the  patient's  strength.  Such  cases  are 
especially  fitte<l  for  the  treatment  of  pyrexia  by  the  bath  and  pack.  The 
latter  is  most  efficacious  where  the  very  energetic  application  of  cold  has  a 
tendency  to  prostrate  the  patient.  Xo  fear  nee»l  be  felt  regarding  the  in- 
duction of  labor  by  treatment  addressetl  to  controlling  the  temperature,  for  it 
will  not  be  such  treatment,  but  its  failure  to  modify  the  fever,  which  will 
bring  about  a  premature  ending  of  gestation.  The  fact  that  in  many  pregnant 
patients  suffering  from  typhoid  the  stomach  is  excessively  irritable  will  lead 
the  physician  to  abstain  from  the  administration  of  drugs  by  the  stomach  s(» 
far  as  possible. 

TJrynipelas  during  pregnancy  is  of  not  infrequent  occurrence,  and  it  is 
grave  or  is  slight  as  a  complication  in  accordance  with  the  accompaniment 
of  other  forms  of  septic  germs.  Facial  erysipelas  may  occur  in  the  pregnant 
patient,  and  even  abortion  may  follow,  without  the  development  of  puerj)cral 
sepsis.     Such  a  result,  however,  is  possible  only  when  strict  antiseptic  pre- 


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THE  PATHOLOGY   OF  PUEGXANCY. 


243 


cautions  are  observed.  Erysipelas  of  the  genital  tract — or  of  the  lower 
extremities,  where  the  infective  germ  gains  ready  access  to  the  genital  tract — 
resnlts  almost  invariably  in  puerperal  septic  infection.  The  symptoms  of 
erysipelas  complicating  pregnancy  do  not  differ  essentially  from  those  of  the 
disorder  in  the  non-pregnant  patient.  The  treatment  consists  in  supporting 
carefully  the  patient's  strength,  and  in  avoiding  all  unnecessary  examinations 
and  manipulations  in  the  genital  tract,  as  interference  with  this  portion  of  the 
patient's  body  is  an  addetl  risk  of  infection.  Smith '"  reports  the  case  of  a 
woman  six  months  pregnant  who  injured  her  knee.  Erysipelas  develojied  in 
the  thigh  eight  days  afterward,  and  it  was  followed  by  a  large  abscess  burrow- 
ins:  beneath  the  muscles.  Premature  labor  occurretl  at  seven  and  a  half 
months.  The  puerperal  period  was  normal  and  the  child  survived.  In  a 
recent  case  of  facial  erysipelas  under  the  observation  of  the  writer  the  mother 
suffered  but  slight  inconvenience  from  the  infection,  but  gestation  terminated 
prematurely,  the  child  surviving. 

Erysipelas  of  the  face  and  head  seems  to  affect  the  fetus  in  many  cases 
quite  as  markedly  as  in  erysipelas  of  the  pelvic  organs.  Cohn  '"  reports  a 
case  of  facial  erysijielas  at  eight  months'  pregnancy.  The  fetus,  prematurely 
born,  showed  upon  the  corresponding  portions  of  the  head  and  face  an 
edematous  red  swelling  which  gradually  faded,  followed  by  desquamation. 
Examination  of  the  infiltrated  tissues  for  erysipelas-germs  gave  negative 
results.  The  child  perished  from  multiple  abscesses  in  the  kidneys.  A 
similar  condition  of  the  fetus  has  been  described  by  Runge,  Kaltenbach,  and 
Stratz. 

Measles. — Of  about  the  same  relative  virulence  as  erysipelas  is  the  infec- 
tion of  measles  attacking  the  pregnant  patient.  The  symptomatology  of 
this  disorder  occurring  during  gestation  does  not  differ  essentially  from  that 
ordinarily  observal.  If  the  bronchitis  usually  accompanying  measles  l)e 
severe,  the  incessant  cough  and  movements  of  the  abdominal  walls  thus 
occurring  greatly  increase  the  probability  of  abortion.  The  child  may  be 
born  with  an  anomalous  eruption  or  it  may  apparently  escape.  The  prog- 
nosis of  measles  complicating  pregnancy  is  to  be  based  upon  the  severity  of 
the  infection,  and  especially  the  continuance  of  high  temperature. 

The  infection  of  measles  may  be  transferred  from  mother  to  child,  as  illus- 
trated by  a  case  described  by  Lomer;'"  the  child  perishe<l  from  intestinal 
catarrh  ;  the  mother  recovered.  The  child's  eruption  was  characteristic  on 
the  forehead  and  breast  a  few  hours  afler  birth.  Gautier  "*  found  measles 
transmitted  from  mother  to  fetus  in  six  out  of  11  cases:  the  maternal  mortal- 
ity of  the  11  cases  was  two. 

Scarlatina  is  a  serious  com])lication  of  pregnancy,  and  its  virulence  is 
shown  from  the  great  prom|)titude  with  which  it  affects  the  fetus  in  ntero. 
The  fact  that  the  germ  of  scarlatina  is  morphologically  held  by  mariy  ob- 
servers to  be  identical  with  various  forms  of  septic  bacteria  renders  scarlatinal 
infection  of  grave  im])ort.  An  illustrative  case  is  reported  by  Ballantyne 
and  Milligan,"*  in  which  the  infection  occurred  during  the  seventh  month  of 


m 


244 


AMERICAN   TEXT-BOOK    OF   OBSTETRICS. 


n 


1/ 


prcfjiiaiu'V.  Two  days  later  gestation  ended,  and  the  f'etn.s  was  found  to  have 
scarlatina. 

In  21  cases  of  scarlatina  during  pregnancy  Meyer '"  found  it  impossible  to 
detwt  the  nicdiuin  of  contagion.  Tiio  incubation  period  was  from  three  to 
five  days.  In  six  out  of  21  cases  the  disease  ran  a  mild  course  without  com- 
plications. In  8  cases  sepsis  occurred  with  two  deaths.  The  resemblance  of 
puerperal  scarlatina  to  diphtheritic  infection  of  woun<ls  was  strikingly  illus- 
tratetl  in  Meyer's  complicated  cases.  The  interruption  of  pregnancy  by 
scarlatina  is  well  illustrated  by  Rcmy;"*  abortion  occurred  at  five  months, 
the  patient  making  an  uncomplicated  recovery. 

Variola  resembles  scarlatina  in  its  infective  energy  and  in  its  rapid  trans- 
mission to  the  fetus.  It  possesses,  however,  the  fortunate  distinction  (>f  being 
susceptible  to  modification  by  vaccination.  While  pregnancy  renilcrs  the 
mother  more  liable  to  the  infection  of  small-pox,  in  those  cases  in  which  variola 
occurs  in  women  who  have  formerly  l)ecn  vacc'inatcd  the  disease  runs  a  com- 
paratively mild  and  favorable  course.  Vaccination  during  pregnancy  is  to  be 
performed  without  hesitation  v.henever  variola  is  epidemic.  Especial  care 
.should  be  exercised  in  procuring  pure  virus,  and  antiseptic  precautions  are 
necessary  in  performing  the  vaccination.  There  is  abundant  reason  to  believe 
that  the  fetus  is  protected  by  such  vaccination. 

Pneumonia  during  pregnancy  is  a  serious  complication  for  mother  and 
child.  The  interference  with  respiration  ocr'asionwl  by  the  size  of  the  preg- 
jiant  womb,  and  the  unfavorable  conditions  under  which  the  heart  labors 
ihiring  pregnancy,  account  in  large  part  for  the  st^verity  of  the  couiplication. 
Jurgensen,  among  247")  women  suffering  from  pneumonia,  found  43  who  were 
pregnant.  Of  this  number  more  than  half  aborted.  As  in  the  other  infiK;- 
tious,  the  degree  of  fever  present  is  of  great  importance  in  prognosis.  The 
symptomatology  of  pneumonia  in  the  pregnant  does  not  differ  from  that  of 
the  disorder  in  the  non-pregnant.  It  is  observed,  however,  in  pregnant 
patients  that  embarrassment  of  the  circulation  is  very  often  present,  and  that 
heart  failure  develops  more  rapidly  than  in  the  non-pregnant.  Mann '^' 
reports  the  case  of  a  woman  aged  forty-two  with  typical  pneumonia  at  eight 
months'  jiregnancy.  Tiie  fetal  heart-sounds  ceased  five  days  after  the  initial 
chill.  Shortly  after  the  crisis  of  the  pneumonia  the  child  was  born  with 
the  aid  of  forceps.  During  labor  the  patient  became  cyanotic,  and  she  was 
allowed  to  bleed  freely  from  the  umbilical  cord  :  although  an  unfavorable 
prognosis  had  been  given,  the  patient  made  an  iMiinterru])ted  recovery.  The 
writer  reports  in  this  connection  the  case  of  a  young  primigravida  aged  twenty 
who  developed  pneumonia  when  near  the  end  of  gestation.  A  temperature  of 
lO-'i'^  F.  rapidly  developed,  and  an  acute  pneumonic  process  catarrhal  in  nature 
was  found  over  both  lungs.  Although  the  os  was  partly  dilated,  no  labor- 
pains  v.ere  present.  The  patient's  distress  and  dyspnea  steadily  increasetl, 
and  three  days  after  the  beginning  of  the  ]>neumonia  the  child  was  expelled 
with  three  or  four  powerful  labor-pains.  The  child  was  cyanosed,  had  fever, 
and  after  passing  through  an  attack  of  pneumonia  recovered  (Pis.  20,  21). 


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THE  PATHOLOGY   OF  PREGNAyCY. 


24r, 


Although  the  mother's  urgent  symptoms  were  relieveil  tcnjporarily  by  her 
hihor,  she  i)erisho<l  of  heart  failure  soon  afterward.  Examination  of  her  urine 
iluring  the  pneumonia  and  before  her  delivery  showed  the  presenee  of  albumin 
in  apprev'iable  quantity,  and  the  proportion  of  urea  was  1.2  per  cent.  Epithe- 
lium from  tiie  kidneys,  with  abundant  crystals  of  oxalates  of  lime,  were  found 
l)V  microscopic  examination.  The  urine  containinl  large  quantities  of  bacteria 
of  various  kinds. 

The  treatment  of  pneumonia  complicating  pregnancy  is  that  of  the  non- 
pregnant. The  patient  is  in  no  way  improved  by  the  induction  of  labor,  and 
the  occurrence  of  labor  shoidd  often  l)e  made  the  occasion  for  depleting  the 
circulation  through  controllable  post-j)artuin  hemorrhage.  Pneumonia  com- 
plicating pregnancy  offers  more  opportunities  for  depletion  than  does  ])neu- 
monia  in  the  non-pregnant  woman,  and  symptoms  of  threatened  asphyxia 
with  profound  cyanosis  should  be  met  promptly  by  this  resource.  Cupping 
gives  great  relief  in  these  cases,  while  the  hypo<lermatic  use  of  strychnia  and 
atropia  has  proven  of  comfort  to  the  patient.  The  complication  is  serious  in 
proportion  to  the  extent  of  lung-tissue  involved  and  the  tolerance  or  intoler- 
ance displayed  by  the  circulatory  apparatus. 

The  prognosis  of  pneumonia  occurring  during  pregnancy  has  been  made 
the  subject  of  study  by  Wallich,'^  who  found  that  pneumonia  interrupts 
pregnancy  in  one-third  of  all  cases  before  the  sixth  month,  and  from  the  sixth 
to  the  ninth  month  in  two-thirds  of  all  cases.  The  maternal  mortality  varied 
from  50  to  100  per  cent,  of  recorded  cases,  while  the  fetal  mortality  was  80 
per  cent. 

Cholera  during  Pregnancy. — Cholera  during  pregnancy  well  illustrates  the 
severity  of  a  pronounced  infection  with  the  pregnant  patient.  From  a  series 
of  10  cases  Klautsch  '*'  describes  two  stages  of  the  disease — one  attended  by 
copious  evacuations  from  the  stomach  an<l  intestines,  the  second  by  a  period 
of  intoxication  or  asphyxia.  The  patients  were  usually  taken  ill  at  midnight 
or  early  in  the  morning,  and  when  temporary  relief  from  the  symptoms  of 
collapse  had  been  obtained  by  the  injection  of  saline  fluids  a  typhoid  stage 
frequently  developed,  with  active  delirium,  followal  by  deepest  coma. 
Diu'ing  the  coma  the  pulse  was  strong,  dicrotic,  and  the  respiration  irregular. 
Hemorrhage  into  the  conjunctiva;  was  often  ])resont.  The  fetus  usually 
perished  in  these  cases  during  the  stage  of  intoxication.  The  mothers 
complained  that  in  the  first  stage  of  the  disease  fetal  movements  were  exces- 
sively violent.  It  has  been  shown  by  Slaviansky,  Tijyakoff",  and  Simmonds 
that  the  epithelium  of  the  placenta  is  extensively  diseased,  and  that 
liemorrhages  and  premature  separation  often  occur.  Whore  the  fetus  died  it 
was  usually  expelled  at  the  end  of  the  stage  of  asphyxia  and  in  the  begin- 
ning of  the  typhoid  delirium.  Instrumental  delivery  was  frequently  neces- 
sary. Post-partum  hemorrhage  was  rarely  observe<l,  and  where  the  mother 
survived  involution  often  proceeded  promptly.  As  regards  the  prognosis  for 
tiie  mother,  it  was  as  good  as  the  prognosis  in  cholera  in  non-pregnant  women. 
For  the  fetus  the  prognosis  was  excessively  grave.     The  treatment  of  preg- 


'J  111 


AMKiiivAX  Ti:xT-iiO()K  OF  onsTi'/mics. 


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naut  patients  attaclxtnl  l)y  <'h(»l('ra  is  the  trpatinciit  of  cliolcra  in  the  non- 
pregnant. X(i  attcntiun  should  tx*  paid  to  the  pregnant  contlition,  other  than 
to  complete  hihor  as  rapidly  as  possil)h>  wiien  it  begins,  and  to  scHUiro  good 
nterine  contractions  (hiring  and  after  the  lalxtr.  A  more  unt'avorahle  view  of 
the  prognosis  for  the  mother  is  given  by  (Sallianl."^  In  Ids  ca^v,-.  tlie  hietie- 
acid  nietiuKl  of  treatment  was  extensively  employed  with  negative  resnits.  In 
ndid  cases  a  nnmber  of  his  patients  recovered. 

Tvtnnnx  in  I'ra/iKinvif. — Among  the  acnte  infections  that  attack  with  great 
viridence  the  nervons  system  of  the  pregnant  patient  tetaims  is  the  most 
fortnidable.  Onr  knowledge  of  infection  explains  by  the  tetanns  bacillns  the 
exciting  canse  of  this  complication.  A  predisposing  cause  is  to  be  fonnd  in 
the  snsceptibility  which  pregnant  patients  manifest  dnring  the  first  three 
months  of  this  period.  Indeed,  the  first  half  of  gestation  shows  by  far  the 
greater  nundx-r  ut'  cases  of  this  infection.  Tetanns  develops  usnally  after 
some  minor  manipulation  in  the  early  niontlis  of  j)regnancy,  and  especially 
where  abortion  requires  interference  on  the  part  of  the  physician.  Tliiw 
Vinay'*"  in  lOG  cases  found  but  one  after  craniotomy  and  one  after  C'esirean 
section  ;  the  infection  is  one  ttf  early  pregnancy,  and  is  not  usnally  cwnnectcil 
with  parturition  at  ternu  Patients  most  apt  to  be  attacked  by  the  tetamis 
bacillus  are  nudtipartx;  above  the  average  age  anil  those  who  have  been  living 
in  damp  and  stpialid  lodgings.  The  direct  conveyantf  of  the  infection  has 
been  noted  by  Henricins  and  by  Anion.  The  latter,  while  treating  a  case 
of  tetanus  in  the  husband,  infected  the  wife,  who  aborted,  dnring  the  manual 
delivery  of  the  placenta.  Tetanus  is  most  frecpient  among  pregnant  patients 
in  the  tropics,  where  the  condition  of  the  soil  is  favorable  to  the  growth  of 
the  infecting  germ.  An  association  of  tetamis  in  pregnancy  and  the  pueiperal 
period  with  endt)metritis  has  been  pointed  out  by  Markus.'*' 

The  treatment  of  tetanus  in  pregnancy  is  largely  prophylactic.  Remem- 
bering the  peculiar  susceptibility  of  pregnant  patients,  especially  during  the 
first  months,  any  minor  operation  or  examination  shoidd  be  conducted  with 
scrupulous  antisepsis.  When  once  tetanus  infecti  has  occurretl,  but  little 
esui  be  d(»ne  to  save  the  patient. 

Tetany  is  a  condition  which  is  commoner  during  pregnancy  than  is 
tetanus.  It  is  characterized  by  tonic  spasms  beginning  in  the  muscles  of  the 
extremities,  especially  those  of  the  hands.  In  severe  cases  spasmodic  move- 
ments may  extend  over  the  entire  muscular  system.  The  spasms  are  symmetrical 
wher  not  artificially  produced.  Attacks  of  tetany  are  not  accompanie<I  by  loss 
of  consciousness.  Such  seizures  are  intermittent  and  of  short  duration.  As  a 
rule,  recovery  ensues,  the  spasms  gradually  becoming  less  frcipient.  Patients 
<leseribe  a  tingling  or  a  numb  sensation  of  the  extremity  affected  as  precetling 
the  spasm,  and  the  same  phenomenon  follows  the  cessation  of  convulsive  move- 
ments. If  the  main  artery  or  the  nerve  of  the  extremity  in  which  spasmodic 
movements  are  observed  be  compressed,  these  sensations,  followed  by  spasm, 
may  be  induced.  The  application  of  cold  causes  the  spasms  of  tetany  to 
itnise.     The  flexor  muscles,  and  especially  the  interossei  in  the  hands  and  feet. 


Till-:  rATiioiJXfv  OF  j'/ii:(iXAy(y. 


247 


nro  oftcnost  iiffi'ctcil.  Tlii'  elect ricnl  reneti(»n  of  the  nerves  in  the  iifr<H'te«I 
region  is  njiieli  iiieroas(><l.  The  patient's  >;i'iieral  temperature  is  not  afFiH-twl. 
Any  nieehanieal  irritation  of  tlie  |)oripheral  nerves,  <>yA\  as  tappin^r  tlie  trunk 
of  the  faeial  nerve  in  front  of  the  ear,  results  iii  spasm.  The  disorder  is 
generally  s|H)radie  and  in  rarely  epidemic.  It  is  most  usually  observetl  in 
women  during  the  childhearing  pcritMl  or  during  menstruation.  TrousHcau 
foinul,  of  44  cases,  forty  amid  mu'sing  women.  Kussmaul  found  transient 
allniminuria  present,  and  Stiel  observed  glycosuria.  Dakin"**  reports  the  cast; 
of  a  mnltigravida  of  nervous  tem|)erament  who  in  the  third  month  of  her 
fourth  gestation  was  seized  with  frecjuent  vomiting  during  the  <lay.  Afler 
this  condition  had  persisted  for  eleven  days  she  developed  spasm  of  various 
mustrles,  j>re<'e<UKl  by  numbness.  The  hands  and  feet  assnuieil  tlu'  jjostiire 
seen  in  tetany,  the  flexors  in  crontraction,  and  the  interossci  producing  exten- 
sion of  the  phalanges.  The  soles  of  the  feet  wen'  Ivdlowitl  by  spasmmlic 
extension.  The  affected  muscles  were  slightly  i)ainli  Tiie  condition  ex- 
tended to  all  the  extrenuties,  and  vomiting  was  inere;"sed.  On  the  second 
day  of  tetany  the  spasmodic  condition  bccanie  so  i  :eessiv<-  as  to  "  luse  intense 
sutl'ering.  The  temperature  was  s  I'jnormal.  '1  tie  pati"nt  'K-u  of  asphyxia 
produce'  b  spasm  of  the  muscles  of  respiration  on  t!ie  third  day  of  the 
t<'tany.  Trousseau  recognizes  three  varieties  of  tetany  in  accordance  with  the 
.-•verity  of  the  affection.  He  rarely  oUservwl  a  fatal  result.  Meinert  saw 
five  cases  end  in  recovery.  In  one  of  these  cases  the  patient  suffi-red  from 
tetany  in  successive  pregnancies.  One  of  Meinert's  patients  had  her  th\  i<>id 
gland  removed.  Between  the  attacks  of  tetany  the  patient  is  normal  to  all 
appearances.  In  non-fatal  cases  the  pregnancy  is  tiot  interrnptetl  nor  is  labor 
influence<l,  the  spasms  ceasing  as  .soon  as  the  uterus  is  emptied  or  within 
a  few  days. 

In  contrasting  tetanus  with  tetany  in  pregnant  i)atients  it  is  well  to  remem- 
ber that  in  tetanus  the  spasm  begins  in  the  face  or  the  r.eck,  and  advances  cen- 
trifiigally  with  opisthotonos.  In  tetany  the  spasm  begins  in  the  extremity  and 
advances  centripetally,  producing  the  characteristic  posture  of  the  extremities. 
In  tetanus  the  spasm  is  constant :  in  tetany  it  is  intermittent.  The  great 
fatality  of  tetanus  and  the  comparative  mildness  of  tetany  are  to  l>c  kept  in 
mind.  Tetamis  is  commonest  among  men,  who  by  virtue  of  their  oc<!upatlons 
arc  exjMJsed  to  infection  from  the  tetanus  bacillus.  Tetany  is  jwculiarly  com- 
mon among  pregnant  women  or  women  in  a  depressed  and  susceptible  condition. 
The  differential  diagnosis  between  the  convulsions  of  toxemia  and  those  of 
tetany  is  not  difficult  with  accurate  observation. 

The  treatment  of  tetany  in  pregnancy  consists  in  giving  the  patient  such 
sedatives  and  anotlynes  as  shall  procure  ;  iccp.  Vomiting  or  diarrhea  requires 
especial  attention,  as  it  induces  a  condition  of  debility  favoring  a  fatal  issue. 
Abortion  should  not  be  producetl  in  tetany,  as  the  disorder  rarely  fails  to  yield 
before  intelligent  medication. 


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AMERICAN   TEXT-BOOK   OE   OBSTETRICS. 


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4.  Accidents  and  Surgical  Operations  during  Pregnancy. 

Although  the  nervous  s^-stem  of  the  pregnant  woman  is  remarkably  suscept- 
ible in  many  ways  to  reflexes,  she  sometimes  exhibits  a  very  decide<1  power  of 
tolerance  to  severe  injury  or  to  surgical  interference.  The  difference  in  this 
resisting  power,  as  shown  by  some  patients  and  as  seen  to  be  lacking  in  othei-s, 
de|>ends  not  only  upon  the  condition  of  the  nervotis  system  in  these  cases,  but 
also  upon  the  normal  or  abnormal  state  of  the  uterus  and  its  lining  membrane. 
In  a  woman  in  perfect  health  a  considerable  injury  or  a  surgical  shock  may 
be  received  without  the  interruption  of  ]>regnancy,  while  if  the  patient  is  of 
extraordinarily  susceptible  nervous  system  or  if  the  endometrium  is  in  a  con- 
dition of  disease,  interruption  of  pregnancy  is  almost  inevitable.  Accompany- 
ing the  premature  ending  of  gestation  serious  hemorrhage,  shock,  and  greatly 
increased  susceptibility  to  septic  infection  are  observetl. 

Those  operations  most  frequently  demandeil  during  pregnancy  are  surgical 
proceilures  undertaken  for  some  condition  of  the  uterus  or  of  its  appendages. 
Thus  cancer  of  the  uterus  demands  the  complete  extirpation  of  that  organ  as 
soon  as  the  diagnosis  is  made,  irrespective  of  the  existence  or  tiie  period  of 
gestation.  One  of  two  methods  of  ojjcration  may  be  chosen— (extirpation  per 
vaginam  when  the  diseased  uterus  is  small,  or  the  com])lete  removal  of  that 
organ  through  the  abdominal  cavity  when  its  size  precludes  the  possibility  of 
its  removal  through  the  vagina.  In  either  instance  the  prognosis  for  the 
recovery  of  the  mother  is  by  no  means  desperate  if  the  operation  be  per- 
formed before  her  strength  has  been  reduced  by  the  development  of  cancerous 
cachexia.  It  is  sometimes  possible  to  combine  the  two  methods  of  operation, 
as  in  an  interesting  case  reported  by  Stocker,'***  in  which  a  multigravida  was 
found  to  have  cancer  of  the  cervix.  At  the  sixth  month  of  pregnancy  the 
cervix  was  removed  per  raf/innm,  and  the  conij)lete  extirpation  of  the  uterus 
was  accomj>lished  by  t>pening  the  abdominal  cavity.  The  patient  made  a 
good  recovery  from  the  operation. 

Myomotomy  and  myomectomy  are  demanded  during  j)regnancy  for  fibroid 
tumors  (complicating  the  development  of  the  pregnant  uterus.  The  choice  of 
operation  will  depend  upon  the  size  and  location  of  the  tumor,  and  upon  the 
amount  of  pressure  which  it  is  exercising  or  which  it  will  cause  upon  the 
growing  womb.  Flaischlen  '*  found  two  fibroid  *^umors  behind  the  uterus  in 
the  case  of  a  patient  pregnant  three  months  ;  one  tumor  sprang  from  the  cornu 
of  the  uterus,  the  other  from  the  base  of  tiie  womb.  Both  tumors  were  ligated 
and  removed  without  the  interruption  of  pregnancy. 

Amputation  of  the  pregnant  womb  is  a  familiar  operation  for  contracted 
pelvis.  It  may,  however,  be  performed  at  any  period  of  gestation  when  the 
interests  of  the  patient  demand  hysterectomy.  The  method  of  procedure  best 
adapted  to  such  cases  is  abdominal  incision,  ligation  of  the  ovarian  and  uterine 
arteries,  and  amputation  of  the  uterus,  leaving  a  short  stump  to  close  the 
vagina  and  stitching  the  peritoneum  over  the  surface  of  the  stump. 

Tumors  of  the  ovary  are  justly  considered  serious  complications  of  prcg- 


THE   PATHOLOGY   OF  PREGNANCY. 


24!) 


lie 
1st 
lie 
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nancy.  Dsirne'"  colloctcil  135  cases  in  which  pregnancy  was  complicated  by 
tnmor  of  the  ovary.  He  finds  that  the  gravity  of  this  complication  increases 
as  pregnancy  advances.  There  is  rarely  any  reason  in  this  complication  for 
delay  in  removing  such  a  tumor  by  abdominal  incision.  Puncture  of  an 
ovarian  cyst  and  the  artificial  interruption  of  pregnancy  are  to  be  avoided : 
they  are  to  be  consideretl  only  in  the  light  of  proceilures  adapted  to  an 
unforeseen  emergency.  The  preferable  time  for  operation  in  such  cases  is  before 
the  fourth  month  of  gestation.  The  fetus  is  least  likely  to  be  lost  when 
operation  is  performed  in  the  third  or  the  fourth  month.  No  period  of  preg- 
nancy, however,  contra-indicates  ovariotomy,  but  this  complication  uniformly 
demands  operative  treatment.  Double  ovariott>my  during  pregnancy  may  be 
successfully  performed,  as  exemplified  by  Polaillon.'**  His  patient,  agetl 
twenty-three,  had  a  good-sized  ovarian  cyst  upon  one  side  and  a  diseased 
ovary  upon  the  other  side.  Her  general  condition  at  the  time  of  operation 
was  not  promising,  and  numerous  adhesions  complicated  the  removal  of  the 
tumor.  Operation  was  performed  in  the  third  month  of  gestation,  and  it 
resulted  in  the  continuance  of  pregnancy,  which  terminated  in  normal  delivery 
with  a  healthy  child.  The  patient's  pulse  and  temperature  showed  little 
reaction  following  operation.  Kreutzman  "®  reports  two  cases  in  which  ovarian 
tumors  were  successfully  removed  from  pregnant  patients  without  interrupting 
gestation.  One  of  these  women,  who  was  in  her  second  pregnancy,  had  gone 
two  weeks  over  time.  She  had  a  large  ovarian  cyst  in  the  loft  ovary,  the 
pedicle  of  which  had  recently  become  twisted,  the  contents  of  the  tumor  being 
tinged  with  blood. 

Affections  of  the  Fallopian  tubes  may  call  for  operative  interference  during 
pregnancy.  The  prognosis  in  these  cases  is  equally  good  with  that  of  opera- 
tion for  the  removal  of  ovarian  tumors,  and  the  reasons  for  prompt  interfer- 
enci!  are  quite  as  cogent  as  in  the  former  case.  In  hematosalpinx  it  is  often 
impossible  to  make  a  differential  diagnosis  between  this  condition  and  eetojiic 
gestation.  Tliis  fact  is  well  illustrated  in  the  experience  of  Doraii,"**  who  re- 
moval both  tubes  and  ovaries  from  a  patient  who  had  suftered  from  attacks 
of  violent  pelvic  pain  at  various  intervals.  One  tube  had  ruptured,  allowing 
the  free  escape  of  blood  ;  the  tube  contained  a  structure  in  the  midst  of  a  clot 
resembling  an  aborted  ovum.  It  is  probable  that  double  ectopic  gestation 
existed.     The  patient  made  an  uninterrupted  recovery. 

Aocuh'ntu  and  Injuries. — As  regards  tolerance  to  general  accidents  and 
injuries  during  jiregnancy,  American  observers  have  noted  the  remarkable 
tolerance  displayed  by  negro  women  under  such  circumstances.  Thus, 
Tiffany'"  reports  the  case  of  a  negro  woman  wlio  fell,  striking  the  abdomen 
violently  against  the  edge  of  a  tub.  Peritonitis  with  retention  of  urine  fol- 
lowed. The  patient,  however,  under  faithful  attendance  recovered  without 
the  interruption  of  jiregnancy.  Stab-wounds  oi"  the  abdomen  occurring 
durin.-  the  pregnant  period,  but  without  interrupting  gestation,  are  reported 
by  Belin,"^  in  whose  patient  a  considerable  portion  of  tiie  (>piploon  protruded 
from  the  wound.     Sloughing  ensued,  but  the  patient  made  a  good  recovery. 


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AMA'IilCAA'   TEXT-BOOK   OF   OBSTETRICS. 


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Richard  "*  describes  the  case  of  a  pregnant  woman  who  fell,  lacerating  the 
abdominal  wall  near  the  umbilicus.  A  mass  of  intestine  protrudetl  as  large 
as  a  man's  head.  The  woman  was  at  term,  and  soon  after  normal  labor 
ensued,  from  which  the  patient  recoveretl.  Harris '"  describes  the  case  of  a 
woman  pregnant  six  months  whose  abdomen  was  torn  open  by  the  horn  of  a 
bull.  Although  omentum  and  intestine  protruded,  pregnancy  was  uninter- 
rupted. The  viscera  were  replaced  and  the  wound  was  closed  by  suture. 
A  similar  case  in  which  a  lacerated  wound  of  the  abdominal  wall  5  inches 
long  was  made  is  reported  by  Corey.'**  In  this  case  the  pregnancy  was  at 
the  third  month.  The  patient  went  two  hundretl  and  two  days  longer  in  ges- 
tation, and  had  a  normal  labor.  Obstruction  of  the  intestine  calling  for 
abdominal  section  is  described  by  llydygier,"*  who  operated  in  the  sixth 
month  of  gestation  upon  a  patient  who  had  symptoms  of  strangulation  for 
seven  days.     Recovery  without  abortion  ensued. 

In  fractures  retardetl  union  is  reported  by  Petit  "^  and  others  in  pregnant 
women  sustaining  this  accident. 

An  interesting  operation  for  stone  in  the  bladder  upon  a  patient  eight 
months  pregnant  is  I'cported  by  Keelan.'^*  The  calculus,  which  weighed  12 J 
ounces,  was  successfully  removed  without  the  interruption  of  pregnancy. 

Gunshot  wounds  not  penetrating  the  uterus  do  not  commonly  inter- 
rupt gestation.  A  remarkable  instance  is  cited  by  Prozowsky.'^  The  patient 
was  wounded  in  many  places  by  pieces  of  lead  pipe  fired  from  a  gun  but  a 
few  feet  distant.  Neither  she  nor  her  child  suffered,  so  far  as  gestation  was 
concerned,  from  the  accident.  A  pistol-shot  wound  of  the  lung  occurring 
during  pregnancy,  followed  by  hemorrhage  and  shock,  is  reported  by  Ban- 
croft.^    A  healthy  child  was  born  at  term. 

A  remarkable  case  is  described  by  Lihotzky,^'  which  illustrates  the  fact 
that  the  changes  occurring  in  pregnancy  may  bring  into  active  irritation  a 
foreign  body  that  had  previously  been  inert ;  he  describes  the  case  of  a  patient 
perishing  from  rapid  peritonitis  in  the  eighth  month  of  pregnancy.  At  the 
autopsy  the  duodenum  was  found  perforated  by  a  s})oon  which  the  patient  had 
swallowed  two  and  a  half  years  previously — an  occurrence  almost  forgotten. 

The  remarkable  tolerance  shown  by  the  pregnant  woman  to  direct  injury 
from  mechanical  causes  is  illustrated  in  a  case  reported  by  JMilner.™^  The 
woman  in  the  sixth  month  of  pregnancy  was  accidentally  shot  through  the 
abdominal  cavity  and  the  lower  part  of  the  thorax,  the  missile  penetrating  the 
central  tendon  of  the  diaphragm  and  lodging  in  the  lung.  Localized  pneu- 
monia and  peritonitis  seemed  to  limit  the  injury,  the  wound  draining  through 
the  lungs  by  very  free  expectoration.  Recovery  ensued,  the  patient  giving 
birth  to  a  healthy  child  sixteen  weeks  later. 

Direct  mechanical  injury  may  rupture  the  pregnant  uterus,  usually  causing 
the  death  of  the  i)atient.  It  is  interesting  to  observe  that  the  membranes 
may  remain  unruptured  in  these  cases,  thus  obscuring  the  diagnosis  of  rupture 
of  the  womb.  Neugebauer  ^'^  describes  a  case  of  suicide  in  which  a  primi- 
gravida  threw  herself  from  the  third  story  of  a  house  upon  a  stone  pavement ; 


THE  PATHOLOGY  OF  PREGNANCY. 


251 


the  immetliate  cause  of  death  was  fracture  of  the  skull.  The  uterus  ruptured, 
and  the  fetus  in  its  unbroken  membranes  was  found  among  the  mother's 
intestines.     The  patient's  pelvis  also  sustaine<l  serious  injury. 

That  pregnant  women  can  endure  terrible  injury  complicatet^l  by  er\'sipe- 
las,  and  still  go  on  to  term,  is  illustrated  by  a  case  reported  in  the  Prugcr 
medicinische  Wochenschrift,  1881,  No.  6.  A  woman  in  the  eighth  month  of 
pregnancy,  while  working  in  a  brickyard,  was  buried  beneath  a  mass  of  earth 
and  rock.  A  terrible  gash  was  cut  through  the  scalp,  and  many  bruises  and 
lacerated  wounds  were  sustained.  Erysipelas  attacked  the  wounds  of  the 
scalp,  and  the  patient  was  for  a  time  very  ill.  She  did  not,  however,  mis- 
carry, but  bore  a  healthy  child  at  term.  Fancou  ^*  describes  the  case  of  a 
woman  who  had  an  injury  to  the  knee  requiring  drainage.  She  was  attacked 
by  erysipelas,  which  spread  over  the  whole  body  save  the  genital  organs  and 
the  head  and  neck.     Her  pregnancy  was  uninterrupted  and  recovery  ensued. 

Operations  upon  the  rectum  are  to  be  avoided  if  possible  in  pregnant 
patients.  It  has  been  sliown  by  Tiffany  ^''  that  such  operations  are  an  excep- 
tion to  the  rule  in  usually  producing  abortion  or  miscarriage.  On  the  con- 
trary, a  diseased  kidney  may  be  removed  from  a  pregnant  patient,  as  shown 
by  Tiffany,  ***"  with  complete  success. 

While  major  operations  seem  well  borne  by  pregnant  women,  minor 
surgical  procedures  of  an  irritant  character  are  sometimes  attended  by  disas- 
trous results.  Thus,  Fancon  observed  in  the  clinic  at  Strasburg  a  case  where 
cauterization  over  the  ankle-joint  was  practised  for  a  neglected  sprain.  Abor- 
tion followed,  complicated  by  septic  infection,  necessitating  amputation.  The 
patient  finally  succumbed.  Pregnant  women  often  survive  burns  without 
the  interruption  of  gestation  if  the  pregnancy  is  not  far  advanced  and  the 
burn  is  not  severe.  Hunt  ^^  reports  a  case  of  excessive  burn  in  the  ninth 
month  of  pregnancy  that  seems  to  have  affected  the  fetus  directly,  for  the 
child  was  born  dead  and  blistered  over  an  area  corresponding  with  the  burns 
upon  its  mother's  body.  Curiously  enough,  cases  are  reported  where  preg- 
nant women  have  suffered  from  abscess  of  the  breast,  in  which  the  abscess  has 
been  opened,  curetted,  and  drained  without  interrupting  pregnancy,  although 
interfering  with  the  breasts  nsually  results  in  profound  disturbance  of  the 
uterus.  Pregnancy  is  nocontra-indication  to  excision  of  the  cancerous  breast, 
as  illustrated  in  a  case  reported  by  Pilcher.^*  Parasitic  growths  of  the 
abdominal  cavity  requiring  abdominal  section  have  been  treated  by  surgical 
interference  during  pregnancy  with  success.  Amputation  for  crushing  injury 
and  severe  blows  has  been  sustained  by  pregnant  patients,  and  recovery 
ensued.  A  remarkable  case  is  reported  by  Fancitn,  in  which  a  pregnant 
woinan  jumped  from  a  second-story  window  without  interrupting  the  gesta- 
tion. Amputation  at  the  hip-joint  during  pregnancy  has  been  successfully 
performed  by  Keen.**  The  reason  for  operating  was  malignant  disease  of  the 
femur.  The  patient,  who  was  five  months  j)regnant,  had  been  living  in  the 
tropics.  She  made  a  good  recovery  after  the  operation,  without  symptoms  of 
abortion  durinj;  her  convalescence. 


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In  deciding  upon  operations  upon  pregnant  patients  care  should  be  taken 
that  the  various  excretory  organs  of  the  body  be  phiced  in  the  best  possible 
condition.  All  unnecessary  shock  is  carefully  to  be  avoided,  as  is  also 
hemorrhage.  Although  a  hemorrhage  does  not  seem  to  produce  abortion,  it  is 
dangerous,  because  it  renders  the  patient  more  susceptible  to  septic  infection. 
Fractures  unite  poorly  in  pregnant  patients,  and  aj)plication  of  cauterizing 
agents  should  not  be  practised  during  pregnancy.  Major  operations  on  the 
abdominal  contents  are  especially  well  borne.  Pregnancy  does  not  contra- 
indicate  operation  for  diseased  conditions  of  the  uterus,  the  tubes,  or  the- 
ovaries,  provided  the  fetal  sac  is  not  opened. 

A  striking  instance  of  the  benefit  which  pregnant  patients  sometimes 
receive  from  operative  interference  is  shown  by  those  cases  of  osteomalacia 
during  pregnancy  greatly  benefited  by  oophorectomy.  A  good  example  of 
this  is  the  case  described  by  Kasch  :  ^"'  the  patient,  a  niultigravida,  aged  forty- 
one  years,  suifered  from  osteomalacia,  which  continued  after  the  birth  of  her 
twins.  As  the  condition  continued  to  grow  worse,  the  tubes  and  ovaries  were 
removed,  when  the  patient  began  immetliately  to  improve,  and  subsequently 
became  able  to  walk. 

The  almost  incredible  power  of  resistance  which  the  pregnant  uterus  dis- 
plays to  interference  is  well  illustrated  by  a  case  reported  by  Vickery  :  ^''  this 
patient  was  subjected  to  medication  and  operative  interference  to  empty  the 
uterus  ;  it  was  supposed  that  incomplete  abortion  occurred,  and  her  physician 
curetted  the  uterus  and  applied  tincture  of  iodin  followed  by  injections  of 
hot  water.     Notwithstanding  this  treatment  pregnancy  continued. 

The  prognosis  of  pregnancy  complicatetl  by  tumors  in  cases  subjected  to 
operation  must  be  considerefl  as  decidedly  favorable.  Gordes  ^'^  gives  an 
interesting  account  of  16  cases  of  pregnancy  complicated  by  abdominal 
tumors ;  out  of  the  16  cases,  four  perished :  all  the  cases  were  treated  by 
operation,  and  many  of  them  in  the  most  radical  manner. 

5.  Diseases  of  the  Ovum. 

Under  Diseases  of  the  Ovum  will  be  included  the  disorders  of  the  mem- 
branes, the  deciduae,  the  placenta,  and  the  funis.  The  following  syllabus 
presents  the  topicji  taken  up  for  consideration  in  their  expressed  order : 


Amnion 


Chorion 


Decidual 
endome- 
tritis : 


C  Adhesions  and  bands, 
<  Polyhydramnios, 
(  Oligohydramnios. 


f  Vesicular  mole  or 
\  Myxoma. 


Placenta : 


''Placentitis, 
Calcareous  degeneration, 
Fatty  degeneration, 
Apoplexy, 
Tiunors, 
Syphilis. 

Anomalies  in  position,  size, 
weight,  shape,  and  number. 


Polypoid, 

Hvpertrophic, 
j  (Ystic, 
(^Catarrhal. 


Cord : 


r  Coils, 

j  Knots, 


j  Torsions, 

(^Stenosis  of  its  vessels. 


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253 


A.  Diseases  op  the  Amnion. 

Amniotic  Adhesions  and  Bands. — Adhesions  between  the  fetus  and  the 
amnion,  supposed  to  arise  from  an  arrest  of  development,  are  occasionally  met 
with.  As  the  amniotic  fluid  increases  the  adhesions  are  elongated,  forming 
bands.  They  cause  certain  deformities,  as  webbed  toes  and  fingers.  Rarely, 
an  amputation  of  a  fetal  limb  results.  When  the  bands  and  adhesions  are 
accompanied  by  a  deficiency  of  the  amniotic  fluid  (oligohydramnios),  they  are 
regarded  as  the  cause  of  malformations  of  the  lower  extremities,  because  the 
fetus  cannot  preserve  its  normal  attitude,  and  it  is  therefore  subjected  to 
injurious  compression,  residting  in  deformities. 

Polyhydramnios,  or  dropsy  of  the  amnion,  is  an  excess  of  the 
amniotic  fluid.  When  this  fluid  is  in  marked  excess  of  two  quarts,  poly- 
hydramnios may  be  said  to  be  present.  Cases  are  recorded  whore  more  than 
twenty  quarts  existed.  This  condition  is  found  more  frequently  in  multiparse 
than  in  primiparse — 23  to  5 ;  more  frequently  in  twin  pregnancies  of  the 
same  sex  than  in  single  pregnancies.  In  some  cases  of  twins  one  sac  contains 
an  excess  of  fluid,  while  the  other  sac  contains  less  than  the  usual  amount. 
This  condition  has  been  found  in  extra-uterine  pregnancy. 

Two  forms  of  polyhydramnios  have  been  described,  the  acute  and  the 
chronic.  In  the  former  the  accumulation  of  the  fluid  is  very  rapid,  producing 
fever.  In  the  latter  the  fluid  increases  slowly,  and  the  uterus  thereby  tolerates 
its  pressure  to  a  greater  extent.  This  condition  is  sometimes  dangerous, 
because  the  centrifugal  pressure  conduces  to  a  critical  tensity  of  the  uterine 
walls,  threatening  rupture.  In  labor  the  sudden  free  exit  of  the  fluid  favors 
malposition  of  the  fetus,  and  especially  prolapse  of  the  umbilical  cord. 

Pathologij. — The  i)athology  of  polyhydramnios  is  most  obscure.  This 
disease  has  been  attributed  to  a  defective  maternal  cardiac  action,  permitting 
transudation  of  serum  from  the  maternal  blood  through  the  fetal  membranes. 
Inflammation  of  the  amnion  (amniotitis)  has  been  held  as  a  cause.  To  great 
activitv  of  the  renal  fiuiction  of  tiie  fetus  it  has  also  been  attributed.  There 
is  no  settled  opinion  at  present  as  to  its  causation.  A  recent  author  states  that 
Miere  is  a  frequent  and  an  undeniable  connection  between  polyhydramnios  and 
the  insertion  of  the  placenta  in  the  inferior  part  of  the  uterus.  The  blood- 
stasis  resulting  from  such  a  low  insertion  favors  osmosis  into  the  amniotic 
cavity. 

Si/mptoinatohg!/. — The  unnaturally  rapid  increase  in  the  size  of  the  uterus 
is  the  most  striking  symptom  of  polyhydramnios.  The  uterus  at  five  months 
becomes  as  large  as  it  should  be  at  term.  Fluctuation  becomes  a  conspicuous 
symptom,  even  to  the  jioint  of  utterly  obscuring  the  presence  of  pregnancy. 
Obstetric  auscidtation  and  palpation  are  easily  rendered  nugatory.  Pressure- 
symptoms  relating  to  circulation  and  to  respiration  become  especially  urgent. 
Vaginal  examination  reveals  a  nearly  or  (piite  obliterated  cervix  and  a 
resilient  mass  filling  entirely  the  pelvic  inlet. 

Treatment. — Induction  of  labor  is  ;\'mau(led  in  the  acute  form,  but  in  the 


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chronic  form  only  when  the  presstire-syniptoras  become  urgent.  It  has  been 
recommendal  to  cautiously  draw  off  the  cxcei^s  of  fluid  with  an  aspirator. 
Two  things  must  be  guarded  against :  first,  the  malposition  of  the  fetus  and 
precipitate  labor ;  second,  a  post-i>artum  hemorrhage,  which  is  so  liable  to 
result  from  uterine  atony  after  over-distcntion. 

Oligohydramnios  means  a  deficiency  '  f  the  amniotic  liquid.  Its 
pathology  is  unknown.  Adhesions  and  bands  are  frequent  in  this  condition. 
It  cannot  be  detected  prior  to  delivery  ;  it  is  revealed  at  that  time  only.  Fetal 
malformations  are  frequently  encountered  in  oligohydramnios.  The  fetus  is 
subjected  to  an  abnormal  pressure  which  results  in  deformities.  Webbed  toes 
and  fingers  are  alleged  to  arise  from  this  condition.  Amputation  of  a  fetal 
extremity  may  follow  the  abnormal  deficiency  of  fluid.  Malformations  of  the 
inferior  extremities  are  ascribed  to  this  complication. 

B.  Diseasp:8  of  the  Choriox. 

Vesicular  Mole  (CVstic  mole ;  Hydatidiform  degeneration  of  the 
chorionic  villi ;  Dropsy  of  the  villi  of  the  chorion  ;  Myxoma  of  the  placenta; 
Molar  pregnancy). — The  villi  of  the  chorion  occasionally  undergo  myxomatous 
degeneration,  which  produ(!es  a  vesicular  mole.  The  mole  is  a  mass  of 
pedunculated  vesicles  resembling  in  aj)pearance  grapes  or  gooseberries.  There 
may  be  as  many  as  five  or  six  thousand  of  such  vesicles.  The  vesicles  vary 
in  size  from  a  millet-seed  to  that  of  a  filbert,  and  they  conUiin  a  fluid, 
usually  colorless,  transparent,  liquid  as  water,  holding  albumin  in  solution. 
Rarely  the  fluid  is  reddish  in  color.  If  all  the  villi  of  the  chorion  are 
involved  in  the  degeneration,  the  life  of  the  ovum  is  always  sacrificed.  If 
only  a  small  portion  of  the  villi  are  involvetl,  the  life  of  the  ovum  is  not 
necessarily  destroyed  and  development  to  term  may  proceed.  In  twin  preg- 
nancies one  chorion  may  un-'Ugo  myxomatous  degeneration  M'liile  the  other 
ovum  may  proceed  to  full  develoj)meut  and  be  born  at  term.  Often  in 
double  pregnancy  the  development  of  a  cystic  mole  in  one  chorion  seriously 
compromises  the  life  of  the  other  ovum,  resulting  in  a  miscarriage.  Vesicular 
mole  is  very  rare.  One  author  reports  only  one  case  in  over  twenty  thousand 
deliveries.  It  is  oftenest  found  in  multiparte  of  from  twenty-five  to  forty 
ycai's  of  age.  Nimierous  recorded  cases  of  women  who  have  repeatedly 
developed  vesicular  moles  exist ;  one  case  developed  this  condition  in  eleven 
pregnancies. 

PatJioloffi/. — An  endometritis  is  generally  supposed  to  be  the  factor  predis- 
posing to  the  development  of  a  molar  pregnancy.  The  villi  of  tiie  chorion 
undergo  hypertrophy  and  myxomatous  degeneration.  Three  cases  have  been 
reported  wherein  the  chorionic  villi  grew  so  rapidly  as  to  penetrate  the  uterine 
wall  even  to  the  peritoneal  covering,  rer.dering  successful  removal  impossible 
without  a  fatal  hemorrhage  or  a  subsequently  fatal  peritonitis. 

Symptomntolof/y. — Three  symp  jms  characterize  molar  pregnancy:  first,  an 
abnormally  rapid  increase  in  the  size  of  the  abdomen  ;  second,  uterine  hemor- 
rhage ;  and  third,  the  expulsion  per  vaginam  of  the  vesicles  of  the  mole. 


THE  PATirOLOaV  OF  PREGNANCY. 


266 


It  may  be  possible  to  feel  the  grape-like  masses  through  the  cervical  canal. 
Exsanguiuation  of  the  patient  and  septic  infection  are  the  chief  dangers.  As 
a  rule  the  fetus  dies.  Rarely,  a  bunch  of  the  vesicles  may  lie  expelled  without 
the  course  of  the  pregnancy  being  interruptal. 

Treatment. — No  active  interference  is  demanded  until  the  hemorrhages 
occur.  If  they  are  small,  rest  and  an  oi)iate  may  suffice.  If  severe,  the 
uterus  must  be  dilated  and  very  carefully  curetted,  subsequent  hemorrhage 
being  prevented  by  an  intra-uterine  tampon.  The  possibility  of  the  growth 
hav'ng  penetrated  and  thinned  the  uterine  wall  makes  it  necessary  to  use  the 
curette  cautiously  to  prevent  perforation  of  the  uterus. 

C.  Decidual  Endometritis. 

One  of  the  commonest  diseases  of  the  ovum  is  decidual  endometritin. 
Four  varieties  of  this  disease  are  described  to-day :  the  polypoid,  the  hyper- 
trophic, the  cystic,  and  the  catarrhal.  The  names  of  the  different  varieties 
indicate  the  predominating  characteristic  of  the  endometritis.  In  catarrhal 
endometritis  the  discharge  of  a  watery  fluid  is  so  abundant  as  to  receive  the 
name  hydrorrhea  gravidarum.  It  may  occur  as  early  as  the  third  month,  but 
usually  it  is  not  encountered  until  the  last  months  of  pregnancy.  It  is  more 
frequently  seen  in  multi})ar8e  than  in  primiparfe.  It  is  found  upon  close 
observation  to  be  a  mucous  secretion  rather  than  the  yellowish  amniotic  fluid  ; 
the  latter  is  further  differentiated  by  containing  urea.  The  sudden  appearance 
of  the  fluid  in  a  large  quantity  is  generally  mistaken  for  premature  rupture  of 
the  membranes.  In  most  instances  it  is  repeated  several  times  before  delivery 
occurs.     Should  pains  follow,  quietude  and  an  opiate  are  indicated. 

The  etiology  of  hydrorrhea  gravidarum  is  obscure.  It  has  been  attributed 
to  syphilis,  to  overwork,  to  an  exaggeration  of  a  pre-existing  endometrial 
inflammation,  to  gonorrhea,  and  to  an  infection  following  the  death  of  the 
o"um,  to  be  followed  sooner  or  later  by  a  miscarriage.  The  frequency  of 
miscarriage  from  an  old  endometritis  is  a  well-known  fiicfc  in  obstetric 
observations. 

The  treatment  of  this  malady  during  pregnancy  is  absolutely  nil.  All  that 
can  be  done  for  it  must  be  done  in  the  intervals  between  gestations. 

D.  Diseases  of  the  Placenta. 

Placentitis,  inflammation  of  the  placenta,  is  a  very  rare  disease.  Its 
origin  is  very  obscure,  but  it  is  supposed  to  start  from  the  decidual  tissue  or 
from  the  larger  fetal  arteries.  It  soon  terminates  in  induration,  oftentimes 
resulting  in  strong  adhesions  between  the  placenta  and  the  uterine  wall,  con- 
stituting the  adherent  placenta.  Apoplectic  infarcts  are  often  found  in 
placentitis. 

Calcareous  Degeneration  (Placental  calculi ;  Ossiform  concretions;  Pla- 
cental ossification). — By  this  term  is  meant  the  deposits  of  lime  on  the  edges 
of  the  cotyledons  or  in  their  s\ibstance  in  the  shape  of  particles  of  sand  or  of 
needles  or  of  scales.     They  consist  of  amorphous  carbonates  and  phosphates 


1*11. 

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of  lime  and  inafjiiasia.  The  presence  of  these  secretions  is  without  therapeutic 
significance,  and  has  no  ill  effect  on  the  functions  of  the  placenta ;  so  many  as 
five  hundred  have  been  found   in  one  placenta. 

Patty  Degeneration. — A  fil)rous,  fi)llowed  by  a  fatty,  degeneration  of 
placental  villi  is  of  very  common  occurrence,  especially  toward  the  margin  of 
the  placenta.  When  it  involves  a  small  area  no  serious  interruption  of  the 
function  of  the  placenta  follows.  When  a  large  area  is  involved  the  death 
of  the  fetus  occurs.  The  etiolof/t/  of  this  condition  is  unknown.  A  fibrous 
degeneration,  undoubtedly  the  condition  denominatetl  by  the  earlier  writers 
"  aclerases,"  or  "scirrhous"  or  "cartilaginous  degeneration"  is  regarded  as 
the  precursor  of  fatty  degeneration,  because  it  diminishes  the  blood-supply, 
which  leads  directly  to  fatty  degeneration,  or,  in  some  cases,  to  amyloid 
degeneration.  The  diagnosis  of  this  condition  is  quite  impossible  during 
pregnancy. 

Apoplexy. — Blootl  escapetl  from  a  ruptureti  blood-vessel  and  occupying 
circumscribed  cavities  formed  in  the  tissue  of  the  placenta  is  called 
"  placental  apoplexy."  It  is  occasioned,  as  a  rule,  by  the  rupture  of  some 
of  the  maternal  blood-vessels.  The  effused  blootl  rarely  comes  from  the 
placental  vessels.  The  clots  vary  in  size  from  that  of  a  millet-  or  a  hemp- 
seed  to  that  of  a  ]>igeon  egg.  Usually  there  are  several  clots,  a  large 
number  being  twenty  or  more.  They  are  situated  at  various  depths  in  the 
substance  of  the  placenta,  from  the  fetal  to  the  uterine  surface,  upon  which 
some  of  them  have  a  small  and  irregular  orifice.  Owing  to  the  spongy 
nature  of  the  substance  of  the  placenta,  the  normal  condition  of  the 
tissue  is  disturbed  only  a  few  lines  from  the  boundary  of  the  cavities. 
The  cffuboi.1  blood  soon  separates  into  two  parts,  one  solid,  the  other  liquid. 
The  serum  disappears  by  osmosis,  while  the  solid  part  contracts,  becomes 
denser  and  smaller,  and  loses  its  color.  These  whitish  homogeneous  masses 
have  been  denominated  concrete  pus  or  tuberculous  matter.  Cutting  into  the 
cotyledons  of  a  placenta  often  reveals  apoplectic  clots  in  the  various  stages  of 
chronological  consecutive  changes. 

The  results  of  placental  apoplexies  depend  upon  the  period  of  gestation 
in  which  the  hemorrhages  occur,  and  upon  their  number  and  the  extent 
of  territory  invaded.  Aboi'tion  or  premature  labor  is  rarely  produced. 
If  the  infarcts  arc  small  and  few  in  number,  the  gestation  will  be  com- 
pleted and  the  fetus  will  continue  to  live,  its  nutrition  suffering  little  or  not 
at  all.  If,  however,  the  effusions  are  large  and  numerous,  the  offspring  will 
be  born  feeble,  puny,  and  emaciated.  If  the  apoplectic  attacks  recur  at  short 
intervals,  there  will  occur  a  progressive  diminution  of  fetal  motions  and  heart- 
pulsations  until  they  cease  altogether.  In  all  cases  of  a  dead-born  fetus  pla- 
cental apoplectic  infarcts  shoulil  l)e  sought  after  carefully.  It  is  by  no  means 
rare  that  women  miscarry  repeatedly  from  this  cause,  and  when  they  do  com- 
plete their  gestations  their  placentas  will  be  found  to  contain  a  number  of 
effusions,  both  old  and  recent. 

Symptoms  and  Treatment. — The  occurrence  of  placental  apoplectic  infarcts 


THE   PATirOLOGY  OF  PREGNANCY. 


257 


varcly  betrays  itself  by  any  recognized  symptoms,  providetl  the  hemorrhage  is 
limited  in  amount.  In  some  cases  there  may  be  present  indications  of 
internal  hemorrhage,  whose  occurrence  will  Imj  suspected,  chiefly  in  women 
who  have  experienced  this  condition  in  previous  gestations  and  in  whom 
placental  apoplexy  was  found.  Should  placental  apoplexy  be  susjwctcd, 
especially  in  women  predisposed  to  the  affection,  the  prophylactic  treatment 
of  uterine  hemorrhage  is  indicated.  Absolute  rest,  small  phlebotomies,  and 
saline  cathartics,  repeated  pro  re  nata,  are  the  most  rational  treatments. 

Tumors. — Both  solid  and  cystic  tumors  of  the  placenta  have  been 
described.  They  are  very  rare.  They  may  originate  in  the  meshes  of  the 
cellular  tissue  or  in  the  glandular  cavities  of  the  decidua  serotina.  Solid 
tumors  may  cause  death  and  expulsion  of  the  fetus,  while  the  placenta  may 
remain  for  weeks  and  even  months  before  being  expelled.  The  presence  of 
tumors  can  be  determined  only  after  delivery,  for  there  are  no  known  symp- 
toms indicating  their  presence. 

Syphilis. — Syphilis  of  the  placenta  is  a  well-established  condition.  The 
observations  of  Fninkel  are  classic,  and  comprise  all  that  is  fully  settled,  to- 
day, upon  this  subject.  The  appearances  of  the  placenta  with  syj>hilis 
derived  from  the  father  differ  from  those  of  the  placenta  with  syphilis  derived 
from  the  mother.  In  the  former  the  fetus  ?8  diseased  and  the  villi  are  filled 
with  fatty  granulations,  their  vessels  are  obliterated,  and  their  epithelial 
coverings  are  thickenetl  or  absent.  In  the  latter  there  may  be  present  one  of 
three  conditions,  which  vary  according  to  the  time  of  infection  : 

1.  If  the  mother  be  infected  during  the  generative  act  at  the  same  time  as 
the  fetus,  syphilitic  foci  will  often  develop  in  the  maternal  placenta  (placental 
endometritis). 

2.  If  the  mother  is  syphilitic  before  conception  or  becomes  so  shortly  after, 
the  chances  of  the  placenta  remaining  healthy  arc  about  even. 

3.  If  the  mother  is  not  infected  until  after  the  seventh  month  of  preg- 
nancy, both  fetus  and  placenta  escape  entirely. 

A  syphilitic  placenta  is  heavier,  larger,  and  paler  than  normal.  Its 
general  color  is  pale  red,  but  in  its  diseased  parts  it  is  yellowish-white.  Here 
and  there  the  tissue  is  firmer,  more  resistant,  compact,  and  friable  than 
normal  placental  tissue. 

Anomalies  of  the  Placenta. — The  more  important  anomalies  of  the  ]ila- 
conta  arc  anomalies  in  position,  size,  weight,  shape,  and  number.  At  the  end 
of  pregnancy  the  placenta  is  normally  situatal  at  the  fundus  of  tiie  uterus, 
anteriorly  or  posteriorly ;  it  is  from  2  to  3  centimeters  (1  inch)  thick  at  its 
central  portion  and  from  17  to  18  centimeters  (7  inches)  in  diameter.  It 
weighs  about  one  pound. 

The  abnormal  position  of  the  placenta  of  greatest  clinical  imjwrtance  is 
placenta  pra;via,  by  which  is  understood  a  situation  of  the  placenta  in  any 
portion  of  the  lower  uterine  segment — that  is,  in  that  portion  of  the  uterine 
body  which  is  dilated  during  the  progress  of  labor. 

The  size  of  the  placenta  is  exceedingly  variable ;  sometimes  it  is  very  thin 

17 


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and  correspond iiifjjly  \i\r^v.  This  nhiiornmlity  is  most  remarkably  exhibited 
in  the  so-called  "  placenta  meinhranaeea,"  a  placenta  forme<l  by  the  hyper- 
trophy of  the  entire  chorion,  the  normal  atrophy  of  the  chorion  levo  not  occnr- 
r\\\^.  The  placenta  is  freqnently  enlarged  by  edema  when  there  is  dropsy  of 
the  amnion  from  either  local  or  general  causes.  An  increase  in  weight  of  the 
placenta  usually,  although  not  always,  accompanies  an  increase  in  size. 

The  variations  in  shape  are  of  interest,  and  the  anomalies  of  number  arc  of 
great  clinical  importance.  The  shape  is  usually  round  ;  it  may  be  very  irreg- 
ular, one  or  more  lobes  being  more  or  less  developed,  when  the  names  placenta 
duplex,  tripartita,  multiloba,  etc.  are  applied  (1*1.  22,  Figs.  1-3) ;  it  may  be 
oval,  as  is  (piite  frequent  in  the  so-calletl  *' battkxlore  placenta"  (1*1.  22,  Fig. 
6) ;  it  may  have  a  horse-shoe  or  crescentic  shape. 

The  anomalies  of  number  are  of  greater  clinical  importance  than  the 
variations  in  size  and  shape.  The  danger  of  accessory  growths  lies  in  the 
possibility  of  one  or  more  of  these  growths  being  retained  in  the  uterus  and 
undergoing  decompositit>n  with  the  production  of  septic  infection.  When  these 
accessory  placental  growths  serve  as  a  channel  of  conununication  between  the 
blootl-sinuses  of  the  decidua  and  the  main  placental  growth — in  other  words, 
when  they  arc  finictionally  active  in  carrying  nutriment  to  the  growing  fetus — 
they  are  ciillcd  "  jdaccnta;  succentiu'iatie  "  (1*1.  22,  Figs.  4,  5).  Placcntte  spu- 
riie  are  analogous  accessory  formations  whose  villi  have  no  direct  communica- 
tion with  the  maternal  blood. 


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E.   AXOMAIJES   OF  THE   COUD. 

Coils. — One  or  more  coils  of  the  funis  may  be  around  the  botly  of  the  child 
or  around  one  or  more  of  its  members.  The  neck  is  the  part  most  commonly 
encircletl.  As  many  as  eight  coils  around  the  neck  have  been  reported.  They 
are  found  more  often  with  male  than  with  female  children.  They  occur  more 
frequently  in  multiparae  than  in  primipara;.  Their  injurious  eifect  is  to  pro- 
duce sufficient  constriction  of  the  vessels  to  result  in  fetal  death. 

In  cases  where  the  coil  passes  over  the  portion  of  the  fetus  lying  against 
the  anterior  wall  its  presence  can  sometimes  at  least  be  inferred  by  the  detec- 
tion in  it  of  a  murmur  which  is  synchronous  with  the  fetal  heart-sound.  A 
positive  diagnosis  cannot  be  established  before  labor. 

Coils  are  found  at  least  once  in  five  or  six  deliveries.  In  breech  presenta- 
tions and  when  around  the  neck  they  are  the  most  dangerous  to  the  child. 
Cases  of  amputation  of  the  members  by  the  pressure  of  the  cord  coils  have 
been  reported,  but  it  is  generally  thought  that  these  aniputations  result  from 
amniotic  bands  rather  than  from  coils  of  the  cord. 

Knots. — When  the  cord  is  abnormally  long  or  the  liquor  amnii  very 
abundant,  knots  in  the  cord  are  liable  to  be  found.  They  may  be  double  or 
be  single.  One  case  is  reported  where  five  knots  were  found.  In  recent 
knots  the  Whartonian  jelly  is  not  displaced,  the  cord  diameter  being  normal. 
In  old  knots  the  jelly  is  displaced,  and  the  diameter  of  the  cord  is  decidedly 
lessened  in  the  knot.     Ordinarilv  the  circulation  in  the  cord  is  not  molested, 


rUKCNANCY. 


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Hicccntuiiiitii  .Itilu'iMiiiii  Lrpimri.    r.   '■  lliillli'ilun'"  pliwiiiin,  nviil  lAuviiicli.    7.  I'liii'i'iilii  with  vi'liiiiu'iiluus 


Itiiclllllfllt  111'  cnlll  I  l;iln'lllnlll    l.l'pil^^' 


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269 


Imt  twcasionnlly  the  knot  is  so  tifilitly  drawn  as  to  cause  fatal  fotal  aspliyxia. 
Ono  case  of  twins  is  reporto<l  where  a  hard  scjnare  knot  tliat  united  both  curds 
was  found,  resultinj;  in  the  loss  of  both  children. 

Torsions. — In  the  vast  majority  of  cases  the  cord  is  twisted  upon  itself 
from  left  to  right ;  the  cause  is  unknown.  Torsions  are  likely  to  be  very 
numerous  when  fetal  death  has  occurred  several  days  before  delivery,  are 
commoner  in  male  than  in  female  children,  and  are  most  numerous  near  the 
two  extremities  of  the  cord.  In  some  cases  the  jelly  of  Wharton  is  wanting  at  the 
twiste<l  points,  and  the  lite  of  the  infant  is  endangered  from  cini)arrassnieiit  «»f 
circidation.     Complete  atresia  of  the  cord  and  death  of  the  fetus  may  follow. 

Stenosis. — Independently  of  knots  and  torsions,  narrowing  of  the  vessels 
nf  the  cord  may  occur,  usually  in  the  vein  near  the  placenta.  The  causes  of 
these  stenoses  are  believinl  to  be  syphilis  and  atheromatous  degeneration.  But 
one  eventuation  succeeds  the  development  of  such  stenosis,  and  that  is  the 
death  of  the  fetus. 

().  Abortion. 

Definition. — In  a  general  sense  by  "  abortion  "  is  meant  the  interruption 
and  termination  of  pregnancy  by  the  expulsion  of  the  ovum  before  the  end  of 
the  twenty-eighth  week,  or  the  seventh  lunar  month  of  gestation.  In  a  more 
restricted  sense  the  term  is  used  to  denote  the  expulsion  (»f  the  ovum  prior  to 
the  comi)lete  formation  of  the  placenta — that  is,  before  the  end  of  the  twelfth 
week,  or  the  third  lunar  month — "miscarriage"  being  the  term  applied  to 
expidsion  of  the  ovum  from  the  twelfth  to  the  twenty-eighth  week.  Expul- 
sion t)f  the  fetus  between  the  twenty-eighth  week  and  a  short  period  before 
full  term  is  designated  "  prenuitnre  labor."  A  goodly  number  of  eases  are 
recorded  where  fetuses  have  been  born  alive  between  the  fourth  and  seventh 
liuiar  months,  the  greater  number  living  a  few  hours  only,  while  several  six 
months'  fetuses  lived  and  were  successfully  rearetl. 

Another  classification  of  abortion  sometimes  used  is  that  which  divides  the 
subject  into  "  ovular  abortion,"  occurring  before  the  twentieth  day,  "  embry- 
onic abortion,"  occurring  between  the  twentieth  and  the  ninetieth  day,  and 
"  fotal  abortion,"  occurring  between  the  twelfth  and  the  twenty-eighth  week. 

Frequency. — Statistics  as  to  the  frequency  of  abortion  are  necessarily 
incomplete,  and  therefore  unsatisfactory.  A'^ery  many  abortions  take  place, 
especially  during  the  first  three  months  of  pregnancy,  that  do  not  come  to  the 
knowledge  of  the  physician,  and  it  is  fair  to  presume  that  prior  to  the  third 
month  an  inunense  number  occur  which  are  not  even  suspected  by  the  patients 
themselves.  The  actual  number  of  abortions,  therefore,  must  largely  be  in 
excess  of  estimates  based  upon  statistics  of  observed  cases.  The  relative 
frccjuency  of  abortion  to  labor  at  term  has  been  estimated  varicisly  by  differ- 
ent authors  as  1  :  5J  and  1  :  8,  while  the  relation  based  upon  hospital  statistics 
has  been  placal  at  from  1  :  75  to  1  :  80.  According  to  some  investigators, 
from  thirty-five  to  forty  out  of  one  hundred  mothers,  to  their  own  knowledge, 
have  abortetl  at  least  once  before  their  thirtieth  year. 


1.-^ 


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260 


AMERICAN   TEXT-BOOK    OF   OBSTETRICH. 


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Time  of  Occurrence. — Abortions  occur  most  frequently  during  the  first, 
second,  and  third  niontlis  of  pregnancy,  when  the  ovum  is  usually  thrown  off 
in  tofo.  The  throwing  off'  of  the  ovum  so  fre(]uently  at  this  jK'riod  is  due  in 
part  to  the  great  vascularity  of  the  uterine  mucous  membrane  at  this  time,  in 
part  to  the  feeble  attachment  of  the  undevelopetl  chorionic  villi  to  the  decidua, 
in  part  to  the  space  existing  between  the  chi>rion  and  the  deeidua  reflexa  (this 
latter  allowing  of  the  easy  accumulation  of  blood  between  the  membranes),  as 
well  as  to  the  inability  of  the  ovum  at  this  early  stage  to  offer  sufficient  resist- 
ance to  disease-processes.  The  changes  incidental  to  ])lacenta- formation  is  no 
doubt  also  an  imjwrtant  factor  in  the  pro<luction  of  abortion  at  the  third  and 
fourth  months.  Abortion  is  more  apt  to  take  place  ui)on  the  days  correspond- 
ing with  the  menstrual  periods.  The  disposition  to  abortion  diminishes  after 
the  fourth  month,  as  the  placenta  bci'omes  more  fully  developed  and  the  connec- 
tion between  the  ovum  and  uterus  becomes  stronger,  and  the  uterus  adjusts 
itself  to  the  new  order  of  things. 

Etiology. — Abortion  is  the  direct  result  either  of  fetal  death  or  of  uterine 
contractions.  The  causes  which  result  in  fetal  death  or  in  uterine  contractions 
are  usually  subdivided  into  those  referable  to  the  father,  to  the  mother,  or  to 
the  fetus,  and  may  be  either  preiUsposiuc/  or  exciting. 

Exciting  causes,  either  alone  or  in  connection  with  some  j)reilisposition,  act 
quickly  and  more  directly  upon  the  uterus  or  the  ovum.  Such  are  violent 
coitus,  blows,  falls,  contusions,  the  jarring  of  railroad  travel,  missteps,  run- 
ning of  a  sewing-machine,  lifting  of  heavy  weights,  rapid  stair-climbing, 
sea-bathing,  stretching  of  the  arms  above  the  head,  etc.  Abortion  produced 
for  therapeutical  purj)()ses  will  be  treated  of  in  another  section. 

Exciting  causes  are  generally  only  active  in  the  presence  of  the  predispos- 
ing ones,  while  many  of  the  predisposing  causes  remain  inactive  except  in 
connection  with  some  exciting  cause.  We  caiuiot,  as  a  rule,  say  in  a  given 
case  what  will  and  what  will  not  produce  abortion,  for  on  the  one  hand  there 
are  many  notable  instances  where  pregnancy  has  been  terminated  prematurely 
by  the  mildest  of  exciting  causes  in  the  a[)j)arent  abseiuie  of  any  i)re(iis- 
position,  and  on  the  other  hand  where  the  most  serious  traumatisms  in  the 
presence  of  a  demonstrable  i)redis])osition  has  failed  to  pn)duce  abortion. 

Faterndl  Cannes. — A  syphilitic  father  may  produce  syphilis  in  the  ovum 
without  necessarily  infecting  the  mother.  Other  causes  on  the  part  of  the 
father  are  extreme  youth  and  old  age,  debauchery,  and  feebleness. 

Maternal  Causes. — Systemic,  recurrent,  or  so-called  "  habit "  abortion  is 
jn'obably  due  not  so  much  to  a  maternal  constitutional  predisposition,  the 
result  of  habit,  as  was  once  t)elieved,  as  to  a  continuance  of  the  origirud  cause. 
7)(bercuhsis  and  si/j)hi/is  of  the  mother  may  destroy  the  fetus  by  transmission 
of  these  diseases  either  to  the  placenta  or  to  the  ovum,  or  simj)ly  by  lowering  tlic 
mother's  vitality.  Sy])hilis  is  responsible  for  most  recurrent  abortions.  The 
acute  infectiouH  diseases  kill  the  fetus  eitlu-r  by  the  direct  action  of  the  poison 
transmitted  through  the  placenta,  by  the  action  of  high  temperature,  or  by  the 
tendency  to  placental  hemorrhage  jiroducetl  by  the  disease-process.     Diseases 


THE  PATJIOLOGY   OF  PRKaXAXi'Y. 


261 


of  the  heart,  Imh/s,  lirrt;  and  kidnci/a  destroy  the  fetus  by  producing  passive 
congestions  in  tlie  placenta. 

An  excess  of  carbonic  acid  gas ;  chronic  lead-poisoning ;  convulsive 
diseases,  such  as  chorea,  eclampsia,  epilepsy ;  excessive  vomiting  and  cough- 
ing ;  an  irritable  nervous  organization  and  the  habits  associated  with  the 
extremes  of  social  life ;  excessive  i)hysical  exertion,  fright,  anxiety,  and  other 
emotional  excitements, — are  all  more  or  less  potent  factors  in  the  causation  of 
abortion.  Hot  sitz-  and  loot-baths  tend  to  produce  abortion  by  dilating  the 
pelvic  blood-vessels,  in  this  way  causing  an  excessive  amount  of  blood  to  be 
sent  to  the  uterus. 

Among  the  local  causes  may  specially  be  nv^iuIontJ  subinvolution,  acute 
and  chronic  inflammatory  diseases  of  the  uterus  and  its  appendages,  as  well  as 
tiunors,  displacements,  adhesions,  and  degenerations.  Utidomctritis  and  retro- 
flc.vion.  are  particularly  prone  to  act  as  inciters  of  uterine  contractions.  Adhe- 
sions of  the  uterus  to  adjoining  organs,  as  well  as  tumors  of  the  uterus  and  in 
its  vicinity,  contractinl  pelvis,  and  tight-laciiig,  occasionally  cause  fetal  death 
by  impeding  the  development  of  the  uterus.  While  sun/ical  operations  of  the 
most  serious  nature  have  been  performed  on  the  uterus  and  other  pelvic  organs 
during  pregnancy  without  in  any  way  influencing  the  ovum,  operations  of  a 
minor  kind  upon  distant  organs  have  produced  abortion. 

Fetal  Cames. — Any  morbid  condition  of  the  ovum  or  its  appendages  that 
endangers  the  life  of  the  fetus  is  liable  to  bring  about  premature  expulsion  of 
the  fetus.  Syphilitic  disease  of  the  membranes  and  the  placenta  is  a  frequent 
cause.  Among  other  causes  may  be  mentioned  hydrorrhea,  cystic  degenera- 
tion of  the  chorionic  villi,  placental  apoplexy,  and  the  various  degenerations  of 
the  j)lacenta ;  abnormal  relations  of  placenta,  especially  placenta  jjrjevia ;  too 
short  a  cord  and  the  knotting  of  the  cord.  Death  of  the  fetus  may  be  brought 
about  by  d'sease  transmitted  from  or  through  the  mother,  such  as  syphilis, 
small-pox,  and  other  infectious  diseases,  and  rarely  tuberculosis. 

Pathology. — Hemt»rrhage  from  rupture  of  the  utero- placental  vessels 
usually  takes  |)lace  in  the  decidua  vera,  but  the  blood  is  often  forced  between 
the  decidua  and  the  chorion.  Occasionally  hemorrhage  breaks  through  the 
decidua,  and  even  through  the  amnion  and  into  the  anuiiotic  cavity,  filling 
tiie  sac  with  blood.  ITlerine  contractions  separate  the  chorionic  villi  from  the 
decidua  reflexa  from  above  downward,  and  the  detached  ovum  is  forced  into 
and  through  the  dilated  and  thinned  cervical  canal.  The  decidua  vera  is 
usually  the  last  to  be  expelled,  and  it  is  this  that  most  fretiUfUtly  remains  long 
alter  everything  else  has  been  discharged,  owing  to  the  inability  of  the  unde- 
veloped Uterine  musculature  to  entirely  throw  it  off.  The  decidua  reflexa  may 
he  torn,  leaving  the  other  memhranes  intact,  the  chorion,  amnion,  embryo,  and 
anuiiotic  fluid  being  expelled  first,  followed  by  the  rest.  Rarely,  the  chorion 
ruptures  with  the  decidua,  leaving  the  amnion  intact,  cither  entirely  free  from 
other  membranes  or  perhaps  covered  at  one  point  by  chorion  and  decidua. 

Occasionally,  owing  to  the  rigidity  of  the  external  os,  especially  in  prim- 
ipane,  tiie  ovum  becomes  fixed  in  the  cervical  canal,  and  it  nuiy  remain  there 


.'I  i 


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a  long  time  unless  relieved  by  incision.     The  term  "  cervical  jiregnancy  "  has 
wrongly  been  applied  to  this  condition.     The  appearance  of  the  extruded  mass 

(Figs.  147,  148)  differs  according  to  the  causes,  the  time, 
and  the  duration  of  the  abortion,  but,  as  a  rule,  in  tiie 
early  months  the  ovum  will  be  found  imbedded  in  a 
large  blood-clot,  the  coagnlum  arranged  in  layers  cor- 
responding with  successive  hemorrhages.  When  blood- 
cK)ts  are  formed  at  different  times  between  the  mem- 
branes, there  results  what  is  designated  a  "  blood  mole." 
If  the  coloring  matter  has  been  absorbed  from  these 
clots,  the  mass  is  called  a  "  flesh  mole." 

The  fetus  is  usually  much  smaller  than  it  would  be 
at  the  same  time  under  normal  conditions,  especially 
where  the  cause  has  been  slow-acting.  Sometimes  the 
fetus  can  be  recognized  only  by  aid  of  the  microscope, 
or  it  may  have  entirely  disappeared  after  maceration  in 
Fio.  i47.-specimciis fnim  ^^^^  liquor  aumii.  After  partial  maceration  in  tiie 
New  York  Hospital  (iibintt,   liquor  anuiii  the  retained  fetns  mav  dry  up,  and  finallv 

sliowiiiK    tho    coiuiitiims   in    ,  n    i  •  •(•     i  i'  •  i      /•       •   ' 

wiiicii  ova  are  found.  bc  cxijelletl  ui  a  mummiiiea  condition,  or,  putreiactive 

changes  setting  in,  it  may  be  exjielled  piecemeal. 
Clinical  History. — In  a  simple,  uncomplicated  case  of  abortion  occurring 
before  the  third  month  of  gestation  the  patient,  with  very  little  if  any  warn- 
ing, has  a  more  or  less  profuse,  generally  continuous,  hemorrhage  from  tiic 
uterus.  After  a  variable  period,  more  or  less  severe,  regularly  recurring 
modified  labor-pains  occur,  due  to  uterine  contractions.  Under  the  influence 
of  tiie  uterine  contractions  the  cervical  canal  is  expanded,  the  external  os  is 
dilated,  and  the  ovum  is  either  forced  out  entire,  imbedded  in  a  large  cU»t, 


Fl<i.  14K.-(ivuni  iniln'<l(UMl  in  Ijlondclot  (Alilfeld). 


or  the  embryo  is  first  exj)elle(l,   followed  shortly  by   the  already  Iooscikm 
membranes.     During  the  third  and  fourth  months,  owing  to  the  more  rigi< 


|t 


THE  PATHOLOGY   OF   PREGNANCY. 


263 


condition  of  the  cervix  and  external  os,  the  pains  bceonie  niorc  severe,  more 
force  being  required  of  tiie  uterus  to  overcome  the  resistance  of  these  parts. 
Owing  to  the  firmer  connection  of  the  oviihu*  to  tiie  uterine  surfaces,  more  force 
is  also  necessary  for  detaching  tiie  membranes,  and,  as  the  uterine  muscle  is 
still  undeveloped,  a  greater  length  of  time  is  taken  to  complete  the  abortion. 
The  anmiotic  sac  in  tiiese  cases  umally  ruptures  before  the  com))lete  separation 
of  the  membranes ;  the  fetus  is  expelled,  generally  with  a  portion  of  the  mem- 
branes ;  and  the  remaining  portions  are  finally  entirely  detachetl  and  forced 
out  of  the  uterus.  Afler  the  fifth  month  the  process  more  and  more  resembles 
labor  at  term. 

The  above  outline  of  the  clinical  progress  of  simple,  uncomplicated  abor- 
tions occurring  before  and  after  placental  formation  probably  does  not  repre- 
sent the  class  of  cases  usually  coming  under  the  physician's  care.  It  will  be 
well  on  this  account  to  consider  briefly  the  more  common  symptoms  and 
variations  in  detail. 

Prodromal  Ssmiptoms. — Reliable  symptoms  and  signs  indicative  of  ap- 
jiroaching  abortion  very  rarely  exist  before  the  third  month,  and  they  arc 
not  constant  after  that  time.  The  occurrence  of  shifting  pains  in  the  back 
and  abdomen,  frequent  urination,  sometimes  nausea  and  vomiting,  and  a 
mucous  or  watery  disciiarge  from  the  uterus  sho»dd  be  a  warning  of  the  pos- 
sibility of  approaching  abortion,  and  early  and  appropriate  treatment  should 
1)0  instituted. 

Duration  of  Abortion. — The  duration  of  the  abortive  process  varies  accord- 
ing to  the  j)erio(l  of  gestation,  the  cause  of  the  abortion,  and  the  condition  of 
the  OS  and  cervix  and  the  energy  of  the  uterus.  As  a  rule,  abortion  is  slower 
tiian  normal  labor  at  term.  Especially  after  a  fall  the  ovum,  in  the  earlier 
period  of  its  development,  may  be  thrown  off  and  expelled  instantaneously,  or 
it  may  rapidly  be  expelled  after  a  few  gushes  of  blood  and  a  single  painful 
contraction.     These  cases,  however,  are  but  rarely  observed. 

Hemorrhage  and  Pain. — In  early  abortion  liemorrliage  is  the  leading 
symptom,  and  it  is  the  first  that  attracts  attention  in  the  majority  of  eases. 
It  is  often  excessive  and  alarming,  and  may  be  so  profuse  as  to  endanger  tiie 
niothci-'s  life.  Hemorrhage  may  i)reee(le  pain  many  hours  or  even  days  and 
weeks,  or  in  rare  cases  it  may  take  place  conjointly  with  pain.  It  may  be 
very  slight  at  first,  cease  after  a  variable  period,  and  then  recur,  or  it  may 
l)('gin  with  a  sudden  ])rofuse  discharge.  Hemorrhage  may  take  place  contin- 
uously from  the  uterine  surface,  but  it  may  oidy  appear  at  intervals  externally 
in  the  shape  of  clots,  sometimes  collecting  in  the  uterus  in  considerable  quanti- 
ties before  being  expelled.  This  "concealed  hemorrhage"  rarely  happens 
Ijcfore  the  fourth  or  the  fifth  month  of  gestation.  The  amount  of  blood  lost 
varies  considerably  with  the  period  at  which  the  hemorrhage  occurs,  being,  as 
a  rule,  less  the  nearer  the  abortion  is  to  the  end  of  pregnancy,  and  it  depends 
((I  a  considerable  degree  uj)on  the  extent  of  separation  of  the  ovum  from  the 
uterine  wall,  as  well  as  ujH)n  the  activity  of  the  uterine  contractions.  Gen- 
cnilly  the  hemorrhage  will  continue  until  the  uterus  is  empty.     Hemorrhage 


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AJfERICAN   TEXT-BOOK   OF    OBSTETRICS. 


is  sornetimos  preceded  in  these  cases  by  the  passage  of  small  quantities  of 
dark-coloretl  blowl-seriini. 

The  pains  of  abortion,  which  resemble  those  of  labor  at  term  in  many 
instances,  vary  considerably  according  to  existing  conditions.  Many  patients 
complain  that  abortion-pains  are  harder  to  bear  than  those  of  normal  labor, 
and  not  so  easily  forgotten.  In  exceptional  cases  the  pains  may  begin  some 
time  prior  to  the  occnrrence  of  hemorrhage. 

Expulsion  of  Uterine  Contaifii. — Instead  of  the  membranes  ancl  the 
placenta  being  expelled  with  the  fetns  or  shortly  afterward,  a  jiortion  or  all 
of  the  placenta  may  remain  behind,  either  only  |)artially  or  wholly  detached 
from  the  uterine  wall,  constitnting  what  is  designated  "  incomplete  abor- 
tion." There  may  be  considerable  delay  before  the  remnants  are  entirely 
expelled,  the  process  of  nnaided  expnlsion  recpiiring  days,  weeks,  and  even 
months,  for  completion.  So  long  as  ".ny  portion  of  the  ovnin  or  its  coverings 
remains  in  the  uterns,  just  so  long  will  the  patient  be  subjected  to  the  risk  of 
hemorrhage  and  sepsis.  Frequently  after  several  days  there  is  a  return  of 
hemorrhage  and  pain,  with  slow  dilatation  of  the  external  os,  and  the  decom- 
posing uterine  contents  come  away  piecemeal. 

Sometimes  in  twin  pregnancies  symptoms  of  threatened  abortion  will  sub- 
side without  rupture  of  the  membranes,  and  the  pregnancy  Avill  continue  to 
term,  at  which  period  a  living  child  will  be  born,  and  at  the  same  time  a  dead 
fetus  or  "blighted  ovum"  will  be  expelled. 

Diagnosis. — While  there  is,  as  a  rule,  but  little  doubt  as  to  the  existence 
of  abortion  in  the  majority  of  cases  coming  under  the  physician's  care,  it  is 
nevertheless  true  that  there  are  cases  where  it  is  quite  impossible  to  make  a 
positive  diagnosis,  and  others  in  which  the  diagnosis  can  only  be  arrived  at 
after  a  searching  examination  into  the  history  of  the  case,  a  careful  analysis 
of  the  symptoms,  and  a  thorough  physical  exploration. 

Where  the  entire  ovum  is  expelled  suddenly,  as  sometimes  happens  in  early 
pregnancy  after  falls  or  blows,  and  the  expelled  mass  is  either  lost  or  thrown 
away  without  being  examined,  a  positive  diagnosis  is  not  possible. 

In  dealing  with  a  ease  of  iitcrine  hemorrhage  and  pain,  unless  there  be 
sufficient  evidence  of  its  cause,  the  first  point  to  determine  is  as  to  the  e.ri.'^tcnce 
of  j)n'(/)i(tm'if.  In  the  early  months  of  gestation  this  determination  may  l)i> 
impossible,  and  in  the  absence  of  positive  signs  we  can  only  presume  that  preg- 
naniy  does  or  does  not  exist.  It  may  be  denie<l  by  those  who  may  have  an 
object  in  denying  it,  or  it  may  be  admitted  by  those  who  simply  believe  them- 
selves to  be  pregnant.  Abortion  may  be  sinuilated  in  the  non-pregnant 
woman  by  dysmenorrhea,  by  pain  and  hemorrhage  caused  by  the  presence  of 
submucous  uterine  tumors,  and  may  even  be  feigned  by  hysterical  girls  at  the 
menstrual  period  or  l)y  women  with  intention  of  blackmail.  In  the  absence  of 
a  history  of  previous  attacks  of  dysmenorrhea,  and  of  a  record  "  running  over  " 
two  or  three  months,  u  vaginal  examination  should  be  insisted  upon,  which 
examination,  with  that  of  the  napkins,  would  probably  settle  the  diagnosis  one 
way  or  the  other.     A  carefid  inquiry  into  the  patient's  history,  together  with 


THE  PATHOLOGY  OF  PREGNANCY 


205 


physical  exploration  and  examination  of  the  discharges,  will  assist  in  clearing 
up  doubts  in  the  case  of  hemorrhage  and  pain  from  uterine  tumors.  The 
examination  of  membranes,  clots,  and  pieces  of  tissue  offered  in  evidence  as  to 
abortion  will  expose  any  attempt  at  malingering. 

Having  determined  that  pregnancy  exists  in  a  case  of  suspected  abortion, 
the  next  thing  to  be  determined  is  whether  we  have  to  do  with  abortion  ot 
with  something  sinudating  it.  Abdominal  pain  and  uterine  hemorrhage 
occurring  at  the  same  time  in  a  woman  supposed  to  be  pregnant  is  presump- 
tive evidence,  at  least,  of  imi)ending  abortion,  but  such  evidence  alone  is  not 
sufficient  for  a  positive  diagnosis.  For  instance,  hemorrhage  may  take  place 
from  a  diseased  cervix  in  pregnant  women,  and  at  the  same  time  there  may  be 
present  intestinal  colic,  neuralgia,  stretching  of  old  visceral  adhesions,  or  the 
discomfort  of  an  over-distended  bladder.  Nor  is  the  presence  of  membrane 
always  positive  evidence.  In  extra-uterine  pregnancy  the  expulsion  from  the 
uterus  of  a  deciduous  membrane,  together  with  more  or  less  hemorrhage,  may 
lead  to  a  wrong  diagnosis  of  abortion.  In  the  latter  case  the  absence  of 
chorionic  villi  will  count  against  the  case  being  one  of  abortion. 

Pregnancy  existing,  and  abortion  determined  upon  as  the  cause  of  the 
symptoms,  the  next  inquiry  will  be  as  to  whether  abortion  is  simply  fhreatrn- 
Infj,  whether  it  is  inevitable,  or  whether  it  has  been  completed.  Li  threatening 
abortion  the  os  uteri  is  undilated,  the  cervical  canal  is  unoxpanded,  the  hemor- 
rhage is  not  profuse,  and  the  ])ains  are  easily  controlled.  In  inevitable  abor- 
tion the  OS  is  usually  dilated  sufficiently  to  admit  the  index  finger,  the  cervical 
canal  is  expaniled  or  expanding,  the  angle  between  the  upper  and  lower 
uterine  segments  is  effiiced,  the  uterine  contents  are  forced  down  within  reach 
of  the  finger  with  each  pain,  and  the  hemorrhage  and  pains  cannot  be  con- 
trolled ;  or  profuse  hemorrhage  alone,  if  uncontrollable,  may  be  sufficient  evi- 
dence of  inevitable  abortion.  A  critical  examination  of  the  discharges  from  the 
uterus  by  floating  them  in  water  will  often  determine  whether  or  not  the  integ- 
rity of  the  ovum  has  been  destroyed,  and  will  thus  assist  the  diagnosis.  Abortion 
is  complete  when  the  uterus  is  free  from  ovular  tissue.  The  continuance  of  pains 
or  of  hemorrhage,  or  both,  is  conclusive  evidence  that  the  abortion  is  incomplete. 

Prognosis  and  Sequelae. — For  the  child  the  prognosis  is  necessarily  fiital. 
As  a  rule,  the  ])rognosis  fi)r  the  mother  is  remarkably  good,  better  even  than 
after  labor  at  term,  a  fatal  termination  rarely  taking  place  except  in  badly- 
managed  or  neglected  cases.  The  danger  of  general  septic  diseases  is  much 
less  after  early  abortion  than  later.  Even  under  conditions  that  would,  if 
existing  at  the  end  of  j>rcgh'Uicy,  prove  most  disastrous,  such  as  septic  intox- 
ication from  putrefaction  of  retained  membranes,  rapid  disappearance  of  the 
symptoms  is  the  rule  in  abortion  under  appropriate  treatment.  But  while  the 
immediate  danger  to  the  mother's  life  is  less  than  it  is  at  the  termination  of 
pregnancy,  the  pernicious  consequences  of  neglected  or  badly-managed  abor- 
tions are  far  more  common,  and  not  nearly  so  amenable  to  treatment. 

The  nature  and  severity  of  the  sccpielaj  vary  with  the  causes.  Anenn'a, 
with  great  debility,  consequent  upon  excessive  hemorrhage  at  the  time  of 


2(i6 


AMERICAN    TEXT- HOOK    OF   OBSTETIUCS. 


\A 


W  -I 


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abortion  or  upon  rocurring  licniorrlKigcs,  tlio  result  of  subinvolution  or  of 
retained  fetal  membranes,  is  very  fr('(|uently  observed.  Among  the  more 
eonnnon  local  results  of  abortion  are  acute  and  chronic  inflammatory  diseases 
of  the  uterus,  the  ovaries,  and  the  tubes,  and  of  adjacent  structures,  from  a 
more  or  less  marked  septic  infection.  Such  diseases  are  endometritis,  acute 
cellulitis,  pelvic  peritonitis,  ])elvi(!  abscess,  salpingitis,  pyosalpinx,  ofjphoritis, 
etc.  Hydatidiforin  moles,  the  result  of  retained  chorion,  and  placental  or 
decidual  polypi,  the  result  of  retaine<l  fragments  of  placenta  or  decidua,  are 
often  noticed.  Secondary  infectious  are  not  infre(]uently  encountered  as  a 
result  of  abortion.  Suppurative  arthritis  may  be  mentioned  as  an  ex- 
ample. One  abortion  nearly  always  predisposes  to  recurrences,  giving  rise  to 
wiiat  is  known  as  "habitual  abortion,"  indess  the  original  cause  be  removed 
and  the  abortion  be  managed  in  a  proper  maimer. 

A  most  important  sequel  to  abortion  is  its  baneful  effect,  at  times,  upon 
the  nervous  system.  There  is  scarcely  a  single  manifestation  of  the  so-called 
"functional  nerve  disorders,"  from  slight  irritability  of  temper  or  mental 
depression  to  actual  insanity,  that  may  not  have  its  origin  in  a  pathological 
condition  the  result  of  abortion.  While  local  irritation  alone  may  be  respon- 
sible for  some  of  these  disorders,  the  possibility  of  autoinfection  from  the 
slow  but  continuous  absorption  of  mildly  septic  material  from  a  chronically 
inflamed  mucou'    surface  should  be  borne  in  mind. 

Treatment. — In  the  treatment  of  abortion  we  have  to  consider — 1.  Pro- 
phylaxis ;  2.  Treatment  of  threatening  abortion ;  Ji.  Management  of  actual 
abortion  and  treatment  of  its  accidents ;  4.  Treatment  of  incomplete  abortion  ; 
5.  After-management.  Abortion  is  truly  a  surgical  condition,  and  its  treat- 
ment requires  and  should  receive  the  application  of  the  same  well-known  j)rin- 
ciples  in  regard  to  the  prevention  of  sepsis  as  do  other  surgical  affections. 
Surgical  cleanliness  is  as  much  indicated  in  abortion  as  it  is  in  labor  at  term. 

Prophijlaxis. — Tlie  prophylaxis  of  abf)rtion  consists  in  the  treatment  of  all 
those  general  and  local  conditions  which  predispose  the  patient  to  its  occur- 
rence, in  the  restoration  of  the  patient  as  nearly  as  possible  to  normal  health 
before  and  after  conception,  and  in  the  avoidance  after  ])regnancy  has  begim 
of  those  exciting  causes  which  are  more  or  less  prone  to  precipitate  an  abor- 
tion, at  least  in  predisposed  cases.  T^ocal  causes,  such  as  tumors  in  and  about 
the  uterus,  subinvolution,  endometritis  and  other  inflammations,  displace- 
ments, etc.,  sliould  be  sought  for  and  should  appropriately  be  treated  before 
conception.  General  pathological  conditions,  such  as  tuberculosis,  syphilis, 
lucmii,,  the  neuroses,  as  well  as  diseases  of  the  thoracic  and  abdominal  viscera, 
•  '>uld  also  receive  treatment  both  before'  and  after  i>regnancv  has  begun.  As 
«\j)'iilis  is  probably  resimnsible  for  a  much  larger  number  of  abortions  than 
aay  olacr  single  cause,  its  presence  in  one  or  both  parents  should  receive 
})roni[)t  and  thorough  attention.  In  those  instances  where  no  other  cause  can 
be  found  and  there  is  no  indication  of  syphilis  existing  in  either  parent,  father 
and  mother  should  be  placed  under  antisyphilitic  remedies,  as  an  apparently 
cured  syphilis  may  still  exist  sutticiently  to  affect  the  ovum.     During  preg- 


'  'I 


THE  PATHOLOGY   OF  PREGNANCY. 


267 


nancy  the  jifi-oatcst  care  should  be  taken  to  avoid  all  jjossible  sources  of 
irritation,  such  as  fatiguinj;  work,  too  long  walks,  riding,  dancing,  lifting, 
reaching,  stair-climbing,  jumping,  sea-bathing,  corsets,  tight  clothing,  conta- 
gious diseases,  poorly-ventilated  or  overheated  rooms,  crowded  theatres  or 
crowded  churches,  emotional  excitement,  late  hours,  etc.  The  diet  should  be 
regulated  carefully,  in  order  that  acute  dyspepsia,  fla*^«lence,  colic,  diarrhea, 
and  constipation  may  be  avoided,  and  the  kidneys  and  the  bowels  should  be 
r(>gidated  properly.  Coitus  should  be  prohibited.  The  patient  should,  if 
possible,  spend  several  days  in  bed  at  the  times  corresponding  with  the  men- 
strual periods.  A  retroflexed  uterus  should  carefully  be  righted  and  be  held 
in  position  by  an  aj)|)ropriate  pessary. 

In  cases  of  habitual  abortion  it  would  be  well  for  the  patient  to  allow  an 
interval  of  six  months  or  a  year  to  elapse  between  the  last  abortion  and  the 
next  pregnar.cy  while  under  treatment.  In  some  cases  confinement  to  bed  the 
greater  part  of  the  time  seems  to  be  the  only  way  in  which  pregnancy  can  be 
carried  through  to  term. 

Treatment  of  Threatening  Abortion. — If  upon  examination  the  os  is  found 
undilated,  the  cervical  canal  unexpanded,  hemorrhage  not  profuse,  and  pains 
absent  or  moderate,  the  case  shoidd  be  considered  as  preventible  and  be 
treated  accordingly.  If  we  knew  for  a  certainty  that  the  fetus  was  dead,  there 
would  be  no  reason  for  treating  the  case  as  preventible,  but  as  there  are  no 
reliable  signs  of  fetal  death  where  abortion  is  only  threatening,  we  must  treat 
it  as  though  the  fetus  were  alive.  Our  aim  is  to  prevent,  if  possible,  any 
further  separation  of  the  ovum  from  the  uterus,  and  to  allow  of  the  healing 
of  the  already  injured  surfaces.  To  this  end  we  endeavor  to  control  hemor- 
rhage and  uterine  coiitractionn. 

Absolute  rest  and  quiet  are  essential  to  the  proper  treatment  of  threatening 
abortion.  Tlie  patient  should  be  put  to  bed  in  the  quietest,  best-ventilated 
room  in  the  house.  She  should  maintain  a  recumbent  position  for  sevei-al 
days  or  until  all  danger  is  past.  She  should  not  rise,  even  to  a  half-sitting 
])osition,  for  any  purpose,  the  bed-pan  being  used  for  defecation  and  urination. 
Everything  having  a  tendency  to  produce  nervous  disturbance  should  be 
avoided,  such  as  talking,  visitors,  and  worry  of  any  kind.  Secure  free  move- 
ment of  the  bt)wels  each  day  by  sufficient  doses  of  castor  oil  or  other  mild 
laxative,  aided,  if  necessary,  by  enemata  of  glycerin  and  water  or  of  sweet  oil. 
The  clothing  should  be  cool  and  light,  the  diet  nutritious  and  easily  assim- 
ilated, but  non-stimulating. 

In  tiie  way  of  drugs,  opium  in  one  of  its  forms  is  mostly  to  be  relied  upon 
as  a  general  sedative.  It  should  be  given  in  full  doses,  and  repeated  often 
enough  to  preserve  systemic  quiet.  In  some  cases  it  may  be  advantageous  to 
give  with  the  opium  such  nerve-sedatives  as  chloral  hydrate,  the  bromids,  or 
j>Iienacetin.  These  drugs  should  be  given  per  rectum  if  the  stomach  is  sen- 
sitive. The  fluid  extract  of  viburnum  prunifolium  in  drachm  doses  is  said  to 
assist  materially  in  quieting  uterine  contracticMis.  Ergot  in  small  doses  (15  to 
20  min.  of  the  fluid  extract)  may  be  of  benefit  in  selected  cases  (where  there  is 


1' 

I 

■  !"^  ';i^ 

1  4'| ! 

I 

■    1^1 

;     1 


,  I 


i  I 


268 


AMERICAN   TEXT-BOOK   OF   OBNTETIiWS. 


little  pain,  hut  much  lioniorrhn<;o)  in  assisting  in  tlio  control  of  hemorrhage  by 
contracting  the  arterioles,  bnt  as  a  general  thing  it  shonlil  not  be  used,  owing 
to  the  tendency   for  even  small  doses  to  excite  uterine  contractions. 

The  vaf/lnal  (ampnii,  as  a  rule,  should  never  be  used  in  threatening  abor- 
tion, on  account  of  its  action  in  exciting  uterine  contractions.  In  exceptional 
cases,  however,  where  there  is  not  much  pain,  but  considerable  hemorrhage 
which  cannot  be  controlled  by  other  means,  the  tampon  may  be  useful  in 
connection  with  the  sedatives  already  mentioned.  A  vaginal  injection  of  hot 
alum-solution  (.^ss-Oj)  may  be  used  instead  of  the  tampon.  Any  malposition 
of  the  uterus  siiould  l)e  remedied  by  the  gentlest  manipulations. 

Treatment  of  Actual  Abortion. — If  the  os  is  dilated  and  the  cervical  canal 
is  expanded,  or  the  pains  and  hemorrhage  continue  notwithstanding  treatment, 
and  there  seems  to  be  no  prospect  of  checking  the  progress  of  the  abortion,"  the 
expulsion  of  the  ovum  becomes  inevitable.  The  main  indication  now  will  be 
to  control  hemorrliar/e  and  to  secure  complete  evacuation  of  the  uterus. 

If  it  has  not  been  done  before,  the  vagina  and  the  external  genitals  should 
be  placed  in  as  nearly  an  aseptic  condition  as  can  be  done  with  hot  water, 
soap,  and  an  antiseptic  solution.  The  physician's  hands  and  the  instruments 
should  also  be  rendered  surgically  clean  before  an  examination  is  made.  If 
the  ovum  is  protruding  with  membranes  unruptured,  it  may  easily  be  dis- 
lodged from  the  cervical  canal,  but  we  should  refrain  from  manipulations  that 
miglu  cause  rupture  before  its  complete  extrusion. 

Before  the  fourth  month  we  may  best  meet  the  indications — to  control 
hemorrhage   and   to   expedite   delivery — by  the   use   of  a   vaginal  tampon. 

Properly  applied,  the  tampon  will  surely  con- 
trol hemorrhage  ;  further,  it  hastens  the  com- 
plete separation  of  the  ovum  by  causing  an 
accumulation  of  blood  between  the  uterus  and 
the  membranes,  and  it  is  a  powerful  exciter 
of  uterine  contractions.  The  tampon  may  be 
made  of  a  long  strip  of  aseptic  or  antiseptic 
gauze,  of  pledgets  of  aseptic  or  antisejitic  ab- 
sorbent cotton  or  wool,  or,  in  the  absence  of 
these  materials,  of  "My  soft  fabric,  such  as  a 
silk  handkerchief,  a  soft  towel,  or  strips  oi' 
pieces  of  sheeting,  cheese-cloth,  an  ordinary 
roller  bandage,  etc.  Whatever  material  is  used, 
it  is  understood  it  nuist  be  stcrili/ed  thor- 
oughly by  boiling,  by  dry  heat,  or  by  steam, 
or  it  may  be  scalded  thoroughly  in  some  hot 
Fm.iio.-sims'simsition  for  tamponing    autiscptic   Solution.     If    a   large   number   of 

aiulciiretlinK  (.skonu).  .         '  .... 

j>ieces  are  used,  as  of  antiseptic  wool,  they 
should  be  so  secured  to  each  other  by  a  string  as  to  facilitate  their  withdrawal. 
If  the  material  has  previously  been  prepared  or  if  it  can  be  sterilized  by  dry 
heat  before  using,  it  is  better  to  use  it  without  soaking  in  an  antiseptic  solii- 


-li 


s 


THE  I'AriiOLoav  or  PiiixiXAXvY. 


269 


tion,  as  more  accurate  tamponade  can  l)o  done  when  the  tampon  is  dry  than 
when  it  is  wet. 

For  introducing  the  tamjion  the  patient  shoidd  be  placetl  across  the 
bed,  or,  better,  on  a  table,  in  the  dorsal  or  in  Sims's  position,  with  the 
hips  at  the  edge  of  the  bed  or  the  table  (Fig.  149).  A  very  cojiioiis 
hot-water  or  hot  antiseptic  vaginal  douche  shotdd  next  be  given,  after  the 


Fi<i.  )"0.— Frozen  section  of  the  utonis,  showing  placenta  iind  partially-detached  membranes  (Frcund). 

Itladder  has  been  emptied.  The  tamponing  may  be  done  with  the  aid  of  a 
Sims  speculum  if  assistance  is  at  hand  ;  if  not,  then  a  bivalve  speculum  may 
bo  used,  or,  as  is  preferred  by  some,  one  or  two  fingers  of  (Mie  hand  are  intro- 
ducetl  into  the  vagina  and  there  act  as  a  guide.  With  dressing  forceps  one 
end  of  tlie  strip  of  gauze  or  a  pledget  of  the  tampon  material  is  passed 
into  the  vagina  along  the  introduced  fingers,  and  is  accurately  packed  by 


|i^^: 


"Mi-     !      I     illfl' 

{ '   J  ijir 

Ail"  ; 


I  i'    ill 

'     '  ft    A       k 


i  i 


hi  .    * 


1 


W^'- 


hi  "--ft. 


\i 


m: 


270 


AMEIUCAX    TEXT-BOOK   OF   OBSTETRICS. 


them  into,  against,  and  about  the  os  antl  the  cervix.  The  tamponing 
should  be  continued  in  this  way  until  the  vagina  has  been  moderately  filled. 
All  antiseptic  pad  is  placed  over  the  vulva  and  is  held  in  place  by  a  T 
bandage.     Moderate  doses  of  fluid  extract  of  ergot  (iTtxv  to  oss)  should  be 


Fig.  l')!,— Frozen  section  of  the  uterus,  showinj;  retained  memliriuies  (Freund). 

administered  every  two  or  three  hours,  together  with  quinin  or  strychin'a 
where  these  are  indicated  for  debility.  If  there  is  much  pain,  5  grains  (tf 
phenacetin  will  give  the  patient  comfort  without  interfering  with  uterine 
contractions.     A  second  tampon  and  other  accessories  should  be  in  readi- 


j; 


THK   PATJfOLOaV    OF  PRKaXAXVY. 


271 


I108S  before  the  removal  of  the  first.  Tlie  tiunpon  slioiihl  Ik?  remove*! 
earefiilly  after  from  six  to  twelve  hours,  when,  as  is  usual,  the  entire 
ovum  or  the  fetus  alone  will  he  found  in  the  vagina  or  adheriu}?  to  the 
tampon,  ff  the  ovum  has  not  been  expelled  or  oidy  a  portion  has  been 
thrown  oflf,  we  should  tampon  again,  after  emptying  the  bladder  and  douch- 
ing the  vagina,  in  the  same  manner  as  before. 

If  after  the  removal  of  the  second  tampon  it  is  found  that  the  membranes 
have  ruptured,  and  oidy  a  portion,  if  any,  of  the  ovum  has  been  expelled,  the 
uterine  cavity  shotUd  be  explored  by  the  introduction  of  one  or  two 
thoroughly  antiseptieized  fingers,  the  vagina  having  first  received  a  thorough 
cleansing  with  hot  water  or  with  antiseptic  fluid.  If  much  pain  is  to  be  fearwl 
or  the  patient  is  nervous  and  resisting,  an  anesthetic  should  be  employed. 
If  the  OS  is  not  sufficiently  dilated  to  admit  the  finger,  graduated  metal  or 
hard-rubber  dilators  should  be  employed.  The  introduction  of  the  finger  may 
be  aided  materially  by  })roperly  applied  counter-pressiu'c  on  the  fundus  through 
the  abdominal  walls.  The  cavity  of  the  uterus  must  be  explored  thoroughly 
and  the  retained  portions  (Figs.  150,  151)  be  separated,  if  adherent,  and 
removed.  In  case  the  use  of  the  finger  is  unsuccessful,  the  adherent  mass 
should  be  removed  by  the  careful  use  of  a  not  too  sharp  intra-uterine  curette. 
The  instrument  devised  by  Carl  Braun  or  one  similar  to  it  answers  the 
purpose  admirably,  being  at  the  same  tiiiie  a  curette  and  an  irrigator.  Either 
])lain  hot  water  or  a  hot  mildly  antiseptic  solution  of  creolin  (1  to  2  per  cent.) 
or  of  boric  acid  (4  per  cent.)  or  straw-colored  tincture  of  iodin,  are  recora- 
inendcd  for  irrigating  the  uterus,  as  being  the  fluids  least  liable  to  do  harm. 
In  the  use  of  the  curette  great  care  shoukl  be  observed  lest  more  harm  be 
(lone  than  the  good  we  seek  to  acconiplish.  The  dangers  to  be  avoided  are 
perforation  of  the  uterus  by  careless  manipulation,  and  in  needlessly  injuring, 
hy  indiscriminate  curettage,  uninvolved  mucous  membrane.  After  complete 
emptying  and  irrigation  of  the  uterus  in  this  way  an  antiseptic  pad  should  be 
placed  against  the  vulva. 

The  tampon  is  contra-indicated  in  abortion  after  the  fourth  or  the  fifth 
month,  as  the  uterus  at  this  period  is  sufficiently  large  to  contain  considerable 
l)lo()d.  Fov  the  control  of  hemorrhage  rupturing  of  the  membranes  is  to  be 
|)referred,  but  if  tamponage  is  resorted  to  the  uterus  must  closely  be  watched. 
The  incfFectual  uterine  contractions  usually  found  may  be  stimulated  by  from 
')-  to  10-grain  doses  of  quinin.  If  after  rupture  of  the  membranes, 
liemorrhage  continues,  the  uterus  must  be  emptied  as  quickly  as  possible,  the 
cervix  being  dilatetl  if  necessary,  the  fetus  be  extracted,  preferably  by  turning, 
and  the  placenta  be  removed  if  detached  or  easily  detachable.  If  the  placenta 
is  firndy  adherent,  it  may  safely  be  left  for  a  few  days  to  become  detached  by 
natural  means,  provided  the  uterus  and  the  vagina  can  properly  be  irrigated 
antiseptically,  the  former  twice  in  twenty-four  hours,  the  latter  from  four  to 
six  times  or  continuously.  The  insertion  into  the  uterus  of  an  iodoform- 
nanze  tampon  has  been  used  successfully  in  these  cases.  After  the  pla- 
centa has  become  detached,  it  and  the  remaining  adherent  fragments  may  be 


\ii 


-m 


irfi 


IF 


■mr 


u 


272 


AMFJtIVAy    TEXT-nOOK    OF   OJiSTKTIilVS, 


rlJ 


i  / 


I  (■ 


reruovtil  in  tlio  niaiiner  already  (U'st'rihod,  oitlior  by  moans  of  tlio  fingers  or 
the  curette. 

Tiratincut  of  T)icnmj>frtr  Abortion. — If  tlioro  is,  after  the  apparent  com- 
pletion of  abortion,  more  or  less  hemorrhaj^e,  either  eontinuons  or  interrupted, 
with  slijrhtly  dihited  os  and  flabby  cervix,  especially  if  there  be  pain  and  an 
odor  of  drcomposition,  it  is  evident  that  some  portion  of  the  ovnm  still 
remains  in  the  ntenis. 

In  tl>e  mildet^t  cases,  in  which  there  is  as  yet  no  infection  of  the  retained 
j)ortion  and  the  os  is  contracted,  conservative  measures  might  l)e  ailvisable  in 
tliose  cases  tliat  could  Ih'  kept  under  observation  and  in  those  in  which  the 
treatment  could  properly  be  carried  out.  Such  conservative  treatment  woidtl 
consist  in  keeping  the  j)atient  quietly  ih  bed,  stimulating  uterine  contrac- 
tions by  repeated  moderate  doses  of  ergot  and  by  the  use  of  the  vaginal 
tampon,  and  by  keeping  the  vagina  and  the  vulvu  in  a  strictly  aseptic  con- 
dition. 

In  neglected  cases,  where  there  is  nuich  hemorrhage  or  pain,  and  especially 
if  there  be  even  a  minimum  amount  of  fetid  odor  to  the  lochia  as  it  comes 
from  the  uterus,  the  indications  arc  clearly  to  empty  the  uterus  com])lctely 
and  at  once — with  the  fingers  if  possible,  with  tlu'  curette  if  necessary ;  to 
render  the  uterus  and  the  vagina  as  nearly  aseptic  as  possible  by  antiseptic 
irrigation,  and  to  keep  them  so.  In  the  treatment  of  incomplete  abortion, 
whether  the  case  is  seen  early  or  late,  there  should  be  observed  the  same  rigid 
adherence  to  the  principles  of  asej)tic  or  antiseptic  surgery  as  is  observed  in 
any  other  case. 

After-management  of  Abortion. — There  is  no  valid  reason  why  the  woman 
who  has  aborted  should  not  require  as  much  time  for  the  repair  of  uterine 
lesions  and  for  the  proper  involution  of  her  eidarged  uterus  as  does  the 
woman  who  has  been  delivered  at  term.  Owing  to  the  inn)erfect  develojiment 
of  the  enlarged  uterus  after  abortion,  the  process  of  involution  is  even  shnver 
than  the  same  ))rocess  after  labor  at  term.  There  would  be  a  marked  decrease 
in  the  number  of  pelvic  disorders,  and  there  would  be  almost  as  great  a 
falling  off  in  the  number  of  abortions,  if  wonien  \ ere  treated  after  aborting 
more  nearly  as  they  arc  after  a  normal  labor. 

Missed  Abortion  and  Missed  Labor.--  Am  a  child  at  full  term  may  die 
and  may  remain  in  ntero  for  weeks  or  for  months  afterward,  this  condition  is 
called  *'  missed  labor."  A  similar  conditicn — missed  abortion — is  observed  in 
the  earlier  months  of  pregnancy  when  the  fetus  dies,  the  ovum  remaining  in 
utero  for  weeks  or  for  months.  The  symptoms  of  pregnancy  are  then  arrested  ; 
the  liquor  amnii  is  absorbed,  the  abdomen  becomes  smaller,  and  milk  appeals 
in  the  breasts.  The  child  in  ntero,  surrounded  by  the  placenta  and  the  mem- 
branes, becomes  macerated  or  mummiHcd.  It  does  not  necessarily  become 
putrid,  because  the  unbroken  membranes  prevent  the  entrance  of  atmospheric 
germs.  In  these  cases  labor  does  not  come  on  at  all,  or,  having  commenced, 
the  ])ains  cease  and  the  fetus  is  retained. 

Oldham  was  the  first  to  ai)ply  the  term  "missed  labor"  to  cases  in  wliicli 


occurred  ii 

the  iiqiioi- 

to  whether 

access  to  tl 

condition  I 

somewhat, 

tion  of  all 

parts   beinj; 

uterine  wal 

through  th( 

peritonitis,  ,' 

hut  convale.' 

and  the  fctu 

Hed  product 

it  n)ay  cause 

results.     I}es 

may  lead  to  i 

A  dead  : 

generally  ser 

('onseqiiently 

iew  weeks,  an 

to  induce  lalx 

<';uition  is  safi 

WJien  nature 

active  efforts 

be  emj)loyed 

Ijc  exercised  t 

«'mia.     Lapa 

very  thing  to  > 

Miiller  of 

are  really  case.* 

<'-\'pulsion,  bee; 

it  may  be  sai( 

fetation  of  the 

ft'tii.-  in  a  biloh 


History. — E 
pathology,  and 
sions  and  'las  c 
or  twenty  years 
attention.  Froi 
of  many  jiractic 
'lot  quite  unkno 

18 


Tin:  PATiroLoav  or  pjiKayAxrv 


273 


occurred  ineffective  uterine  eH'orts  to  expel  the  fJ'tns  ami  other  contents  except 
the  litpior  aninii.  Air  does  or  tloe.s  not  enter  the  uterine  cavity  accordiii};  tis 
to  whether  tiie  membranes  are  or  are  not  ruptured.  If  atmosplicrie  air  lias 
access  to  th(?  fetus,  the  hitter  undergoes  putrefactive  ciianges,  i^ivinj;  rise;  to  a 
condition  Iviiown  as  jihi/xomrtnt,  or  fi/inpaniltH  uteri ;  the  soft  jtarts  licpjefy 
somewhat,  then  escape,  k'aviii}^  tlie  osseous  structure.  A  coinph'tc  evacua- 
tion of  all  the  fetul  structures  is  rarely  effected  l)y  riture  alone.  Some  of  the 
parts  beinijj  retained,  the  projectiui:;  hones  may  ))enetrate  the  surrounding 
uterine  walls,  and  find  their  way  into  the  vaji^ina,  the  rectum,  the  bladder,  or 
through  the  abdominal  walls.  A  similar  action  may  lead  to  suppuratitm, 
peritonitis,  septi(!emia,  and  death.  Most  cases,  however,  eventually  recover, 
but  convalescence  is  long  and  very  tedious.  If  air  is  excluded  from  the  uterus 
and  the  fetus  is  retain<;d,  the  latter  may  become  mummified,  and  this  mummi- 
fied pro(hict  may  remain  indefinitely  without  creating  special  harm.  Possibly 
it  may  Ccausc  irritation,  suppuration,  and  uterine  or  pelvic  abscess  and  their 
results.  Jk'sides  maceration  and  mummification  a  prohniged  fetal  retention 
may  lead  to  adipocerous  changes.     Calcification  very  rarely  oreurs. 

A  dead  fetus  within  the  uterine  cavity,  although  no  air  has  entered, 
generally  seriously  impairs  ti.j  health  and  endangers  the  life  of  th(>  woman. 
Conserpiently,  in  cases  of  this  kind  it  is  always  prudent,  after  the  la|)se  of  a 
i'iiw  weeks,  and  when  there  is  no  physical  evidence  of  a  commencing  expulsion, 
to  induce  labor  artificially — an  oltstetrical  procedure  which  under  careful  pre- 
(•aution  is  safe,  infinitely  more  so  than  allowing  the  dead  fetal  mass  to  remain. 
When  nature  is  successful  in  partially  eliminating  some  of  the  fetal  portions, 
active  efforts  by  the  hand  or  by  instruments,  after  cervical  dilatation,  sliould 
be  employed  to  aid  the  woman.  Every  known  antiseptic  precaution  shoidd 
be  exercised  to  prevent  or  to  control  hectic  symptoms,  peritonitis,  and  septi- 
cemia. Laparotomy,  laparo-hysterectomy,  or  a  Porro  operation  may  be  the 
verv  thing  to  do  under  certain  circumstances. 

^liiller  of  Xancy  has  shown  that  many  cas(>s  of  so-called  "  missed  labor" 
are  really  cases  of  extra-uterine  pregnancy,  with  ineffectual  attempts  at  fetal 
expulsion,  because  of  a  certain  position  of  the  fetal  body.  With  fair  propriety 
it  may  be  said  that  most  of  these  cases  are  those  of  advanced  extra-uterine 
fetation  of  the  intramural  (interstitial)  or  tubal  Viiriety,  or  (>f  retention  of  the 
fetu-  in  a  bilobed  uterus. 


7.  Extra-uterine  Pregnancy. 

History. — Extra-uterine  pregnancy  from  the  standjioint  of  its  etiology, 
pathology,  and  operative  treatment  has  provoked  such  numerous  discus- 
sions and  'las  called  forth  so  many  valuable  essays  within  the  past  fifteen 
or  twenty  years  that  the  historical  side  of  the  subject  iias  received  but  little 
attention.  From  this  one-sided  view  the  impression  has  arisen  in  the  minds 
of  many  practical  men  that  this  anomalous  form  of  gestation  was  almost  if 
not  quite  unknown  even  to  our  immiMliate  predecessors.     A  research  into  the 

18 


Ml 


f^^ 

'IP 

'p 

,' 

;  ' 

i:l    :i 

' 

lii 


^\^- 


i/ 


274 


AMKIx'ICAN    TEXT- HOOK    OF    OliSTF/riilCS. 


niodioal  litoratiire  of  the  past  four  ccnturios,  however,  brinj^s  to  lifjlit  many 
clear  descriplioiis  of  well-recoirnizcd  cases  of  extra-uterine  prejinaiiey. 

Israel  Spacli  ii  his  extensive  fiyneeolot;ieal  work,  ])nl)lishe(l  in  1597,  figures 
a  liiliopedion  drawn  m  i^Ua  upon  a  fnll-lent;th  cut  of  a  wofuan  with  the  belly 
laid  open.  He  df>di<'!ited  to  this  ealeified  fetus,  which  he  rejjjarded  as  a  rever- 
sion, the  followinj:;  eurio'.s  i-pij^rani,  in  allusion  to  the  classical  niytii  that  after 
the  flooil  the  world  was  re|)opulated  by  the  two  survivors,  Deucalion  and 
Pyrrlia,  walking  over  the  earth  casting  behind  them  stones  which  on  striking 
the  ground  becaiue  jieople.  Roughly  translated  from  the  Tiatin,  this  epigram 
reads  as  follows  :  "  Deucalion  cast  stones  behind  him  and  thus  fashit)ned  our 
tender  race  fi-oni  the  hard  marble.  How  comes  it  that  now-a-days  by  a 
reversal  of  things  the  tender  bodv  of  a  little  babe  has  limbs  nearer  akin  to 
.stone?" 

We  find  many  of  the  earliest  writers  mentioning  this  form  of  fetation  as  a 
curiosity,  but  offering  no  explanation  as  to  its  cause.  One  of  the  first  and 
most  natural  suggestions  was  that  the  fetus  had  died  in  idcro,  and  aftcrwarii 
had  become  displaced  into  the  abdominal  cavity,  where  it  excited  suppuration 
and  thus  was  finally  discharged. 

An  important  discussion  was  called  forth  in  1669  by  the  case  of  Benedict 
Vassal,  a  surgeon  in  Corrari,  Italy.  The  great  obstetrician  Mauriceau's  draw- 
ing (Fig.  l'")2)  of  the  specimen  obtained  shortly  after  the  autopsy  is  remark- 
ably clear,  and  it  well  supports  his  judgment  that  this  was  not  a  tubal  preg- 
nancy as  asserted.  His  description  of  tiie  case  is  well  worth  quoting  even  at 
this  day  ;  translated  freely,  it  is  as  follows  : 

"  History  of  a  woman  in  whose  abilomen  there  was  found,  after  death,  a 
small  fetus  about  2%  inches  long,  together  with  a  great  quantity  of  coagulated 
blood. 

"  The  history  of  this  ease  deserves  to  be  carefully  considered  to  decide 
whether  the  fetus,  as  believed  by  many,  was  generatetl  in  tlie  ejaculatory  ves- 
sel, called  the  tube  of  the  womb.  On  the  sixth  of  January,  1669,  in  the 
village  Corrari,  I  saw  in  the  hands  of  a  surgeon  named  Benalict  Vassal  a 
uterus  which  he  had  removed  a  short  time  before  from  the  body  of  a  woman 
aged  thirty -two,  who  had  died  after  three  days  of  the  most  agonizing  pains  in 
the  stomach,  from  which  she  had  fallen  into  frequent  fainting  spells  and  th(> 
most  violent  convulsions.  This  woman  had  borne  eleven  children  at  term, 
but  in  her  twelftli  pregnancy,  at  about  two  and  a  half  months,  the  womi) 
dilated  in  the  direction  of  the  riglit  horn,  and,  unable  to  withstand  this  disten- 
tion, ruptured.  The  fetus  was  expelled  into  the  abdomen,  and  was  fi>und  with 
a  great  quantity  of  coagulated  blood  among  the  intestines  of  the  mother. 
Many  physicians,  surgeons,  and  naturalists  betook  themselves  to  this  surgeon 
to  see  the  uterus  which  was  exhibited  by  him  as  a  prodigy,  as  he  insisted  thai 
the  fetus  was  formed  in  the  ejaculatory  vessel,  which  Fallopius  calls  '  the  triun- 
pet  of  the  womb.'  They  ac<'epted  at  once,  without  further  investigation,  that 
this  was  just  as  the  said  surgeon  claimed,  and  that  this  case  confirmed  stories 
of  a  like  nature  narrated  by  Riolanus.     However,  I  examined  the  parts  of  thi- 


TIIK   PATirOLOGY   OF  PTiT-MXANCY. 


27r> 


ntonis  most  carofully  and  minutoly,  and  it  was  evident  to  mo  that  those  wlio 
aoecptod  this  opinion  had  been  letl  into  error ;  for  this  reason,  tliat  at  tlie 
time  I  made  a  (h'awing  of  the  womb  as  it  tiion  appeared,  and  this  is  a  more 
faithfnl  a>ul  aceurato  repnuhiction  than  that  which  tiiis  snrjjeon  had  engraved 
npon  eopper  after  a  n;onth  had  ehipsed,  as  tlie  uterus  then  retained  ahnost 
nothing  of  its  i)rimitive  form,  and  was  spoiU'd  by  the  handling  of  a  tliousand 
men  or  more  who  had  seen  the  utcrns,  pulled  it,  disturbed  it,  and  tin'ned  it 
inside  out  that  they  might  examine  it. 

"  Many  have  addneetl  this  ease  to  prove  to  us  that  the  testes  "  [ovaries] 
"  of  women  are  full  of  little  ova  which  at  the  moment  of  coitus  free  them- 
selves and  emerge  from  the  body  proper  of  the  testes,  and  are  thence  borne 
into  the  uterus  through  the  tube,  to  serve  for  the  generation  of  the  fetus. 
They  claim  that  one  of  those  so-called  ova  had  by  chance  romainetl  in  the 
tube  of  this  woman,  instead  of  passing  forward  into  the  uterus,  and  that  this 
was  the  cause  of  her  death. 

"  Regner  de  Graaf  among  others  holds  this  opinion,  for  the  confirmation 
of  which  he  brings  forward  the  figure  of  this  uterus,  which  the  surgeon  of 
whom  I  have  spoken  had  already  given  to  the  public ;  as  one  finds  it  on  the 
260th  page  of  his  book  on  the  '  Generative  Organs  of  Women.'     Any  one 


.^f^^^ 


Km.  152.— Cast'  (if  I'Xtni-iili'riiU'  prcnimncy  liuiiviMl  by  Mimrici'iiu,  ri'dniwii,  Imt  p  n.'Ucnlly  unrhniiKod. 
The  Ictus  is  here  slunvii  iiltiuhiil  to  tlu>  siic,  wliich  wiis  not  the  caso  in  liis  lii;ui  .  Tlic  ilistiiict  in'ck 
IwUM'i'll  tile  sue  Mild  llu'  llti'lMis  is  ovidolll  •,  tlic  n>illid  liniiiiifiit  cniiu's  mil  nf  llii'  iiiu  t'l  siirl'iicc  (il'tl.c  sue 
iimri'  tcixviird  its  outor  polo.    Tlio  roliitiiiiis  of  ii  tioniml  iitorus  iirc  in  lii  •■|<mI  Py  M;;iirii'i'iui  in  dotti'd  liiio.s, 

who  will  examine,  earefidly  and  without  prei.ulicc  sin  ..lilowing  figure,  which 
is  ino.st  faithful  and  faultless,  and  at  the  .siiue  time  It  kIc  into  our  reasons,  will 
Hiitl  that  we  have  given  another  demonstri'tion  wli:<l;  we  believe  to  be  the 
true  explanation." 


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276 


AMERICAN   TEXT-BOOK   OF   OBSTETRTCS. 


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Miiiiriccan  with  groat  insiglit  tlion  oltos  the  anatoniioal  relation  of  the 
round  ligaments  to  the  bodv  of  the  uterus  as  substantiating  his  view  of  the 
ease.  He  says,  "  Beliokl  how  elearly  I  demonstrate  that  this  part  in  which 
the  ehild  was  contained  was  a  portion  of  the  body  pro))er  of  the  womb,  and 
not  the  tuba  uterina,  and  this  because  the  round  ligament  is  constantly 
attached  directly  to  the  lateral  wall  of  the  body  of  the  womb,  called  the 
cornu,  and  at  this  place  it  becomes  fused  with  the  substance  of  the  womb.  It 
is  therefore  certain  that  the  ])art  where  the  ligament  ended  (Fig.  162);  and  at 
which  it  was  strongly  attached  on  the  right  side,  where  the  malformation 
existed,  was  a  portion  of  the  womb  its<>lf ;  consequently  the  child  was  engen- 
dered in  a  ])art  of  the  womb  that  was  elongated." 

It  is  interesting  in  this  connection  to  note  that  Mauriceau,  in  this  differen- 
tial diagnosis,  anticipated  some  of  the  results  of  our  latest  investigations  con- 
cerning the  differences  between  tubal  and  corinial  interstitial  pregnancy  and 


Fiii.  153.— Koduci'd  (iguro  of  Dciitsi'li's  cn»c  of  iitnlomiiml  prciriinnpy  dm  norouiit  nf  which  was  putilishiil 

ill  ITUSt  witli  lifi'-si/t'  cdpiior-iplati'  onuraviii),'.-). 

pregnancy  in  a  rudimentary  horn.  From  the  above  it  is  evident  that  Maiiii- 
ceau  was  positive  that  impregnation  had  not  occurred  in  the  Fallopian  tiilic, 
but  in  one  cornu  of  tiie  uterus,  and  that  the  ovum  had  devcl(»i)ed  as  a  hcrni;i 
from  the  uterus.  I  find  that  liegner  de  Graaf,  just  as  Mauriceau  states, 
accepted  the  view  of  Vassal,  and  in  his  description  of  the  Fallopiiin  till' 
reports  the  case  and  reproduces  th<  figure  from  tlie  copper  plutc  wh"  u  Man.' 


IsUcM 


THE   PATHOLOGY    OF  PREGNANCY. 


277 


eoau  condemns.  De  Graaf  believed  this  to  be  a  case  substantiating  his  own 
tlieory  regarding  the  function  of  the  ovaries  and  the  Fallopian  tube.  He 
says,  "  AVe  Judge  that  the  tulxs  called  Fallopian  in  women  and  in  every  kind 
of  female  arc  true  vasa  deferentia,  or,  if  you  prefer,  oviducts,  inasmuch  as  the 
ova  are  transmitted  through  them  to  the  uterus."  He  further  says,  "The 
tube  or  horn  [Falloj)ian  tube]  of  the  wond)  is  dilated  and  affected  by  semen 
corrupted  there  and  seeking  an  outlet ;  but  it  is  remarkable  that  the  male 
semen  should  reach  that  point  and  that  a  fetus  should  have  been  conceived 
there,  as  is  proved  by  histories." 

De  Graaf  believed  that  the  ova  were  fertilized  in  the  ovaries  and  that  they 
were  then  carried  downward  into  the  uterus,  where  they  remained  until  the 
full  term  of  gestation  was  eomj)leted.  He  does  not  offer  any  explanation  for 
the  arrest  and  development  of  the  ovum  in  the  tube ;  on  the  contrary,  he  dis- 
tinctly states  that  he  does  not  know  why  it  occurs.  He  recognized,  however, 
the  dangers  of  this  anomalous  pregnancy,  as  indicated  by  the  following  state- 
ment:  "The  ovum  already  fertilized  is  detainetl  in  its  transit  in  the  tubes, 
and  by  its  increase  in  size  brings  death  to  the  mother."  In  his  critical  remarks 
upon  Vassal's  case  he  says  :  "  And  from  this  our  opinion  it  is  not  difficult  to 
explain  how  a  fetus  occasionally  develops  in  the  abdominal  cavity  among  the 
intestines,  inasnmch  as  the  ova  already  impregnated  fidl  from  the  testes" 
[ovaries]  "  outside  the  cavity  of  the  tubes  and  are  nourished  by  the  neigh- 
boring parts." 

From  these  references  to  the  earlier  literature  it  will  be  seen  that  ectopic 
gestation  was  clearly  recognizetl,  its  symptoms  graphically  described,  and  the 
theories  advanced  those  that  are  accepted  by  many  writers  of  the  present  day. 

Numerous  other  coiuributions  are  found  in  the  literature  of  this  subject, 
following  De  Graaf  and  Mauriceau,  one  of  the  most  interesting  being  figured 
in  the  obstetrical  work  of  Peter  Dionis  of  l*aris,  published  in  j  .  early  part 
of  t!>e  ei$rhteenth  century. 

Evn  so  early  as  J  741,  Bianchi  constructed  an  elaborate  classification  of  the 
foi'ViS  oC  extra-uterine  pregnancy,  that  was  simplifietl  by  Boehnier  in  1752, 
,vlic  'K-iiibed  three  forms — "  gestatio  ovariea,"  "  gestatio  tubaria,"  and  "  ges- 
tatio  a  lop  iiijlis."  From  the  time  of  Boehmer  a  period  of  fi)rty-nine  years 
intcrveucii  in  which  this  classification  remained  practically  unchanged.  In 
1801,  Schmidt  described  the  interstitial  fi)rm  of  ectopic  gestation,  and  with 
this  addition  Boehmer's  classification  must  practically  be  accepted  even  at  the 
])resent  day,  with  the  exception  of  a  primary  abdominal  form. 

Mhlogi/. — Xo  entirely  satisfactory  conclusions  have  yet  been  reached 
"e.'^iii'ding  the  cause  of  this  anomalous  form  of  pregnancy.  Among  many 
il;"ories  none  have  been  demonstrated.  One  great  difficidty  lies  in  the  fact 
tii;'  it  has  not  yet  been  determined  at  what  point  in  the  female  genital  tract 
ii.'.r'ial  impregnation  of  the  ovum  takes  place,  and  until  this  question  is 
settled  the  primary  question,  whether  extra-uterine  fetation  is  an  abnormal 
ectopic  impregnation  or  is  simply  a  detained  impregnated  ovum,  must  remain 
unanswered.     Many  claim  that  the  seat  of  coalescence  of  the  male  and  the 


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278 


AMERICAN    TEXT- BO  OK   OF    OBSTETRICS. 


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female  elements  is  nornially  in  the  Fallopian  tube.  If  this  claim  be  admitted, 
it  can  readily  be  seen  how  u  variety  of  causes  might  operate  to  detain  the  ovum 
in  the  tube,  where  it  may  continue  to  develop  extra-uterine.  Chief  among  the 
causes  ascribed  a  few  years  ago,  at  the  revival  of  this  subject,  was  the  loss  of 
the  tubal  ciliated  epithelium,  which  would  manifestly  conspire  to  prevent  the 
ovum  from  being  carried  on  down  into  the  uterus ;  other  causes  cited  have 
been  flexions  of  the  tube,  dilatations  and  diverticula,  constrictions  from  inflam- 
matory changes,  and  polypi  in  the  tube,  closing  its  Itniien  like  a  valve. 

While  a  variety  of  causes  may  operate,  it  is  most  jirobable,  from  the 
frequency  with  which  old  inflammatory  disease  is  found  coexisting  on 
the  other  side,  that  most  cases  of  tubal  gestation  arise  from  ileus  of  the 
tube,  resulting  in  an  inability  to  transmit  the  contents  of  the  tulie,  due  to 
adhesions.  An  imjiortant  '"a''.se,  operating  in  cases  where  the  pregnancy  is 
toward  the  outer  end  of  tli  iMue,  is  the  })resence  of  a  diverticulum,  as  pointed 
out  by  J.  W.  Williams. 

Clasfiificafion :  Prhnanj  Foi  >  -The  primary  forms  of  extra-uterine  preg- 
nancy are  classified  as  follows  : 

(  Tnbo-uterineor  interstitial. 
1.  Tubal :  <^  Isthmial.  2.  Ovarian. 

(  Ampullar. 

Secondary  forms  are  derived  from  the  primary,  as  follows: 

/  X  7-.         ,1  r  Uterine;  /  \  -e         ii  f  Tubo-ovarian ; 

{(t)  trom  the        )  „       ,  ,.'  ,  (c)  Irom  the  I    41  i      •     ,      ' 

^  '  ....  1   <  Jiroad  ngament;  ^  '  u  \  Alxlomnial: 

rstitial:      .1  i      .*^  1         '  ampullar:  )  ,,       ,  ,.       '     . 

(^  Abdoninial.  '  (^Jiroad  ligament. 

f  Abdominal  ;  {(1)  From  the        J  Abdominal ; 

1^  Broad  ligament.  ovarian  :       |  Tubo-ovarian. 

In  tubal  pregnancy,  when  the  fertilized  ovum  develops  out  near  the  fimbri- 
ated extremity  of  the  tube  it  is  called  ampullar ;  at  the  inner  portion  of  tlie 
tube  it  is  called  idhiaial ;  while  in  that  part  of  the  tube  which  tras'crses  the 
uterine  wall  it  is  designated  intrrxtitial  or  fnljo-uterinc.  It  is  in  the  latter  form 
that  the  term  extra-uterine  pregnancy  becomes  a  misnomer,  as  the  conception 
is  not,  strictly  speaking,  extra-uterine,  being  enclosed  in  the  wall  of  the  uterus, 
although  outside  its  cavity.  For  this  reason  Mr.  Tait  suggested  the  term 
ectopic  gestation.  Many  writers,  more  ])ractical  than  scientific,  were  mis- 
led by  ]Mr.  Tait's  dicta  to  go  so  far  as  to  hold  that  there  is  but  one  form  of 
ectopic  gestation — namely,  the  tubal — and  so  able  a  pathologist  as  IJIand 
Sutton  gives  them  countenance  by  his  denial  of  the  ovarian  and  abdominal 
forms,  as  he  considers  the  cases  which  have  been  reported  do  not  sufficiently 
demonstrate  their  existence.  Xo  criticism,  however,  has  yet  succeeded  in 
destroying  the  claims  of  cases  of  Leopold,  Patenko,  and  ^Fartin,  which  wo 
must  accept  as  primarily  ovarian.  In  Ijcopold's  case  the  j)atient  was  operated 
upon  for  a  pelvic  tumor  of  twenty-five  years'  standing  that  jiroved  to  be  iu\ 
ovarian  tumor  containing  a  lithopedion.  In  the  walls  of  the  tumor  ovarian 
stroma  was  clearly  demonstratetl.  Patenko's  case  is  even  more  striking.  The 
right  ovary  was  the  size  of  a  hen's  egg,  and  it  contained  a  cvst  with  smootli 
walls  in  which  was  found  a  yellow  body,  the  size  of  a  hazel-nut,  composed  of 


niterstiti 

(h)  From  the 
isthmial 


Tin-:   PATHOLOGY   OF  PREGXAM'Y. 


279 


cylin<lric<al  and  flat  bones.  These  bones,  which  were  subniitted  to  a  careful 
microscopical  examination,  were  tbniul  to  be  fetal  in  origin  and  not  the  product 
of"  a  dermoid  cyst.  The  enveloping  wall  contained  corpora  lutea  and  fV)llieles. 
The  tube  of  the  aft'ected  side  had  no  adventitious  connection  with  the  ovary, 
and  its  fimbriated  extremity  was  entirely  free,  although  the  internal  ostium 
was  closed  and  some  of  the  fimbria;  were  gone.  Opponents  of  the  theory  of 
ovarian  j)regnancy  take  exception  to  this  case,  claiming  that  the  gestation  was 
primarily  tubal,  and  that  a  so-called  "tubal  abortion"  had  occurred  into  the 
ovary,  and  that  later  tl»e  ovary  and  the  tube  had  become  detached  from  each 
other ! 

Martin  of  Berlin  re]iorts  two  cases  which  he  believes  to  be  examples  of 
undoubted  primary  ovarian  pregnancy.     In  these  cases  the  gestation-sac  was 


Fig.  IM.— I'rof.  Aiigiist  Mnrtin's  cnso  of  oviirinn  prcfiiiniicy.    Tho  intiict  tube  is  st'on  lying  above  the 

oviiriun  siiu  cuiiluiniiig  tho  IVtiil  unvolnpi's. 

sitiuited  entirely  within  the  ovary,  the  fimbriated  extremity  of  the  tube  being 
intact.  As  an  explanation  of  ovarian  pregnancy  ^lartin  advances  the  very 
natural  suggestion  that  \\\c  spermatozoini  finds  its  way  through  the  fimbriated 
extremity  of  the  tube  into  one  of  the  small  recently-ruptured  cysts  so  fre- 
([uently  found  on  the  surface  of  the  ovary,  and  that  it  there  ct)alesces  with  the 
ovum. 

Too  few  observations  have  yet  been  made  to  prove  the  possibility  of  pri- 
mary abdominal  pregnancy,  although  the  case  of  Schlcctendahl  is  diilicult  to 
explain  upon  any  other  hypothesis.  In  this  case  a  fetus  measuring  15  centi- 
meters (6  inches)  in  length  was  found  attached  to  the  abdominal  wall  near  the 
spleen  in  a  woman  who  had  died  of  hemorrhage.  The  gestation-sac  was  sur- 
rounded by  adherent  intestines,  and  the  uterus  and  appendages  appeared  nor- 
mal. For  the  present,  however,  only  two  primary  forms  of  ecto]ue  gestation 
— tubal  and  ovarian — can  positively  be  accepted.  Practically,  tubal  pregnancy 
is  the  only  primary  form  found. 


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280 


AMERICA X    TEXT-BOOK   OF    OBSTETRICS. 


Secondurii  Forms. — The  secondary  forms  of  ectopic  pregnancy  are  derived- 
froin  the  j)rinuirv.  The  tubo-iiteriiie  or  interstitial  pregnancy  may  rupture 
into  the  uterus  and  be  followed  ii.inu'diately  by  expulsion  of  the  fetus,  or  it 
may  go  on  to  full  term  and  be  delivered  in  the  natural  way.  This  mode  of 
termination,  unfortunately,  is  rarer  than  two  other  possibilities — namely,  rup- 
ture into  tiie  abdominal  cavity  or  rupture  into  the  broad  ligament.  In  the 
istlunial  form  of  tubal  pregnau«;y  the  rupture  occurs  either  into  the  abdominal 
cavity,  thus  forming  a  secondary  abdominal  pregnancy,  or  into  the  broad 
ligament,  forming  extra-peritoneal,  broad-ligament  pregnancy.  The  ampullar 
form  of  tubal  pregnancy  gives  rise  to  secondary  tubo-ovarian,  abdominal,  or 
broad-ligament  pregnancy. 

Tubal  Pregnancy, — In  the  first  week  after  fetuindation  of  the  ovum  the 
tube  begins  to  thicken,  due  chiefly  lo  vascularization  without  hypertrophy  of 
the  muscular  fibres.  In  this  respect  the  tubal  envelope  differs  in  its  develop- 
ment from  that  of  the  uterine  nniscle  in  normal  pregnancy.  In  the  latter  case 
there  is  hypertrophy  of  the  individual  muscle-fibres  to  eleven  times  their 
length  in  a  normal  non-pregnant  uterus ;  the  connective  tissue,  peritoneal 
covering,  blood-vessels,  and  iymi)hatics  being  also  increased  by  hypertrophy 
and  hyperplasia,  so  that  at  full  term  the  uterus  weighs  two  pounds  instead  of 
two  ounces,  the  weight  of  u  ^  rgi  ..1  uterus.  The  thickening  in  the  pregnant 
Fallopian  tube  is  due  to  excessive  vascularization  with  but  slight  increase  in 
the  tissue-elements.  As  the  pregnancy  progresses  the  wall  of  the  tube  becomes 
thinned  and  stretched  until  in  some  cases  it  appears  as  a  thin  transparent  mem- 
brane composed  only  of  an  attenuated  stratum  of  muscle  covered  with  peritoneum. 

The  development  of  the  fetal  membranes  derived  from  the  ovum,  with  the 
exception  of  the  placenta,  is  the  same  as  in  intra-uterine  pregnancy.  Nor- 
mally, the  placenta  is  derived  about  equally  from  the  decidua  serotina  of  the 
uterus  and  the  chorion  frondosum  of  the  ovum.  In  tubal  pregnancy  Bland 
Sutton  holds  that  the  placenta  is  largely  fetal  in  its  origin.  As  the  embryo 
increases  in  size  and  the  walls  of  the  tube  become  stretched,  the  plicae  in  the 
mucous  membrane  lose  their  characteristic  appearance  and  are  gradually 
smoothed  out.  During  the  first  four  to  six  weeks  the  abdominal  ostium  of 
the  tube  becomes  hermetically  sealed.  Until  the  fetal  membranes  are  well 
formed  the  life  of  the  fetus  is  in  constant  jeopardy,  as  the  chorionic  villi  have 
but  a  feeble  hold  upon  their  points  of  attachment  to  the  tube  and  may  easily 
be  dislodged.  This  termination  is  most  favorable  from  the  first  to  the  third 
week  of  the  pregnancy,  and  it  may  be  so  harmless  as  to  give  rise  to  no  serious 
discomfort. 

An  apoplectic  ovum  thus  detached  appears  as  a  lump  of  coagulum,  and 
unless  carefully  examined  its  true  character  n)ay  be  overlooked.  Such  bodies, 
known  as  "tubal  moles,"  are  absolute  proof  of  the  nature  of  the  ])athological 
condition.  As  the  pregnancy  advances  the  formation  of  the  tubal  mole  is 
attended  with  much  greater  danger,  as  the  accompanying  hemorrhage  ofi?n 
causes  rupture  of  the  tube,  followed  by  rapid  death  of  the  mother.  These 
moles,  if  recent  in  origin,  will  be  found  to  contain  the  embryo  and  its  mem- 


THE    PATHOLOGY   OF  PREGNANCY. 


281 


braiies.  The  absolute  diagnostic  point  Is  the  discovery  of  chorionic  villi  or 
of  the  embryo  itself.  If  extruded  into  the  abdominal  cavity  or  into  the  broad 
ligament  the  mole  loses  its  characteristic  appearance  and  soon  becomes  envel- 
oped in  a  yellowish  coat  of  fibrin,  and  there  may  be  such  complete  disinte- 
gration of  the  fetal  tissues  as  entirely  to  obliterate  its  embryonic  characteristics. 
The  villi,  however,  are  most  persistent,  and  they  may  be  found  after  the  other 
evidences  of  their  origin  have  disappeared.  These  villi  have  the  same  appear- 
ance under  the  microscope  as  those  of  normal  pregnancy. 

If  the  ovum  continues  to  grow,  the  point  at  which  the  placenta  is  attached 
is  of  the  greatest  importance  to  the  mother,  as  upon  this  largely  depends  her 
chance  for  life  in  case  of  rupture.  If  the  placenta  is  implanted  on  the  superior 
wall  of  the  tube,  the  mother  is  in  constant  peril,  as  rupture  here  may  be  fol- 
lowed by  frightful  hemorrhage,  the  lacerated  or  detached  placenta  having  no 
counter-pressure  to  control  its  bleeding,  as  is  the  case  when  it  is  attached  to 
the  floor  of  the  tube.  For  this  reason  many  surgeons  claim  that  this  termi- 
nation is  invariably  fatal.  If  the  placenta  is  implanted  v,'  the  floor  of  the 
tube,  the  chances  of  rupture  are  not  necessarily  decreased,  but  the  dangers 
attending  this  accident  are  far  less  to  the  mother.  In  this  position  the  pla- 
centa is  pushed  downward  against  the  resisting  pelvic  floor,  insimiating  itself 
between  the  layers  of  the  broad  ligament.  If  the  embryo  is  extruded  through 
the  upper  wall  of  the  tube,  the  placenta  may  still  retain  a  firm  attachment  and 
only  slight  hemorrhage  follow,  and  the  immediate  danger  be  escaped  in  this 
way.  Occasionally  the  ovum  is  lightly  attached  in  the  ampullar  extremity  of 
the  tube,  and  is  extruded  into  the  abdominal  cavity  without  rupture  of  tne 
tubal  walls.  This  extrusion  is  known  as  "  tubal  abortion."  As  evidence  of 
this  the  fimbriated  extremity  of  the  tube  is  found  enlarged  and  patulous,  and 
there  is  free  blootl  in  the  abdominal  «;avity,  in  which  the  tubal  mole  may  be 
found  if  the  abortion  is  recent. 

Tubo-uterine  or  Interstitial  Gestation. — The  history  of  the  embryonic 
development  in  this  type  of  ectopic  gestation  differs  from  the  tubal  proper  on 
account  of  its  difference  in  environment.  Here  the  muscular  fibres  of  the 
uterus  undergo  the  same  changes  as  in  normal  pregnancy.  Rupture  is  almost 
inevitable,  but  it  docs  not  occur  so  early  as  in  the  tubal  variety,  on  account 
of  the  greater  thickness  of  the  walls  surrounding  the  gestation-sac.  Ilecker 
oollcctei^^l  twenty-six  cases  in  which  rupture  occurred  before  the  sixth  month. 
The  fetus  occasionally  escapes  into  the  uterus,  and  it  is  either  expelled  at 
once  or  it  goes  on  to  regular  term  and  is  born  in  the  natural  way.  Rupture 
occurs  most  frequently  into  the  abdominal  cavity,  and  in  such  cases  the  hcm- 
orriiage  is  profuse  and  usually  terminates  the  patient's  life  in  a  short  time. 
Interstitial  pregnancy  is  rarely  recognized  before  rupture. 

Rapture  of  (he  Sac. — The  time  of  rupture  of  the  sac  depends  u])on  its 
lociition  and,  to  a  certain  extent,  upon  the  attachment  of  the  ])la('enta.  la 
tubal  ])regnancv  primary  rupture  occui's  usually  between  the  second  and  the 
fiinrtcenth  week.  When  tiie  placenta  is  implanted  on  the  floor  of  the  tube,  the 
probability  is  that  the  rupture  will  not  take  place  so  early  as  when  it  is  situated 


5:' 


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282 


AMERICAN    TEXT-BOOK   OF    OJiSTETllJCS. 


on  the  superior  wall.     Tlio  causes  of  rupture  are  tliiiuiiug  of  the  walls  of  the 
tubes  beyoud  the  liuiits  of  elasticity,  heiuorrhage  into  the  sac,  traumatism,  and 

If  the  patient  survive  the  primary  rup- 
ture, the  fetus  niav  still  contiiuio 


gradual  enlargement  of  tiie  embryo. 


to  develoj),  either  burrow'ug  down- 
ward between  the  layers  of  the 
broad  ligament  or  growing  upward 
into  the  peritoneal  cavity  among 
the  intestines.  The  injury  to  the 
])lacenta  is  nuich  less  when  it  is 
situated  on  the  jielvic  floor,  as  the 
displacement  is  not  so  marked,  the 
hemorrhage  is  not  so  ])rofnse,  and 
consequently  the  lives  of  the  fetus 
and  the  mother  are  in  less  jeopardy 
at  the  time  of  rupture.  If  blood 
is  poured  into  the  peritoneal  cav- 
ity, it  will  usually  be  absorbed;  if 
the  collection  of  blood  oecin's  be- 
tween the  layers  of  the  broad  liga- 
ment, it  constitutes  pelvic  hemato- 
cele (Fig.  155).  When  the  fetus 
becomes  intra-ligamentary  and  continues  its  development  in  that  position,  it  is 
known  as  broad-liijiuncnt  (/cshtfion.     After  the  twelfth  week  the  sac  is  liable 


Fui.  155.  — I>iiinriiiii  showing  pi'lvit'  lu'iniitoccU'  posto- 
rior  to  tlie  utorus,  whicli  is  crowdi'd  forwanl  willi  tlio 
blndcU'r  bi'himl  tlio  symphysis  imbis,  wliilo  tlio  ri'Ctiiiu 
is  romi)ri'ssf(i  l)oliin(l  n>;iiiiist  tlu'  siioniiu  (Skenrl. 


4i>\\X^ 


,;f '!  /-^ 


\o> 


%>«j,. 


*<'>■• 


.:m^ 


"  '.•  ?;t>  -. .. 


Fig.  irifi.— Riipturcil  loft  tulml  prt'j;iimu'y,  IVtiis  still  iittuclicil  iiiiil  lylnn  within  the  pi'lvis.  Hydnisiil- 
piiix  and  ndln'sidiis  on  the  rinht  side.  I'tiTiis  disphu  rd  towiml  tlio  rinht  by  tho  sac:  »  is  the  fiuulus 
uteri;  r,  the  rectum;  t,  the  rinht  closed  tube; ,/',  the  fetus;  and  .-•,  the  ruiiturcd  extra-uterine  sac. 

to  secondary  rupture  at  any  time  up  to  term.     Here  again  the  situation  of  the 

placenta  is  of  the  same  importance  in  the  prognosis  as  in  the  primary  rupture. 

The  Fetus. — The  question  as  to  the  possibility  of  life  for  the  fetus  is  iuHu- 

enced  by  the  location  of  the  ])regnancy.     In  the  tubal  variety  the  most  favor- 


THi:    I'ATIIOLOGY    OF  PliEGNAXVY, 


283 


llSlll- 


al)lo  attuclnncnt  of  the  plucenta  is  on  the  floor  of"  the  Fallopian  tube,  as  there 
may  be  .sli<>l)t  it"  any  distnrbance  of  the  fetal  circnlation  if  the  rnpture  be  in 
the  .superior  wall  of  the  tube,  when  the  child  may  <;(>  on  to  full  term  (Figs. 
156,  157).  Even,  however,  if  the  ectopic  fetu.s  be  delivered  alive,  it  i.s  often 
deformed  and  puny  and  rarely  lives  more  than  a  few  day.s.  For  this  reason 
its  life  should  be  but  little  regarded  in  the  tieatnient  of  ectopic  gestation. 

The  <lispo.sal  which  nature  makes  of  the  fetus  in  case  the  mother  survives 
the  rupture  is  also  of  considerable  interest.  The  dead  en)bryo  lying  free  in 
the  abdominal  caviiy  may  be  completely  absorbed  up  to  the  .se<!ond  month ; 
after  that  period  it  either  undergoes  mummification,  calcification,  or  is  eon- 
verted  into  adipocere,  or  decomposes.  Mummification  is  analogous  to  the 
change  which  bodies  undergo  in  a  dry  atmosphere.  A  mummified  fetus  in 
its  general  appearance  closely  resembles  bodies  found  in  arid  regions  buried  iu 


Fig.  1.')7.— ("iirimiil  iiicf,'iiniK'y.    In  tliis  cnsc  ni|itnn'  occiirreil  in   llic  rislit  iiniloveUipcd  oorim  of  a 
bii'oriuito  iitiTus  i^l'rum  n  spucimon  pri'Sfiiti'd  to  the  writer  by  Dr.  Wiitson  of  Biiltiniori'). 

dry  soil  or  in  sand  or  exposed  to  the  air.  The  fluid  con.stitiients  of  the  extra- 
uterine gestation  are  tibsorbed,  and  the  soft  tissues  become  leathery  or  parch- 
ment like.  In  other  eases  the  fatty  elements  are  converted  into  adipocere  or 
into  ammoniacal  soap  in  the  pre.^ienee  of  ammonia  formed  by  the  decom- 
position of  the  tissues.  Either  the  mummified  or  the  adipocere  fetus  may  still 
midergo  further  change  and  become  partially  or  wholly  calcified.  This  pro- 
cess is  not  entirely  confined  to  the  superficial  parts,  as  there  have  been 
described  a  number  of  specimens  which  exhibited  the  saponaceous  or  the 
nmmmification  process  on  the  exterior  while  the  internal  organs  were  calcified. 
A  fetus  which  has  undergone  calcification  is  known  as  a  lUhopalion. 

The  fetal  mass  may  remain  indefinitely  in  the  abdominal  cavity  without 
giving  rise  to  any  discomfort  to  the  mother.     Cases  are  reported  in  which 


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284 


AMKItlVAN    TEXT- BOOK    OF   OliSTETRICS. 


sucli  bodies  liave  stayed  for  ten  and  fifteen  years,  in  one  instance  for  fifty-four 
years,  in  the  pelvis  without  ^ivinj^  rise  to  serious  trouble.  On  account  of  the 
close  anatomical  relation  between  the  gestation-sac  and  the  rectum  and  intestines 
a  slight  rupture  of  the  intervening  walls  may  occur  at  any  time,  or  a  diapedesis 
may  take  place  and  pyogeni(!  organisms  gain  access  into  the  sac;  and  induce 
suppuration.  The  fetus  is  then  converted  into  a  putrid  mass,  which  may  be 
discharged  into  the  rectinn,  the  vagina,  or  the  bladder.  Occasionally  the  sup- 
piu'ating  mass  i-uptures  at  some  point  on  the  anterior  abdominal  wall  even  so 
high  as  the  umbilicus.  The  latter  termination  is  frequently  noted  in  the  older 
medical  literature. 

Symptoim, — All  the  symptoms  characteristic  of  normal  pregnancy  may  be 
present.  Frequently,  however,  the  subjective  symptoms  are  entirely  absent, 
and  the  patient  may  be  quite  unconscious  of  her  condition.  The  increase  in 
the  areolar  circle  around  the  nipple  and  other  mammary  changes,  the  gastric 
disturbance,  pain  on  the  affected  side,  associated  with  amenorrhea,  are  th.e  most 
characteristic  symptoms.  Too  much  stress,  however,  ranst  not  be  laid  upon 
the  absence  of  the  menstrual  flow,  as  it  is  subject  to  the  greatest  variations.  In 
some  cases  instead  of  amenorrhea  there  will  be  profuse  metrostaxis  with  the 
expulsion  of  small  bits  of  decidua. 

It  is  of  importance  not  to  confuse  the  decidua  of  ectopic  pregnancy  with 
that  of  membranous  dysmenorrhea.  In  the  latter  condition  the  decidua  is 
usually  expelled  in  small  pieces  and  rarely  as  a  cast  of  the  interior  of  the 
uterus.  When  floated  out  in  water  numerous  delicate  velamentous  processes 
are  seen.  This  membrane  is  rarely  more  than  one  or  two  lines  in  thickness, 
and  it  is  usually  very  friable.  The  decidua  of  ectopic  pregnancy  is  much 
thicker,  varying  from  6  to  20  millimeters  (^^g^  to  |  inch);  it  is  much  less  fri- 
able, the  uterine  surface  being  covered  with  a  thick,  shaggy,  villous  coat,  and 
instead  of  small  bits  it  is  usually  expelled  in  large  pieces  or  as  a  complete  east 
of  the  interior  of  the  uterus.  Pain  is  variable,  in  some  cases  being  almost 
constant,  in  other  cases  absent.  The  character  of  the  pain  before  rupture 
may  be  sharp  and  lancinating,  or  there  may  be  dull  and  heavy  aching.  The 
statement  of  the  patient  that  she  considers  herself  pregnant  is  of  some  value, 
as  that  ill-defined  sense  upon  which  she  bases  her  opinion  may  be  the  only 
subjective  indication  of  her  condition.  The  appearance  of  the  external  geni- 
talia may  be  the  same  as  in  norn  -d  pregnancy.  Under  these  circumstances 
the  vaginal  mucous  membrane  appears  purplish  in  hue,  the  cervix  is  soft,  the 
OS  uteri  is  usually  closed  with  a  plug  of  mucus,  and  the  uterus,  instead  of 
its  pyriforin  shape,  is  now  globular  and  enlarged  to  the  size  of  a  one-month 
pregnancy. 

If  an  examination  be  made  before  rupture,  the  Fallopian  tube  of  one 
side  will  be  found  enlarged,  and  if  far  advanced  the  uterus  will  be  forced 
from  its  position  in  the  median  line  by  the  growth  of  the  tumor.  If  the 
pregnancy  is  advanced  to  the  third  or  the  fourth  month,  a  circumscribed 
tumor,  well  defined  as  an  area  of  dulness  on  the  anterior  abdominal  wall,  may 
be  outlined  by  percussion.     Vaginal  examination  reveals  this  tumor  lateral 


Till-:    I'ATJIOfAJGV    OF    I'RKGXANCy. 


285 


and  posterior  to  the  titcnis,  with  a  well-marked  sidoiis  between  it  and  the 
uterus.  Unfortunately,  it  is  only  in  the  rarer  instanees  that  a  ])hysieiau  is 
called  before  rupture  occurs,  when,  unless  he  is  a  skilful  spt'cialist,  the  prob- 
abilities are  that  ectopic  gestation  will  not  be  suspected.  The  growth  of  the 
tuujor  may  give  rise  to  pressure-symptoms,  such  as  constipation  and  dysuria, 
but  they  are  of  little  special  significance,  as  any  pelvic  tumor  may  be  attended 
with  similar  disturbances. 

Ruptui'c. — The  sym])toms  of  rupture  are  very  characteristic,  and  they 
usually  are  so  definite  as  to  cause  little  doubt  in  diagnosis.  A  j)aticnt  pre- 
viously healthy  or  only  slightly  (!omi)laining  is  suddeidy  seized  M'ith  severe 
abdominal  pains,  sharp  or  lauciiuiting,  cutting  or  agonizing.  The  attack  in 
many  instances  cannot  be  ascribed  to  external  violence  or  to  undue  exertion  on 
the  part  of  the  jnitient,  as  she  may  be  in  the  midst  of  light  household  work, 
or  walking  on  the  street,  or  even  be  in  bed  when  the  rupture  occurs.  Previous 
to  the  attack  she  may  have  had  no  discomfort  or  oidy  the  slight  disturbances 
of  preguantiy.  If  the  hemorrhage  is  extensive  she  may  fall  unconscious  as  if 
struck  a  blow.  The  pulse,  at  first  rapid,  soon  becomes  almost  or  quite  imper- 
ceptible; the  respiration  is  quickened,  then  becomes  jerky,  and  finally  the  air- 
hunger  so  chara(ieristic  of  severe  hemorrhage  becomes  ])ronounced ;  vertigo, 
nausea,  and  vomiting  are  present.  The  symptoms  soon  merge  into  those  of 
profound  shock,  the  extremities  being  cold  and  clammy,  the  skin  pale,  the 
conjunctivae  pearly,  and  the  lines  about  the  mouth  drawn.  If  the  patient  is 
conscious  and  is  able  to  talk,  she  will  usually  complain  of  intense  abdominal 
pain.  Death  may  follow  soon  after  intraperitoneal  rupture,  or  it  nuiy  be 
delayed  for  a  day  or  even  longer.  In  some  instances  the  bleeding  ceases  for 
a  short  time  and  is  followed  by  gradual  improvement  in  symj^toms,  but  it 
again  begins  a  few  hours  or  some  days  later,  and  the  patient  survives  only 
a  few  minutes. 

In  extraperitoneal  hemorrhage  from  ru])ture  into  the  broad  ligament  the 
symptoms  may  not  be  so  urgent.  The  initial  attack  in  both  instances  is  simi- 
lai',  as  the  peculiar  sharp  pain  at  the  onset  is  due  to  rupture  of  the  tube.  The 
blood  as  it  accunndates  usually  checks  the  hemorrhage  by  its  own  pressure, 
and  the  patient  may  have  no  further  troid)le.  If  the  embryo  dies  at  the  time 
of  primary  rupture  into  the  broad  ligament,  no*fnrther  discomfort  '  ;'^  It,  as  a 
rule,  as  a  harmless  hematocele  is  all  that  remains.  Unfortunate  I  v,  in  many 
instances  this  is  r  jt  the  termination,  and  the  fetus  continues  to  develop,  and 
sooner  or  later  a  secondary  rupture  occurs,  attended  by  the  same  symptoms  as 
the  primary  rupture. 

In  the  rarer  cases,  which  go  on  fiir  nine  months,  labor-like  pains  come  on 
and  closely  simulate  those  of  normal  i)artiu'ition.  These  pains  may  continue 
for  houT's  or  even  for  days,  and  then  cease.  The  escape  of  blood  and  of  por- 
tions of  the  dccidua  occurs  in  a  majority  of  cases  at  this  time,  and  may  mis- 
lead the  attending  physician  into  the  diagnosis  of  abortion  if  the  constitutional 
symptoms  are  not  urgent.  The  subjective  symptoms  of  pregnancy  are  almost 
always  present  in  such  advanced  cases.     The  fetal  movements  may  have  been 


-ji*i 


'2SG 


A.y[Kl{l(\\N    Ti:XT-lt()<)k'   OF  oitsTKrnics. 


so  luiicli  on  OIK'  side  as  to  call  tlic  inotlior'M  attontion  to  this  pliononu'iion. 
Tlic  fl'tal  la'art-souiuls  arc  distinct,  bcin^  heard  w  itii  unusual  clearness. 

In  cases  siu'vivin;;  the  rupture  the  sharp  labor-like  pains  jrradually  sub- 
side, the  secretion  in  the  breasts  tlisappears,  the  tumor  decreases  rapidly  in 
size,  and  as  soon  as  the  patient  recovers  I'roin  the  shock  and  loss  of  blood  she 
may  rej^ain  her  health.  It  is  in  these  cases  that  absorption  or  one  of  the  other 
chanfjcs  that  rendt'r  tlu^  fetal  body  innocuous  takes  place.  Infection  of  the 
incarcerated  fetal  mass  may  occur  at  any  time,  even  years  after  the  death  of 
the  end)ryo,  followed  by  a  train  of  symptoms  similar  to  those  attending  pus- 
formation  from  other  causes. 

J>iti(/noxiK. — 'Plu!  history,  if  carefully  reviewed,  often  directs  attention 
strongly  toward  ectopic  gestation.  The  pregnancy  usually  occiws  in  a  mul- 
tipara some  years  after  the  birth  of  the  last  child,  although  it  may  follow 
shortly.  There  may  have  been  an  intervening  attack  of  acute  intlamination 
(»f  the  tube  or  of  pelvic  peritonitis.  This  is  strongly  insisted  upon  by  those 
who  advocate  the  theory  that  tubal  gestation  is  diu?  to  an  old  inflammatory 
l)rocess  which  has  changcHl  the  normal  histology  of  the  tube. 

A  characteristic  history  is  as  follows:  A  woman  who  has  borne  one  or 
more  children,  after  an  interval  of  from  five  to  twenty  years  of  sterility 
observes  symptoms  of  another  j)re;,nancy.  Her  menses,  which  have  been 
regular,  cease,  and  the  mornin;^  nausea,  \v,\'u\  in  the  breasts,  darkening  of 
the  areola,  and  other  symptoms  characteristic  of  her  former  pregnancies 
appear.  In  addition  to  these  symptoms,  slie  has  in  one  ovarian  region  dull 
])ain,  at  times  so  severe  as  to  cause  her  to  seek  the  advice  of  her  phy- 
sician. This  pain  may  continue  until  it  culminates  in  the  acute  paroxysms 
caused  by  rupture,  or  it  may  cease,  and  not  be  noticed  again  until  the  rupture 
occurs.  The  most  characteristic  symptom  of  all  is  the  sudden  sharp  pain  of 
the  rupture.  If  followed  by  a  marked  anemia  it  is  still  more  decisive.  The 
bimanual  examination,  taken  in  conjunction  with  this  history,  points  with 
absolute  certainty  to  the  nature  of  the  pregnancy,  and  the  diagnosis  is  com- 
paratively simple.  In  the  atypical  cases,  on  the  contrary,  a  positive  diagnosis 
is  often  difficult  or  even  impossible. 

In  the  normal  uterine  pregnancy,  as  the  embryo  develops  the  uterus  is  dis- 
tended equally  in  all  directions,  but  occasionally  the  ovum  develops  in  one 
corner,  distending  the  uterus  on  that  side,  which  may  prove  misleading.  In 
])regnancy  occurring  in  the  rudimentary  horn  of  a  bicornuto  uterus  the  symp- 
toms are  so  nearly  alike  that  a  differential  diagnosis  is  not  likely  to  be  made. 

Kussmaul  collr;'ted  thirteen  cases  of  pregnan(\v  in  rudimentary  cornua,  the 
majority  of  wiiicli  had  been  reported  as  tubal  pregnancies.  If  an  exploratory 
section  be  ])erformed  in  these  doubtful  cases,  the  anatomical  points  insisted 
up(m  by  Mauriceau  are  of  the  greatest  value  in  making  a  differential  diagnosis. 
They  are  as  follows :  In  cornual  pregnancy  the  round  ligament  is  situated 
anterior  to  the  outer  side  of  the  gestation-sac.  In  tubal  pregnancy  the  round 
ligament  is  situated  on  the  uterine  side  (Figs.  loT,  158). 

Pregnancy  occurring  in  one  horn  of  a  well-developed  bieornute  uterus  may 


77//;    /M  TIKH.OU  V    OF   PltKiixWANCY. 


2H7 


go  to  term  ami  jjjivc  riso  to  no  untoward  symptoms.  A  profx'iant  uterus  devi- 
ated to  one  side  by  a  myoma  may  l)e  mislalven  for  ectopic  gestation.  Tiie  diag- 
nosis, however,  can  usually  he  made  it'  the  examination  is  eonchicted  under 
anesthesia,  as  it  will  be  I'ound  tiiat  the  tiuuor  varies  its  position  with  that  of 
the  cidarged  uterus,  and  is  directly  continuous  with  it,  in  addition  to  being 
densely  hard.  The  <|ne-tion  of  interstitial  pregnancy  naturally  arises  in  these 
cases,  and  if  the  character  of  the  tumor  cannot  be  recognized  a(  the  (irst  exam- 
ination, the  patient's  symptoms  shouhl  be  observed  carefully,  and  she  should  be 
examined  again  lat(!r  to  decide  whether  there  is  any  inerease  in  the  size  of  tlie 
.suspected  tumor.  If  there  is  a  perceptible  increase,  the  probabilities  are  that 
it  is  interstitial  pregnaiuiy.  An  adherent  retroverted  gravid  uterus  may  also 
give  rise  to  misleading  symptoms,  such  as  sharp  pains,  obstinate  eonstipatiou, 


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i 


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Via.  I"i8.— Dianrnmnintir  sketch  sliowiiiii  rclaticuis  of  iiu  unniiiturt'd  siic  (»)  to  utpnis  (u),  nmnd  lignmcnt 
(rl),  and  bladder  (h).    The  nuiiifnms  adliesloiis  are  .siigK^'s^tive  as  to  the  etioldtiy. 

pelvic  pressure,  dysuria,  etc.,  but  it  is  readily  differentiated  by  a  bimanual 
rectal  examination,  if  necessary  drawing  the  uterus  down  with  traction  for- 
eoj)S  so  that  the  fundus  may  readily  bo  pal|)ated. 

Ovarian  tumors  and  enlargements  of  the  Fallopian  tubes,  associated 
with  intra-uterine  pregnancy,  may  cause  confusion,  especially  if  the  tumor 
lateral  to  the  uterus  gives  rise  to  sharj)  pain,  as  may  occur  in  pyosalpinx. 
In  such  instances  the  question  of  a  twin  ])regnan('v,  one  intra-utcrine  and 
the  other  extra-uterine,  nuist  be  considered.  As  fever  accompanies  jiyosal- 
pinx  in  the  majority  of  cases,  it  nuist  carefully  bo  considered  in  the  differ- 
ential diagnosis.  If  it  be  im|>ossiblo  to  arrive  at  definite  conclusions  con- 
cerning the  suspected  mass,  and  the  life  of  the  patient  seems  in  peril,  an 
exjiloratorv  celiotomy  is  justifiable,  otherwise  expectancy  is  the  safer  coiu'se. 
Occasionally  a  pedunculated  ovarian  cyst  becomes  strangulated  by  axial  rota- 
tion :  such  an  accident  is  accompanied  by  pain,  vomiting,  rapid  pidse,  and 
other  constitutional  disturbance,  at  times  amounting  to  ])rofound  shock.  Rup- 
ture of  an  ovarian  cyst  may  also  be  difiicnlt  to  differentiate  from  the  rupture 


I 


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288 


AMKIilVAN    TJ'LXT-nOOK    OF   OliSTETlilCS. 


of  an  ectopic  g:\station  sac;  in  such  c  .ses  the  history  and  the  vaginal  examina- 
tion will  cl','ai'  np  the  diagnosis. 

To  snnunarizo  briefly,  it  may  be  said  that  the  diagnosis  of  ectopic  gesta- 
tion depends  npon  the  following  cardinal  points  : 

1.  A  iiistory  of  probable  pregnancy. 

2.  Paroxysmal  pains,  usnally  located  on  one  or  the  other  side  of  the  pelvis. 
'^.  Irregnhir  metrostaxis. 

4.  The  expnlsion  of  bits  of  deeidna. 

5.  Coincident  eidargement  of  the  nterus  and  softening  of  the  cervix  and 

discoloration  of  the  vagina. 
G.  Tnmor  lateral  or  posterior  to  nterus  and  indirectly  connected  with  it, 
nterus  moderately  or  not  at  all  enlarged. 

7.  Changes  in  the  breast. 

8.  Anemia. 

Tiie  diagnosis  of  ectopic  gestation  after  tlie  death  of  the  fetus  is  largely 
dependent  npon  the  clinical  history  ;  if  this  be  deficient,  the  diagnosis  is  fre- 
qnentlv  impossible,  especially  if  there  has  been  a  long  interval  between  the 
rupture  and  the  time  when  the  patient  consults  the  physician.  If  the  fetus 
has  undergone  calcification,  It  may  be  felt  as  a  hard  mass,  but  even  this  is  not 
conclusive,  as  a  calcified  myoma  may  present  similar  characteristics. 

Treatment. — From  the  operative  standpoint  it  is  best  to  divide  ectopic 
pregnancy  into  the  following  periods : 

1.  J^efore  rupture;  2,  at  the  time  of  rupture;  3,  after  rupture;  and  4, 
after  calcification,  saponiflcation,  munnnification,  or  suppuration  of  the  fetus 
has  occurred. 

1.  lirforr  Ixiipfiirc — Tlie  electrical  treatment,  so  much  advocated  a  few 
years  since  for  the  destruction  of  the  fetus,  while  valuable  in  its  day  as  pio- 
neer work,  has  deservedly  fallen  into  disrej)ute,  because  of  its  uncertainty  in 
terminating  the  fetal  life  and  of  its  dangers  to  th(>  mother  through  subsecjuent 
inflammation.  The  injections  of  fluids  into  the  sac  for  the  same  purpose  is 
so  utterly  fonMgn  to  present  ideas  of  treatment  that  it  is  oidy  mentioned  to 
be  condemned.  The  proper  course  to  pursue  is  the  removal  of  the  atfoeted 
tube.  Precipitate  operation,  however,  is  not  advisable,  as  the  diagnosis  should 
be  as  accurate  as  possible  before  resorting  to  radical  measures.  Cases  with  a 
history  suggestive  of  ectopic  gestation  and  a  mass  lateral  to  the  uterus  detected 
by  vaginal  examination  should  bo  operated  upon  without  hesitation.  A  pro- 
portion of  such  cases  will  prove  to  be  pyosalpinx  or  hydrosalpinx,  but  an  error 
is  not  serious,  as  in  either  instance  operation  is  indicated. 

2.  At  the  Time  of  h'liptuir. — If  called  at  the  time  of  rupture,  the  siu'geon 
must  exercise  considerabh*  judgment  in  his  decision  whether  or  not  to  operate 
immediately.  Tf  the  patient  is  in  collapse,  the  pulse  weak  and  rapid,  and 
the  skin  blanched  and  clammy,  an  immediate  examination  should  be  made 
to  discover  if  ])ossiblo  whether  lupture  has  occurred  into  the  broad  liga- 
ment or  is  intraperitoneal.  If  the  rupture  has  taken  i)lace  into  the  broad 
ligament,  a  lateral   tumor-mass  closely  connected   with   the   uterus  will   be 


THE    PATHOLOGY    OF   PREGXAyVY 


289 


<lotcct«l.  Tlic  mass  is  circuniscriboil  aiul  fliK'tiiating,  and  rectal  examination 
shows  the  cul-de-sac  to  be  free  of  fluid.  In  such  a  ease  tiie  method  of  treat- 
ment is  an  expectant  one,  the  possibilities  being  that  the  h(>morrhage  will  soon 
cease  if  it  has  not  already  done  so,  and  that  the  patii'ut  will  recover,  leaving 


)■  11..  IV.l.— 1'iii^'rnni  (if  inlmiu'iilciiu'al  viiptmc  of  liilml  incu'iininy.     I'rrc  IiIiimI  in   Huiinliis's   ciil  dc  sue 
mill  iiiiiHiii;  tlu'  iiiti'sliin's     IiickiiiMini  ;  S,  syiiiiiliysi>  ;  i;,  rccliiiii. 

a  hematocele  to  be  dealt  with  later  if  necessarv.  If  examination  reveals  free 
lliiid  in  the  cul-de-sae  (Fig.  159),  and  there  are  no  signs  of  improvement  in 
tlie  patient's  condition,  the  natural  inference  is  tliat  (he  rupture  is  intraperi- 
toneal, and  an  immediate 
operation  is  indicated,  as 
every  moment  detracts  from 
the  cliances  of  recovery 
(Fig.  IGO). 

PrejHivation  for  Opcra- 
limi. — The  chances  for  re- 
covery I'ollowing  operation 
ill  extra-uterine  pregnancy 
depend  upon  the  careful 
(it)scrvation  of  al'  the  de- 
tails of  antiseptic  and  asep- 
tic   technique.       For    this         „,,..,,. 

'       _    _  1' Hi.  liid.— Dr.  IVi'k  s  cast' O  "''11-^'""  II.  oluci)  ot  ixtni-ntiTJiu' 

reason    a    precipitate   opera-      lirotiiiniiiy  in  Ww  tliinl  munth;  din'ration  lit  time  of  ru|iturc; 

tioii  is  always  attended  with     ■"''•'"^ '■  > • 

greater  danger,  as  of  necessity  care  in  details  must  be  sacrificed.  The  surgeon 
should  always  have  a  com])lete  set  of  abdominal  instruments  and  accessories 
sterilized  and  packed  ready  for  use.     If  the  operation  is  hurritnl,  select  a  wcU- 

19 


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290 


AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 


lightal  room  or  provide  a  portable  electric  light;  remove  all  unnecessary  fur- 
niture, dampen  the  floor  to  prevent  dust  rising,  but  do  not  disturb  the  curtains 
and  other  hangings  further  than  is  absolutely  necessary.  A  common  kitchen 
table  can  be  turned  into  an  operating-table,  with  a  chair  inclined  against  one 
end,  upon  which  the  patient's  feet  may  rest.  Cover  the  table  with  a  folded 
blanket,  lay  upon  this  a  Kelly  ovariotomy  pad,  and  place  a  small  pillow  at 
the  head. 

As  it  may  be  necessary  to  irrigate,  a  douche-bag  should  be  suspended  in 
a  convenient  position  near  to,  and  ibout  4  feet  above  the  level  of,  th((  table. 
Two  smaller  tables  are  required  for  the  instruments  and  dressings,  and  three 
or  four  chairs  for  the  wash-basins  and  sponge-dishes.  A  room  thus  hastily 
improvised  serves  admirably  for  an  operating-room. 

An  abundance  of  boiled  water  is  necessary.  Directions  should  given 
immediately  after  deciding  to  operate  concerning  the  preparation  of  the  water. 
A  wash-boiler  or  other  large  tin  vessel  must  be  scalded  thoroughly,  and  be 
partially  filled  with  water  which  is  allowed  to  boil  for  an  hour  if  possible. 
It  is  best  to  let  the  water  cool  to  110°  F.,  but  if  time  is  pressing  })ure  cold 
water  from  a  well  or  a  hydrant  may  be  used  for  reducing  it  to  proper  tem- 
perature. This  method  of  cooling  the  water,  however,  is  not  advisable  except 
under  stringent  necessity. 

Great  care  nuist  be  observed  by  the  physician  in  disinfecting  his  hands : 
they  should  be  scrubbed  thoroughly  with  a  nail-brush  with  soap  and  water, 
followed  in  succession  by  immersion  in  permanganate  of  potassium  (hot  sat. 
sol.)  and  oxalic  acid  (hot  sat.  sol.).  A  (juart  of  each  of  these  solutions  is 
sufficient.  The  patient,  under  anesthesia,  is  then  transferred  to  the  operating- 
table  and  is  rapidly  prepared  for  abdominal  section.  The  anterior  and  lateral 
surfaces  of  the  abdomen  are  thoroughly  washed  with  soap  and  water,  followed 
by  alcohol,  then  by  ether,  and  finally  by  bichlorid  solution  (1  :  1000).  As  it 
may  be  necessary  to  open  the  sac  through  the  vagina,  this  passage  should  be 
washed  thoroughly  with  soap  and  water,  followed  by  bichlorid  solution 
(1  :  1000)  and  an  iodoform  pack.  All  dressings,  towels,  and  gau/t;  to  be  used 
in  immediate  proximity  to  the  field  of  operation  must  be  i)rovidcd  by  the 
surgeon,  who  slioidd  always  carry  them  among  his  accessories,  as  the  s^teriliza- 
tion  of  these  articles  cannot  be  entrusted  to  an  untrained  person.  Instruments 
are  taken  from  their  sterilized  envelope  and  j)laccd  on  towels  or  in  trays. 

During  the  preparation  the  patient  should  be  given  a  stinndating  enema, 
also  strychnia  (gr.  ^'j^)  and  brandy  hypodermatically.  In  such  cases  as  these 
the  infusion  of  normal  salt-solution  into  the  radial  artery  is  often  of  the  great- 
est service  in  sustaining  the  patient's  vital  forces,  and  occasionally  it  is  abso- 
lutely necessary  to  save  life.  It  is  umiecessarv  to  carry  a  special  infusion 
aj)paratiis,  as  an  ordinary  aspirator  adnurably  serves  the  purpose.  To  prepai-c 
normal  salt-solution  dissolve  6  grains  of  sodium  chlorid  in  one  liter  (a  quart) 
of  boiling  water  and  boil  for  some  minutes.  Select  one  of  the  smaller  blunt- 
pointed  aspirator  needles.  Fill  the  aspirating  bottle  three-fourths  full  of  tin' 
solution,  cork  tightly,  and,  instead  of  making  a  vacuum  in  the  bottle,  force  in  aii- 


THE   PATHOLOGY   OF  PREGNAXCY. 


291 


until  the  pump  works  with  diffifulty,  then  turn  the  entrance  stopcock.  The 
radial  artery  is  the  most  accessible  for  infusion,  as  it  can  be  utilized  if  neces- 
sary for  this  purpose  by  an  assistant  while  the  abdominal  operation  is  in  prog- 
ress. Cut  down  somewhat  obli(piely  on  the  artery,  and  place  a  provisional 
ligature  above  and  below  the  point  of  infusion.  When  ready  to  introduce 
the  fluid  invert  the  bottle,  turn  the  exit  stopcock,  and  insert  the  needle  into 
the  artery  while  the  fluid  is  flowing,  thus  preventing  the  possibility  of  intro- 
ducing air.  The  dangers  of  this  accident,  however,  are  practically  of  no 
moment  if  the  fluid  is  injected  centrally  into  the  artery. 

If  the  exsanguination  is  extreme,  a  liter  (a  (|uart)  of  solution  at  a  tempera- 
ture of  105°  F.  may  be  infused.  After  the  needle  is  withdrawn  both  ligatures 
are  tied  and  the  wound  is  closed  with  a  subcutaneous  stitch.  It  is  remarkable 
how  quickly  the  pulse  improves  under  this  infusion  :  it  may  grow  weaker 
shortly  after,  but  if  the  bleeding  is  completely  checked  the  chances  for  recov- 
ery are  far  greater  if  infusion  is  emj)loyed.  The  fluid  used  must  be  perfectly 
free  from  dirt  or  bits  of  cotton,  etc.,  which  produce  emboli  and  cause  gangrene. 

The  Operation. — The  abdomen  should  be  opened  freely  in  the  median 
line ;  the  clots  should  be  turned  out,  exposing  the  ovarian  and  uterine 
arteries,  which  are  caught  either  with  forceps  or  between  the  fingers.  If  on 
attempting  to  clear  the  pelvis  of  clots  fresh  blood  wells  up,  no  further  time 
should  be  lost  in  attempts  to  expose  the  bleeding  points,  but  the  operator 
must  introduce  his  hand  into  the  pelvis,  grasp  the  arteries,  and  then  apply 
hemostatic  forceps.  Having  controlled  the  active  hemorrhage,  he  can  then 
carefully  cleanse  the  abdomen  of  clots,  inspecting  closely  the  ddbris  as  he  does 
so  for  the  embryo  or  the  tubal  mole.  If  the  pregnancy  is  in  the  first  or  sec- 
ond month,  the  operation  consists  of  a  simple  sal  pi  ngo-oophoreetomy  ;  if,  how- 
ever, the  term  is  farther  advanced  and  the  placenta  is  extensively  attached  to 
the  interior  of  the  tube,  or  in  ease  of  previous  rupture  to  the  intestiiies  and 
pelvic  walls,  the  operation  is  not  so  simple,  and  calls  for  good  judgment  to 
know  how  best  to  deal  with  the  i)lacenta.  It  is  exceedingly  hazardous  to 
attempt  the  removal  of  a  placenta  which  is  firmly  attached,  as  the  hemorrhage 
following  its  dislodgoment  may  be  so  extensive  as  to  defy  control.  In  such 
cases  it  is  best  to  leave  the  placenta  in  xHn,  for  lo  attempt  its  removal  would 
take  away  any  chance  the  patient  has  for  life  in  her  condition  of  shock  and 
exsanguination. 

Xo  means  further  than  those  necessary  to  save  life  at  the  time  of  operation 
sliould  be  undertaken,  as  the  essential  principle  is  first  to  control  hemorrhage, 
leaving  subsidiary  conditions  for  subsequent  consideration.  If  the  placenta  be 
attached  exclusively  to  tlu?  floor  of  the  tube  or  the  pelvis,  its  blood-supj)ly 
may  be  derived  from  numerous  vessels,  and  an  attempt  to  control  these  by 
ligation  would  be  impossible.  The  best  course  to  pursue  in  such  cases  is  to 
cliec^k  the  hemorrhage,  tie  and  cut  the  cord  close  to  its  placental  origin,  and 
leave  the  placenta  undisturbed.  Drainage  should  not  be  employed  in  these 
cases,  because  of  the  increased  danger  of  sepsis.  The  jiroper  treatment  is  to 
clos'    the  abdomen  completely,  and  after  the  i)atient  has  recovered  a  second 


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operation  may  be  performed  for  the  removal  of  the  placenta  if  it  cause  unto- 
ward symptoms.  The  greatest  care  in  aseptic  and  antiseptic  details  should  be 
observed,  as  upon  the  absence  of  infection  depends  the  patient's  chance  for 
recovery  when  the  placenta  is  not  removed.  If  the  operation  is  absolutely 
aseptic,  the  prognosis  is  good,  as  the  placenta  atrophies  and  gives  no  further 
trouble.  If,  however,  the  case  is  infected,  suppuration  of  the  placental  mass 
occurs,  terminating  in  general  peritonitis  or  in  a  pelvic  abscess.  Often  in  the 
course  of  an  operation  the  placenta  becomes  detached  and  may  be  removed 
with  the  fetus.  In  all  cases  in  which  the  operation  follows  the  death  of  the 
fetus  by  some  days  or  weeks  the  placenta  is  only  held  by  the  slightest  attach- 
ment or  it  may  lie  free  in  the  gestation-sac.  It  is  for  this  reason  that  the 
operation  is  more  favorable  at  such  a  time,  as  the  dangers  of  hemorrhage  are 
much  decreased. 

In  some  cases,  especially  those  in  which  there  is  a  temporary  cessation  of 
the  bleeding,  the  slightest  disturbance  of  the  sac  after  the  abdominal  cavity  is 
opened  causes  a  renewal  of  the  hemorrhage.  Bold  surgical  measures  are  then 
demanded  :  the  operator  should  sweep  his  hand  rapidly  around  tiie  ectopic  sac, 
loosening  the  adhesions,  after  which  the  sac  is  delivered  from  its  bed  of  adlic- 
sions.  The  points  of  bleeding  can  then  be  reached  and  controlled.  Adhesions 
to  the  omentum  should  be  tied  off  in  small  sections  to  prevent  necrosis 
en  masse. 

If  the  intestines  crowd  down  into  the  field  of  operation,  and  if  the  opera- 
tor is  unable  to  pack  them  back  satisfactorily  with  sponges,  the  patient  should 
be  placed  in  the  Trendelenburg  position.  In  case  there  is  extensive  oozing 
on  the  floor  of  the  pelvis  after  the  removal  of  tlie  ])l!icenta,  that  it  is  dif- 
ficult or  impossible  to  control  by  ligatures,  a  strip  of  iodoform  gauze  should 
be  packed  down  upon  the  bleeding  points.  If  tliere  is  a  large  amount  of 
debris  scattered  throughout  the  abdominal  cavity,  free  irrigation  with  steril- 
ized normal  salt-solution  (6  per  cent.)  at  a  temperature  of  110°  F.  should  be 
employed ;  3  or  4  liters  (3  or  4  (juarts)  of  the  solution  may  be  necessary  to 
cleanse  the  cavity.  There  is  no  danger  from  the  distribution  of  this  material 
in  the  abdomen  by  irrigation,  as  the  ectopic  product  is  sterile  except  in  the 
rarest  cases. 

In  all  ectopic  eases  that  undergo  operation  the  ojiposite  tube  and  ovary 
should  closely  be  examined,  and  if  normal  or  if  only  slightly  adherent  tlioy 
should  not  be  removed  ;  otherwise  their  extirj)ation  is  demanded,  for  to  allow 
a  diseased  tube  and  ovary  to  remain,  which  can  be  of  little  if  any  further  func- 
tional value,  would  only  subject  the  patient  to  the  dangers  of  a  subsequent 
ectopic  pregnancy  or  to  the  discomfort  and  pain  due  to  adherent  appendages. 

3.  After  liupfior. — Contrary  to  the  natural  Inference,  cases  are  not  usually 
submitted  to  operation  at  the  time  of  rupture,  as  by  the  time  the  surgeon  is 
called  the  patient  is  either  recovering  or  is  dead  from  extensive  hemorrhage. 
In  a  certain  proportion  of  cases  the  i)atient,  although  feeling  the  sharp  pain 
accompanying  the  rupture  and  being  compelled  to  keep  to  her  bed  for  a  day 
or  so  on  account  of  weakness,  does  not  call  her  physician,  as  she  considers  it 


THE  PATHOLOGY    OF  PREGXANCY. 


203 


only  a  trifling  matter  associated  with  her  pregnancy.  There  Is  undonbtetlly  a 
considerable  number  of  cases  like  the  latter  In  which  the  death  of  the  fetus 
occurs  at  the  time  of  rupture  and  no  further  symptoms  are  observed,  and  the 
patient  makes  a  perfect  recovery.  It  is  for  this  reason  that  a  statistical  table 
compiled  for  the  purpose  of  ascertaining  the  rate  of  mortality  in  extra-uterine 
pregnancies  due  to  rupture  is  fallacious.  If  the  surgeon  sees  the  patient  imme- 
diately after  rupture,  and  there  is  a  general  tendency  to  improvement  in  all 
her  symptoms,  he  should  defer  operating  until  a  future  date,  to  be  determined 
by  the  patient's  condition. 

If  the  rupture  be  extraperitoneal  in  a  case  in  which  the  pregnancy  has 
advanced  only  to  the  first  or  second  month,  an  operation  should  not  be  per- 
formed ludess  the  fetus  continues  to  develop  in  its  new  location  or  untoward 
symptoms  arise  from  the  hematocele.  To  subject  a  woman  to  an  operation  for 
a  hematocele  which  is  giving  her  no  trouble  is,  to  say  the  least,  bad  judgment. 
If  the  life  of  the  fetus  is  not  destroyed  at  the  time  of  rupture,  the  operation 
should  be  performed  as  soon  as  the  patient  has  recovered  from  the  primary 
rupture.  The  life  of  the  fetus  must  not  influence  the  determination  to  operate, 
and  under  no  circumstances  should  operation  be  delayed  on  account  of  senti- 
ment in  its  behalf. 

As  the  dangers  of  operation  greatly  increase  as  the  pregnancy  advances 
toward  term,  on  account  of  the  development  of  the  placenta  increasing  the 
dangers  of  hemorrhage,  the  earliest  date  possible  should  be  selected  for  ojjera- 
tion.  A  free  incision  should  be  made  in  the  central  line  of  the  abdomen.  If 
the  pregnancy  is  in  the  early  weeks,  the  operation  may  be  no  more  difficult 
than  a  salpingo-oophorectomy  for  pyosalpinx  or  for  hydrosalpinx.  The  dan- 
ger of  hemorrhage,  however,  from  the  broad  ligament  is  somewhat  greater 
than  in  the  ordinary  salpiiigo-oophorectomy,  on  account  of  the  increased  vas- 
cularity of  the  ttibe,  and  great  care  should  be  exercised  in  placing  the  ligatures 
so  that  they  will  control  all  blood-vessels.  The  "transfixion  needle  should  not 
be  employed  for  this  purpose,  as  the  subse(juent  shrinkage  of  tissue  following 
the  removal  of  the  vascular  tube  is  liable  to  dislodge  the  ligature,  as  more 
tissue  Is  usually  included,  and  a  larger  size  of  silk  is  employed,  than  when  the 
ligament  is  tied  off  in  small  sections.  The  pregnant  tube  when  the  ligatures 
are  laid  should  be  lifted  well  out  of  its  bed  with  a  medium-sized  curved  needle 
armed  with  a  carrier.  The  medium-sized  silk  suture  is  the  best  In  this  loca- 
tion, as  it  stands  sufficient  strain  easily  to  contrc)l  hemorrhage,  and  yet  does 
not  strangidate  the  tissues  en  masse.  Each  suture  should  overlap,  in  an  imbri- 
cated mamier,  the  one  placed  immediately  before  it ;  thus  no  vessels  can  pos- 
sibly escape  ligation. 

If  pregnancy  is  further  advanced  and  adhesions  have  formed  between  the 
gestation-sac  and  the  adjacent  viscera  or  the  pelvic  floor,  or  if  it  is  a  broad- 
ligament  gestation  with  the  placenta  firmly  implanted  on  the  pelvic  floor,  the 
operation  becomes  one  of  the  most  diflicult  in  abdominal  surgery.  The  adhe- 
sions should  be  dissected  off  carefully,  all  bleeding  points  should  promptly  be 
ligated,  and  the  sac  should  be  emicleated  in  the  ordinary  manner.     Drainage 


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ill 


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294 


AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 


sliuukl  1  ot  lie  used  if  it  can  possibly  he  avoided  ;  only  persistent  oozing  which 
cannot  b3  controlled  by  ligatures  justifies  its  employment,  as  the  dangers  of 
infection  are  greatly  increased  by  leaving  the  abdominal  cavity  open. 

The  fact  that  particles  of  clots  and  other  dfibris  are  scattered  throughout 
the  abdominal  cavity  does  not  indicate  drainage,  as  such  material  is  innocuous 
if  the  field  has  been  kept  aseptic,  and  it  will  give  no  trouble  if  the  wound  is 
hermetically  sealed.  It  is  in  these  densely-adherent  or  broad-ligament  cases 
that  enucleation  of  the  sac  is  often  impossible,  and  that  other  measures  must 
be  resorted  to  for  the  relief  of  the  i)atient.  The  treatment  of  the  ectopic  sac 
then  becomes  a  question  of  great  imi)ortance,  as  the  adhesions  to  neighboring 
viscera  or  to  the  pelvic  floor  may  be  so  extensive  as  to  preclude  its  removal, 
as  the  danger  of  hemorrhage  following  its  enucleation  is  too  great  in  such 
cases.  This  question  should  usually  be  decided  after  the  abdomen  is  opened. 
The  extent  of  adhesions  and  the  vascularity  of  the  sac  and  adjacent  tissue 
should  be  noted  carefully,  and  if  of  such  a  degree  as  to  contra-indicate 
removal,  the  next  measure,  that  of  making  an  extra])eritoneal  opening,  nuist 
be  resorted  to. 

Extra  peritoneal  Evacuation  of  Gextat  ion-sac. — The  j)oint  of  opening 
depends  entirely  upon  the  location  of  the  sac :  if  it  is  situated  low  in  the 
pelvis  and  is  of  easy  access  tlu'ough  the  vagina,  unquestionably  the  best 
method  of  procedure  is  to  evacuate  the  contents  of  the  sac  into  that  canal  and 
establish  free  drainage.  The  best  method  of  o])ening  the  sac  is  as  follows : 
After  carefully  examining  the  pelvic  mass  and  deciding  where  the  accessible 
point  for  opening  is — usually  in  the  fornix — the  operator  thrusts  a  pair  of 
medium-sized  sharp  scissors,  guided  by  the  index  finger  of  the  vaginal  hand, 
into  the  sac,  and  withdraws  theiu  jiartially  open  ;  this  is  followed  by  larger 
scissors,  which  are  also  withdrawn  in  the  same  manner.  While  doing  this  it 
is  usually  best  for  the  operator  to  have  his  assistant  press  the  sac  gently  down- 
ward through  the  abdominal  incision.  After  evacuating  the  embryonic  debris 
with  the  fingers  or  with  placental  forceps,  the  sac  should  be  irrigated  freely 
with  sterilized  water  or  with  a  very  weak  bichlorid  solution  (1  :  20,000),  fol- 
lowetl  by  warm  water.  After  cleansing  the  sac  thoroughly  it  can  be  nacked 
with  iodoform  gauze,  care  being  taken  to  leave  a  free  opening  for  subse- 
quent discharge. 

The  greatest  care  must  be  observed  in  passing  fivim  the  abdominal  to  the 
vaginal  operation,  as  to  niake  a  vaginal  examination  followed  by  the  manip- 
ulation necessary  to  evacuate  the  sac  by  the  vagina,  and  then  to  close  the 
abdomen  without  the  most  careful  disinfection  of  the  hands,  would  be  an 
unpardonable  mistake.  It  is  usually  best  for  the  operator  to  entrust  the 
closure  of  the  abdonien  to  his  assistant.  If  the  sac,  instead  of  being  in  close 
relation  with  the  vaginal  fornix,  is  found  to  be  ])ushetl  up  above  the  uterus, 
and  is  situated  nearer  the  anterior  abdominal  wall,  the  vaginal  method  of 
treatment  is  not  advisable,  as  there  may  be  an  intervening  sj)ace  comunuii- 
cating  with  the  general  j)eritoiieal  cavity  between  the  ectopic  sac  and  the  vagi- 
nal fornix,  making  it  both  difficult  and  dangerous  to  reach  the  sac.     In  these 


THE   PATHOLOGY    OF  PREGNANCY 


295 


cases  it  may  be  necessary  to  stitch  the  sac  to  the  abdominal  woimd,  and  then 
to  make  an  extraperitoneal  opening  into  it.  As  a  rule,  however,  the  sac  will 
be  attaclied  by  close  adhesions  to  the  abdominal  wall  above  Ponpart's  liga- 
ment, and  should  be  opened  in  this  region.  The  sac  shoidd  be  washed  out 
freely  as  in  the  vaginal  method,  and  be  packed  with  gauze. 

The  after-treatment  in  these  cases  is  often  of  great  importance,  as  the  sac 
fills  up  very  slowly  and  there  is  constant  purulent  discharge.  The  fistula 
must  not  be  allowed  to  close.  As  a  rule,  the  ganze  which  is  inserted  at  the 
time  of  operation  should  be  withdrawn  one  piecic  at  a  time.  After  the 
removal  of  the  last  piece,  usually  about  the  second  or  third  day,  fresh  gauze 
should  be  inserted,  the  cavity  I,»ing  first  freely  irrigated  with  some  mild  fluid, 
such  as  boracic-acid  solution  (semi-saturated). 

4.  Operation  after  the  Fetus  has  undergone  Mummifieittion,  Calcijicatlon, 
Haponifieation ,  or  Suppuration. — The  fetus  may  remain  for  years  in  any  one 
of  these  conditions,  except  that  of  suppuration,  without  injury  to  the  mother's 
health.  Soon  after  the  death  of  an  ectopic  fetus  the  licjuor  amnii  is  absorbed, 
the  placental  circulation  ceases,  and  the  vascular  connection  between  the  fetus 
and  the  mother  is  broken.  The  liquid  portion  of  the  cctoi)ic  product  is  grad- 
ually absorbed,  leaving  in  many  instances  the  fetus  isolated  in  its  sac  as  an  in- 
nocuous body.  In  such  cases  operation  should  not  be  performed  so  long  as  the 
patient's  health  remains  good,  but  on  the  first  indication  of  constitutional  dis- 
turbance, especially  if  febrile  in  character,  celiotomy  fi)r  the  removal  of  the 
foreign  body  should  promptly  be  resorted  to.  If  suppuration  occurs  and  the 
pus-sac  opens  into  the  rectum,  the  vagina,  the  bladder,  or  externally  through 
the  abdominal  wall,  the  fistula  should  be  enlarged  and  the  fetal  debris  be 
removed.  The  sac  should  tlien  be  irrigated  frequently  until  it  fills  with  gran- 
ulation tissue.     These  sinuses  heal  with  difficulty,  and  they  may  be  persistent. 

8.  Diseases  op  the  Fetus  in  Utero. 

Under  this  head  only  a  r^sumi'  of  the  diseases  occurring  before  birth  will 
be  noticed.  There  are  many  conditions  which  give  to  the  fetus  immunity  to 
disease  and  to  injury  during  the  pre-natal  state,  such  as  the  protection  given 
by  the  liquor  amnii,  the  uterine  wall  and  bony  pelvis,  etc.,  but  there  are 
also  many  predisposing  causes,  such  as  hereditary  influences  from  the  mother 
and  from  the  father,  nervous  disturbances,  high  temperatures,  bad  nutrition, 
diseases  of  the  womb  and  its  appendages,  and  certain  infectious  diseases,  which 
have  their  influence  upon  the  growth  and  development  of  the  fetus,  and  which 
are  not  only  accountable  for  disease,  but  sometimes  also  for  the  death  and 
expulsion  of  the  child  before  it  has  reached  its  full  term.  Certain  tendencies 
to  disease  are  inherited  :  this  pertains  more  particularly  to  abnormal  conditions 
of  the  nervous  system  and  to  disorders  in  nutrition.  Drunkenness,  epilepsy, 
diabetes,  phthisis,  and  cancer  of  either  parent  are  unfavorable  to  the  health 
and  development  of  the  child.  Frequently  a  fetus  of  such  parentage  dies 
In  utero. 

1.  Infectious  Diseases. — Pregnancy  does  not  give  immunity  to  infec- 


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AMKIilCAy    TEXT- BOOK    OF    OBSTETIIJCIS. 


tious  diseases.  If  tlio  niotlior  is  suttbring  from  one  of  the  infecL'oiis  diseases, 
the  fetus  may  eseape  iiiieetion,  hut  generally  it  suffers,  either  indirectly  througli 
tiie  low  state  of  nutrition  or  the  high  degree  of  temperature  of  the  mother,  or 
directly  by  a  transmission  of  the  disease  itself.  In  either  event  the  pregnancy 
may  be  interrupted  by  premature  death  and  expulsion  of  the  fetns,  or,  if  the 
fetus  is  born  alive,  it  usually  dies  s(xm  after  birth. 

The  mod'j  of  infection  is  often  obscure,  and  the  path  or  paths  of  its  trans- 
mission are  siill  unsettled  questions.  Ziemsscn  holds  that  the  poison  circulates 
in  the  blood.  The  transmission  of  disease-germs  from  mother  to  fetus  has  in 
some  instances  been  demonstrated.  Placental  infection  producing  sepsis  hi 
vtvro  will  be  considered  later.  Pus-organisms  have  been  found  to  be  trans- 
mitted to  the  fetus  in  septic  disease  of  the  mother,  and  well-formed  collections 
of  pus  have  been  t)bservcd  in  a  fetus  at  the  time  of  birth. 

All  infections  of  the  mother  do  not  seem  to  be  equally  severe  in  their  effects 
on  the  child,  rrcgnancy  complicated  by  la  grippe,  cholera,  diphtheria,  typhoid 
and  malarial  fevers  in  the  mother  is  very  likely  to  be  interrupted.  It  seems 
probable  that  in  most  of  these  eases  the  death  of  the  fetus  is  produced  by  direct 
transmission  of  the  infection  from  the  mother,  and  in  many  cases  this  has  been 
demonstrated  bv  findino-  the  disease-germs  in  the  fetus. 

So  far  as  his  researches  into  the  subject  have  gone,  the  writer  is  not  aware  that 
there  are  any  instances  upon  record  of  children  being  afflicted  with  diphtheria, 
mumps,  or  whooping-cough  at  birth;  but  children  are  born  with  all  the  patho- 
logical indications  of  malarial  disease,  such  as  enlarged  spleen,  etc.,  and  Play- 
fair  states  that  the  agitation  caused  by  the  chill  is  even  felt  by  the  mother  as 
her  child  in  ntcro  ])asses  through  this  partictdar  stage. 

Cases  of  cong(>nital  recurrent  fever  have  been  reported.  The  fetus  usually 
dies,  and  shows  all  the  pathological  changes  which  characterize  this  disease — 
enlarged  spleen,  pigment  in  the  spleen  and  portal  blood.  Albrecht  reports 
a  case  in  which  he  found  the  spirilla  <if  recurrent  fever.  According  to  Bcmis 
of  Xew  (Orleans,  the  fetus  of  a  woman  who  recovers  from  yellow  fever  is 
immune  to  the  disease.  As  regards  typhoid  fever,  while  a  pregnant  woman 
is  liable  to  take  this  infection,  and  the  presence  of  the  disease  proves  in  many 
cases  the  cause  of  abortion,  the  writer  dt)es  not  know  that  there  is  a  case  on 
record  of  a  child  being  born  with  unmistakable  typhoid  lesions.  In  the  case 
of  a  mother  affected  with  cholera  early  abortion  is  the  rule,  but  if  the  child  is 
born  alive  it  usually  survives  but  a  few  days.  The  theory  of  intra-uterine 
transmission  of  the  bacillus  is  supported  by  the  microscopical  cxaminatious 
of  Tissom  and  C'attam. 

2.  EnuPTiVE  Diseases. — Of  the  eruptive  diseases  contracted  in  the  pre- 
natal state,  variola,  scarlatina,  measles,  and  erysi])elas  have  been  observed  in 
their  typical  form.  Eruptive  diseases  seem  to  affect  the  child  in  ntcro  to  a 
greater  degree  than  any  other  diseases  ;  they  arc  very  likely  to  })roduce  abor- 
tion, possibly  on  account  of  infection  of  the  endometrium. 

Scarlatina  and  Measles. — There  are  a  considerable  number  of  cases  on 
record  of  children  being  born  in  the  difl'erent  stages  of  scarlatina  and  measles. 


THH   PATHOLOGY   OF  PREGKANVY. 


2D7 


When  scarlatina  occurs  in  pregnancy  the  fetus  is  usually,  but  not  invariably, 
int'ected. 

The  prof/noKis  as  regards  both  mother  and  fetus  is  grave,  especially  if  the 
maternal  infection  occurs  at  or  near  the  time  of  labor.  LeopoUl  Meyer  men- 
tions an  epidemic  in  which  twenty  puerperal  cases  became  infected. 

Variola. — In  about  50  per  cent,  of  cases  of  pregnancy  complicated  by 
variola  abortion  takes  place.  In  the  hemorrhagic  form  it  is  almost  certain 
to  do  so.  Manifestations  in  the  fetus  do  not  always  occur  at  the  same  time 
that  they  do  in  the  mother.  A  case  is  on  record  where  the  mother  in  appa- 
rently good  health  gave  birth  to  a  child  with  the  small-pox  eruption  upon  it. 
Vaccination  of  the  mother  will  sometimes  protect  the  fetus. 

Erysipelas  is  likely  to  interrupt  pregnancy.  Cases  of  intra-uterine  trans- 
mission of  ervsipelas  have  been  cited  bv  several  reliable  authors.  Lebcdeff 
found  in  the  fetus  of  a  mother  suffering  with  the  disease  the  erysipelas  coccus. 
Erysipelas  affecting  the  mother  in  the  puerperal  state  may  be  transmitted  to 
the  new-born  child.  The  proc/nosls  is  more  serious  than  that  of  a  case  outside 
of  the  puerperal  condition. 

Tuberculosis. — A  child  born  of  a  mother  suffering  from  tuberculosis  is 
usually  piHiy,  feeble,  and  predisposed  to  pulmonary  disease.  The  question  of 
the  possibility  of  direct  transmission  of  tuberculosis  to  the  fetus  has  recently 
been  the  subject  of  considerable  investigation.*  Several  cases  of  transmission 
of  tubercle  bacillus  from  the  human  mother  to  the  fetus  in  ufero  have  been 
reported  by  Keating,  Jacobi,  and  others.  The  fact  that  the  ])lacenta  some- 
times contains  tubercles  would  show  that  in  those  cases  the  bacilli  were  intro- 
duced through  the  maternal  circidation.  From  clinical  observation  of  cases 
we  may  also  deduce — (1)  tuberculosis  may  be  transmitted  by  either  parent,  and 
(2)  that  the  bacilli  may  gain  access  to  the  fetus  through  the  (<t)  maternal  l)lood, 
[l>)  through  the  areas  of  tuberculosis,  such  as  the  peritoneum,  intestines,  etc., 
and  (c)  from  the  outer  world  through  the  genital  tract. 

Fetal  Syphilis. — Perhaps  the  most  important  as  well  as  the  most  fatal 
disease  which  affects  the  child  in  idem  is  syt)hilis.  It  is  one  of  the  chief 
causes  of  abortion. 

Mode  of  Transmission, — Syphilis  may  be  transmitted  by  either  parent.  If 
a  mother  who  is  healthy  becomes  infected  during  pregnancy,  the  child  may 
escape  if  this  infection  takes  place  in  the  last  month,  unless  the  chiUl  again 
becomes  infected  at  birth  or  ■while  nursing. 

Prof/nosis. — The  earlier  in  pregnancy  infection  of  the  mother  takes  place, 
tlie  more  likely  is  the  fetus  to  die.  If  the  infection  occurs  during  the  first 
three  months  and  is  not  subjected  to  treatment,  the  fetal  mortality  during  the 
iirst  few  days  i^fler  delivery  reaches  100  per  cent.  The  prognosis  is  a  trifle 
better  if  infection  occurs  during  the  fourth  or  the  fifth  month  (fitienne).    As  a 


*  Tho  tliodi-y  of  con<;enitiil  tuberculosis  lias  foniul  support  in  the  experimental  research  on 
lower  animals,  also  in  cases  of  the  human  fetus,  described  by  Johne  (Fig.  1,  Foiischritle  d.  MM- 
ii-iii,  ltd.  iii.,  No.  7)  Merkel  (Fig.  2,  Zcilschrifi  f.  ktinische  Medicin,  1884,  Rd.  viii.),  Bircli- 
llirschfeld,  and   others. 


Iff 


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AMFJilVAM    TEXT-HOOK    OF    OnSTETlilCS. 


rule,  iiifootion  of  tlic  mother  i  ■  safer  for  the  fetus  than  infwtioii  of  tlic  father. 
Whether  tlie  speriiiato/oa  of  the  iiifeeted  father  may  infeet  the  mother  is  uii- 
deciiled.  All  authorities  do  not  admit  the  possibility  (»f  infeetion  of  the  fetus 
unless  the  mother  is  syphilitic,  hut  modern  authorities  (Tarnier,  Schroeder, 
Charpentier,  Priestley,  antl  others)  assert  positively  their  belief  in  the  trans- 
mission of  syphilis  to  the  ovum  without  infection  of  tiie  woman. 

Diaiinon'iH  of  FvUtI  ISi/jihi/in. — The  infection  of  the  fetus  may  be  inferred  if 
either  parent  had  accpiired  syphilis  at  a  day  not  too  far  remote  from  the  time 
of  i)rocreation.  The  limit  ot"  safety  has  not  been  discovered,  but  the  more 
recently  the  father  has  suffered  with  this  disease  the  more  likely  is  he  to  trans- 
mit it  in  severe  form.  Often  the  sipis  of  fetal  syphilis  can  be  looked  for  oidy 
in  the  fetus  after  its  expulsion  from  the  uterus.  In  many  cases  the  child  is  pre- 
maturely born,  and  there  are  traces  of  the  disease;  in  other  eases  the  child  is 
born  apparently  healthy,  the  disease  developinjjf  in  the  course  of  from  two 
to  six  weeks.  The  evidence  of  syphilis,  whether  the  baby  is  born  dead  or 
wh(!ther  the  disease  makes  its  a])pearance  soon  after  birth,  is  usually  charac- 
teristic. (I'rcmature  death  of  the  fetus,  due  to  syphilis,  is  considered  on 
page  310.)  If  born  alive,  the  child  is  often  prematurely  born,  and  presents 
durin<>;  the  whole  of  its  infancy,  and  j)erhaps  during  childhood,  a  ]>rematin'elv 
old  look.  There  is  usually  marked  general  debility.  Among  the  first  manifes- 
tations of  hereditary  syphilis  is  snuffles.  The  eoryza  is  foUowwl  by  a  charac- 
teristic rash  consisting  of  erythema  and  erythematous  patches  about  the  amis, 
the  genitals,  the  thighs,  and  the  forehead.  The  U])per  lip  is  likely  to  become 
excoriated  and  fissured.  The  mucous  mendirane  of  the  larynx  may  be  affected, 
producing  hoarseness,  and  there  even  occurs  ulceration  of  the  larynx. 

Pemjihigus  is  one  of  the  most  characteristic  of  syphilitic  lesions.  A  little 
later  roseola,  the  maculo-syphili<lcs,  psoriasis,  vesicles,  and  pustules  may  also 
occur.  Sometimes  mucous  patches  appear ;  these  may  occur  around  the  anus, 
the  vulva,  the  groin,  and  the  lips,  and  sometimes  in  the  folds  of  the  neck. 
Coryza  may  result  in  caries  of  the  nasal  bones.  Syphilitic  infants  are  liable 
to  suffer  from  broncho-pneumonia. 

Congenital  syphilitic  pneumonia  occurs  in  two  forms — white  hepatization 
(Virchow)  and  the  interstitial  form.  The  white  hepatization  produces  eidarge- 
nicnt  of  the  lungs,  the  cut  surface  presenting  a  mottled  grayish  appearance. 
The  alveoli  arc  filled  with  fatty  epithelial  cells.  Tlie  interstitial  form  consists 
of  increase  of  connective  tissue  between  the  alveoli ;  there  may  also  be  yellow 
induration,  due  to  gummata  on  the  pleural  surface  or  scattered  through  the 
tissues. 

Icterus  and  cyanosis  are  frequent  symptoms  of  sy))hilis.  The  occurrence  of 
the  symptom  of  icterus  is  explained  by  syphilitic  hepatitis,  which  in  the  new- 
born is  of  a  different  character  from  syphilis  of  the  liver  in  the  adult.  Infant 
hf'patic  syphilis  is  always  hereditary  (Chauffard) :  the  blood  carrying  the 
infection  arrives  in  that  organ,  and  the  process  is  markedly  profuse,  rendering 
the  organ  at  an  early  stage  diffuse  and  massive.  In  the  healthy  infant  the  liver 
should  constitute  one-thirtieth  part  of  the  body-weight ;  in  a  syphilitic  chilil 


Till':  PATimr.oav  or  pnEaNAxcv. 


200 


this  proportion  is  much  oxcccdcd,  in  .s(»nio  caws  having  f'onuod  ono-oijfhth  of 
the  weight  of  tho  body.  The  liver  presents  two  chanfres — the  guniinata  and 
ditl'nse  infiltration  of  eonneetivo  tissue.  This  form  of  cirrhosis  is  usually  of 
the  hypertrophic  form.  Cyanosis  is  dependent  either  upon  premature  hirth 
or  upon  syphilitic  chanj^es  in  the  lungs,  Ibr  gununa'a  and  white  hepatization 
in  th(!  lungs  are  found  with  frecpiency. 

The  tendency  of  syphilitic  infants  to  hemorrhago  will  again  be  alluded 
to  under  tho  subject  of  Ifnnorr/i<i(/ic  ])iathvHls,  This  fltrin  is  designated  by 
Behrend  as  sj/plii/is  li(iinorr/i<i(/i('a.  It  usually  attacks  childn>n  of  premature 
birth  who  an;  either  born  dead  or  live  only  a  few  hours.  In  these  children 
are  found  all  the  changes  which  characterize  congenital  syphilis:  numerous 
extravasations  of  blood  under  tho  skin  and  in  the  internal  organs,  also  at 
times  great  (piantities  of  blood  in  the  stonuich  and  intestines,  in  the  perito- 
neal cavity,  and  in  the  membranes  of  the  bniiu.  If  such  children  live  for  a 
little  while,  then  fmiuently  new  hemorrhages  appear  in  the  skin  and  in  other 
organs,  Ruge  saw  a  syphilitic  child  present  hemorrhage  about  the  anus,  at 
the  j)oint  of  the  tongue,  and,  finally,  about  the  eighth  day  of  lifii',  severe 
mnbilical  hemorrhage.  The  hemorrhage  occurred  tlircctly  out  of  the  skin 
like  drops  of  sweat.  Further,  upon  the  ninth  day  severe  icterus  develoj)ed 
and  the  child  died.  Tho  autopsy  showed  well-(levci>ped  syphilitic  changes  in 
the  internal  organs.     Edema  freiiuently  occurs  in  this  hemorrhagic  form. 

Teudorness  and  swelling  of  the  long  bones  arc  strong  evidence  of  hereditary 
svphilis.  Tho  most  characteristic  change  in  fetal  syphilis  occurs  in  the  bones. 
The  white  line  which  noruudly  marks  the  junctinv  of  the  epiphysis  with  the 
♦liaphysis  becomes  broader,  often  irregular,  and  yellow  from  fatty  changes 
following  a  i)rcmaturo  attempt  at  ossification  ;  in  marked  cases  there  is  also 
thickening  of  the  periosteum  and  perichondrium.  Tho  diaphysis  is  sometimes 
sclerotic.  Some  authors  (INIiiller  and  others)  reganl  these  ])rocosses  as  quite 
different  from  those  of  rachitis ;  others  consider  them  idcnti<'al.  Tho  (pies- 
tion  of  identity  between  the  two  must  be  considered  unsettled.  The  thynuis 
gland  is  often  nuich  enlarged,  and  may  present  multiple  abscesses. 

The  (rcdtmnd  of  fetal  syphilis  is  mainly  prophylactic.  In  parents  who  are 
svph'iitic  the  disease  may  be  eradicatcMl  by  long-continued  treatment.  (Jreat 
benefit  may  bo  derived  from  treatment  of  tho  mother  during  pregnancy.  If 
after  thorough  treatment  for  the  disease,  coucoptiou  docs  take  ])lacc,  tho  result 
may  bo  a  child  free  from  syphilis.  Etiemie,  from  a  sttidy  of  thirty-two  cases 
of  pregnancy  in  sy])hilitic  women,  concludes  that  the  mortality  of  the  fetus  in 
cases  whore  the  mother  has  never  been  under  treatment  is  enormous,  reaching 
nr).5  per  cent.  If  treatment  be  a]i])lied  throughout  pregnancy,  wo  may  hope 
to  obtain  complete  innnunity  from  this  infant  mortality.  If  a  mother  who 
has  been  infected  recently,  or  who  has  had  a  number  of  miscarriages  due  to 
syphilitic  infection,  is  again  pregnant,  antisyphilitic  treatment  should  at  once 
be  instituted.     Mercury  and  iodid  of  potassium  are  tho  most  reliable  remedies. 

3.  CoxcKXiTAi-  P'KKOUMITIKS  AND  MAi-FORMAxroNs. — Amniotic  Bands. 
— One  of  the  conditions  to  which  manv  deformities  are  duo  is  the  formation  of 


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AMERICAN    TKXT-IiOOK   OF   OliSTKTRTCS. 


nmniotic  bands.  Simoimrt  (lifroroiitiatos  three  classes  of  amniotic  bands  accord- 
ing^ to  their  origin  and  insertion — tlie  i'eto-amniotic,  the  fetal,  and  the  amniotic. 
Verv  often  the  anomaly  consists  only  in  the  existence  of  these  bands,  but  some- 
times their  existence  is  the  cause  of  serious  disturbance  in  the  normal  develop- 
ment of  the  fetus,  giviufi^  rise  either  to  cleavage  or  to  strangulation,  which  in 
turn  explains  many  of  the  malformations. 

Adhesions  between  parts  of  the  fetus  and  the  amnion  are  favored  by  a 
deficiency  in  the  amount  of  the  amniotic  fluid.  If  these  points  of  adhesion 
l)ecome  firm(>r  or  vascular,  they  may  pi'rsist,  and  if  the  process  develops  at  an 
early  term  of  fetal  life,  the  regular  dev  lopment  at  that  point  will  be  arrested, 
giving  rise  to  morphological  anomalies  which  consist  in  the  failure  of  union 
between  two  parts,  such  as  hare-lip,  extroversion  of  the  bladder,  etc.  If  these 
amniotic  bands  are  attached  to  the  etlge  of  the  fetal  cleavage,  the  cavities  are 
j)articularly  likely  to  remain  open,  giving  rise  to  ectopia  (Miiller). 

iStranf/u/dlioii. — Anuiiotic  bands  disturb  the  development  of  the  extremi- 
ties chiefly  by  producing  constrictions,  causing  at  the  peripheral  end  edema 
or  atrophy.  If  this  strangulati(in  takes  place  at  a  very  early  date  of  fetal 
life,  then  the  growth  of  that  part  will  be  greatly  arrested,  so  that  the  periph- 
eral end  beyond  the  constriction  is  propttrtionately  small  ;  in  other  cases  it 
produces  death  of  the  j)art  and  the  so-called  "spontaneous  amputation." 

Intra-nierinc  Amputation. — It  is  now  generally  admitted  that  the  exist- 
ence of  aiuniotic  bands  is  one  of  the  causes  for  intra-uterine  amputation  (Fig. 

161).  This  amputation  usually  takes 
place  early  in  fetal  life.  Sometimes 
there  are  a  number  of  these  bands, 
and  they  persist  to  the  time  of  birth. 
The  other  causes  recognized  as  such 
^^        ""  V    ki^^'i^*^  are  inflammatory  processes  and  intra- 

Sjl^   \  [^  '      ■!►'  "^  uterine  fractures.   Virchow  attributes 

^KKLla*"*-'^'*^^^^^  them  to  primary  inf1ammati(m   fol- 

lowed by  cicatrix  and  disturbed  nu- 
Fki.  ir,i.-K(tn.mcUis(intra-utorinL-umputution).      tritioii.     Simi)son  hoUls  that  thcrc  is 

a  causative   relation  between   intra- 
uterine fra(!tnre  and  spontaneous  amputation,  the  healing  processes  being  unf;i- 
vorable  for   fractures.      The   bone-ends  may  perforate  the  vessels  and  <l. 
interrupt  the  nutrition  of  the  extremity,  causing  a  sequestrum. 

Intra-uterine  fractures  occur  occasionally,  and  they  are  usually  di  to 
external  violence,  notwithstanding  the  protection  of  the  fetus  by  the  amniotic 
fluid  and  the  maternal  body.  Abnormal  nuiscular  contraction  of  the  fetus 
and  a  diseased  condition  of  the  bones  are  other  causes.  A  syjihilitic  osteo- 
chondritis may  result  in  separation  of  the  epiphysis  and  diaj)hysis  of  the  long 
bones,  simulating  fractures.  Next  to  external  violence,  advanced  rachitis  in 
the  fetus  undoubtedly  is  the  commonest  cause  of  intra-uterine  fractures, 
which  are  commonly  multiple.  Tibial  fractures  are  frequently  associated 
with  an  imperfect  development  of  the  long  bones.     The  intra-uterine  con- 


TIIH  PATHOLOaV   OF  riiKOXAXCY. 


301 


(litiotiH  arc  not  lavoruhle  to  a  good  union.  Union  may  take  ]>laro  before 
birtli,  but  u.sually  it  is  a  union  witii  bad  ilctbrniity.  In  rachitic  t'ctusort  tlio 
conditions  I'or  good  union  arc  particularly  iiutavorablc.  If  these  fractures 
remain  ununited,  or  if  they  have  healed,  but  have  producetl  markoil  disloca- 
tions, they  may  cause  difTicult  labor. 

Congenital  luxations  occur  in  certain  Joints,  and  produce  such  secondary 
changes  on  the  surface  of  the  joint  that  in  some  cases  restoration  at  the  time 
of  l)irth  is  impossible.  Various  joints  may  thus  be  afleeted,  but  this  accident 
occurs  most  frequently  in  the  lilp-joint.  In  Prof  LangenbecU's  clinic  there 
occurred  90  cases  of  luxation  of  the  hip-joint  to  5  of  the  humerus,  2  of  the 
head  of  the  radius,  and  1  of  the  knee.  According  to  Kriiidein,  luxations 
arc  more  common  on  one  side.  Luxations  are  apt  to  be  associated  with  otiier 
malfornhitions ;  they  are  commoner  in  females  than  in  males,  87.6  per  cent, 
occurring  in  females. 

Etiolnffij  of  DiHlocatUmx. — As  to  the  etiology,  many  theories  have  been 
advanced  to  account  for  the  occurrence  of  dislocations,  of  which  the  Ibllow- 
ing  four  are  the  most  plausible : 

1.  That  it  is  due  to  true  traumatic  dislocation  resulting  from  injury  inflicted 
before  birth  or  during  delivery. 

2.  That  it  depends  on  a  relaxed  condition  of  the  ligaments  or  upon  hydrops 
of  the  joints. 

.'J.  That  it  is  a  deformity  caused  by  .spasmodic  muscular  contractions  during 
fetal  life. 

4.  That  it  is  due  to  a  malformation  of  the  acetabulum  characterized  by  the 
pi'oduction  of  deficiency  of  the  socket  in  which  it  is  normally  held. 

Since  in  most  cases  of  congenital  dislocation  the  labor  has  been  easy  and 
natural,  the  first  theory  will  hardly  liold.  It  has  also  been  demonstrated 
(Midler)  that  the  same  force  which  in  an  adult  woidd  produce  a  dislocation 
will  in  the  fetus  produce  epiphyseal  separation.  The  theory  accepted  by 
most  writers  as  the  most  plausible  explanation  for  the  cases  which  have  been 
examined  is  the  fourth — congenital  malformation  of  the  acetabulinn.  This 
theory,  which  was  advanced  by  Paletta,  has  found  adherents  in  Dupuytren, 
Hrechet,  and  most  recent  writi-rs.  The  deformity  is  not  usually  noticed  until 
it  is  time  for  the  child  to  walk.  The  atl'ected  limb  is  slightly  shortened. 
As  the  child  grows  older  oblirpiity  of  the  pelvis  and  compensatory  lateral 
curvature  of  the  spine  may  follow.  Further  discussion  as  to  symptoms  and 
treatment  would  liardly  come  within  the  scope  of  this  work. 

Congenital  Tumors. — Alxhtniual  Tionors. — The  fetus  occasionally  pre- 
sents at  birth  abdominal  tumors  of  considerable  size.  The  abdomen  may  bo 
enlarg*  .  on  account  of  ascites,  which  is  usually  of  syphilitic  origin.  Disten- 
tion of  the  bladder  sometimes  produces  an  immense  enlargement.  Other 
abdominal  enlargements  which  have  been  observed  are  produced  by  hydro- 
iiophrosis,  dilate<l  ureters,  ovarian  tumors,  and  carcinoma  of  the  liver. 

S(i  (d  Tumors. — Vario.is  tumors  also  occur  on  the  surface  of  the  body, 
particularly  in  the  sacral  region.    They  may  be  located  on  the  sacrum  oi  on  the 


s 


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V 


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302 


AMERICAN   TEXT-BOOK   OF  OBSTETRICS. 


sacrum  and  coccyx,  but  usually  on  the  coccyx  alone.  They  are  more  frequent 
in  the  female  than  in  the  male.  Out  of  58  cases  of  sacral  tumors,  forty-four 
were  females,  fourteen  males  (Molk.) 

The  tumors  vary  in  size  and  in  their  general  appearance.  We  distinguish 
the  following  forms:  (1)  Congenital  cystic  tumors;  (2)  Congenital  fatty  and 
fibrous  tumors ;  (3)  Congenital  tumors  with  fetal  remains ;  (4)  Caudal  excres- 
cences ;  (5)  Attached  fetuses. 

The  cystic  tumors  are  usually  hydrencephalocele  or  spina  bifida.  They 
occur  chiefly  in  the  cervical  and  lumbar  regions.  Fibrous  tumors  and  lipoma 
occasionally  occur.  Sometimes  these  tumors  contain  a  part  or  parts  of  a 
fetus.  This  inclusion  results  from  a  cleft  in  the  medullary  fold,  that  may 
give  rise  to  a  double  formation  resulting  in  a  rudimentary  tumor.  These 
tumors  may  be  simple  or  be  multilocular;  they  may  contain  rudimentary  limbs, 
cartilage,  or  loops  of  intestine.  Sometimes  one  rudimentary  fetus  is  attached 
to  the  palate  of  a  fetus  more  developed.  Caudal  appendages  occasionally 
occur :  they  may  be  either  fibrous  or  bony,  assuming  the  shape  of  a  tail. 
Molk  gives  two  such  examples.  Sometimes  in  cases  of  attached  fetuses  an 
extra  limb  is  attached  to  the  sacro-lumbar  region ;  sometimes  it  consists  of 
two  limbs  fused  into  one  (see  Dystocia).  In  these  cases  the  pelvis  usually 
shows  some  malformation. 

Treatment  of  Congenital  Tumors. — Of  all  these  tumors  the  treatment  is 
excision,  but  it  is  only  indicated  in  cases  where  the  attachment  is  not  too 
extensive  or  where  the  growth  does  not  to  any  extent  encroach  on  the  pelvic 
cavity  or  the  viscera. 

Deformities  of  Special  Regions  and  Organs  of  the  Body. — Tlie  in- 
fluence of  amniotic  bands  in  arresting  development  by  preventing  tlie  normal 
fusion  at  an  early  stage  of  embryonic  life  is  now  generally  admitted  as  an 
explanation  for  such  deformities  as  hare-lip,  cleft  palate,  fissure  of  the  nose, 
etc.     Often  a  number  of  malformations  occur  in  the  same  individual. 

Deformities  of  the  Face. — If  the  frontal  process  fails  to  unite  with  the 
superior  maxillary  process,  which  in  the  normal  course  of  development  unite 
in  front  of  the  mandibular  tissues,  a  defect  in  the  soft  parts,  producing  hare- 
lip, may  result ;  if  the  inward  growth  of  the  palatine  processes  is  arrested, 
cleft  palate  results. 

Ifare-lip  occurs  in  various  degrees.  Sometimes  there  is  only  a  slight 
notch  in  the  lip,  and  again  there  may  be  one  or  two  fissures  extending  to  the 
nostril,  and  it  may  or  may  not  be  associated  with  cleft  palate.  The  existence 
of  hare-lip  interferes  more  or  less  with  nursing,  especially  if  associated  with 
cleft  palate.  Often  feeding  with  a  spoon  is  unsatisfactory,  because  the  food 
will  regurgitate  through  the  nose.  Infiuits  with  hare-lip,  as  a  ride,  are  there- 
fore imperfectly  nourished,  and  if  they  survive  are  likely  to  possess  a  low 
vitality.  The  treatment  consists  in  sustaining  the  strength  of  the  child  as  well 
as  possible  fi)r  the  first  few  weeks  of  life;  after  that  an  ()]>eration  should  be 
perfi)rmed.  A  consideration  of  the  methods  of  operating  would  hardly  be 
within  the  scope  of  this  work. 


THE   PATHOLOGY   OF  PREGNANCY. 


303 


Congenital  occlusion  of  the  posterior  nares  occurs,  but  very  rarely.  Con- 
genital cysts  of  the  floor  of  the  mouth  sometimes  manifest  themselves  in  the 
form  of  a  swelling  under  the  tongue  or  the  chin. 

Toiif/t'e-tie. — Very  frequently  the  frenum  of  the  tongue  binds  this  organ 
to  the  floor  of  the  mouth,  immobilizing  the  tip  of  the  tongue  more  or  less. 
This  condition  interferes  with  suckling,  and  if  not  corrected  will  prove  an 
inipediment  to  speech.  The  treatment  consists  in  operating,  as  soon  as  the 
discovery  is  made,  by  raising  the  tongue  either  with  a  spatula  or  a  finger, 
rendering  the  freiiimi  tense,  snipping  the  membrane  with  scissors,  and  making 
any  further  separation  by  tearing  with  the  finger.  Care  must  be  taken  not  to 
cut  too  deeply,  to  avoid  profuse  hemorrhage. 

In  the  second  jiart  of  the  digestive  tract  strictures  or  pouches  may  occur. 

Malformations  of  the  stomach  arc  not  common.  The  "  hour-glass  "  deformity 
sometimes  occurs.  Congenital  obstruction  of  the  bowel  may  be  located  in  the 
duodenum  or  the  jejunum,  but  more  fre(piently  in  the  ileum.  Portions  of  the 
intestine  m.-xy  entirely  be  absent,  or  be  represented  only  by  a  band  of  fibrous 
structure  running  along  the  free  edge  of  the  mesentery.  Volvulus  and  hernia 
may  cause  obstruction. 

Couf/euital  im/nitial  hernia  is  due  to  a  patulous  condition  of  the  inguinal 
canal,  through  which  a  loop  of  intestine  protrudes. 

A  few  cases  of  perforation  of  the  intestine  are  recorded.  In  these  cases 
death  occurred  within  the  first  few  hours  after  birth.  In  three  cases  the  rup- 
ture was  found  at  the  sigmoid  flexure ;  in  one  case  in  the  splenic  flexure ;  in 
one  case  the  transverse  colon  was  perforated.  The  etiology  is  tissue-necrosis, 
probably  accumulation  of  meconiiuu. 

Tiie  large  intestine,  including  the  sigmoid  flexure  and  the  rectum,  is  liable 
to  various  malformations.  The  commonest  malformation  is  obstruction  of  the 
bowel,  due  to  deficient  development.  In  an  imperforate  rectum  there  may  be  a 
well-defined  exterior  opening  or  it  may  bo  absent ;  the  rectum  is  usually  deficient 
to  a  greater  or  lesser  degree.  In  imperforate  anus  the  rectum  is  well  developed, 
but  the  external  opening  is  hi'-king.  In  some  of  these  cases  where  the  amis 
is  absent  the  rectum  passes  into  the  anterior  or  genito-urinary  segment. 

Hydrocele  is  a  not  infrequent  atfection,  and  is  dependent  somewhat  upon 
congenital  defi)rmity  when  the  processus  vaginalis  remains  patent. 

Congenital  defects  in  the  generative  organs  of  female  children  are  not  so  com- 
mon as  tliey  are  in  the-  male,  and  they  are  fre([uently  not  noticed  until  a  later 
period  in  life.  The  defects  of  the  internal  organs  are  gynatresia  and  defect  of 
the  uterus  and  of  the  ovaries.  INIalformations  of  tiie  organs  of  generatit)n  of  the 
female  are  usually  due  either  to  absence  of  Midler's  ducts,  to  failure  of  union 
or  bicftnniity,  complete  or  partial,  or  to  persistence  of  tiie  septum,  giving  rise 
to  the  double  formation  of  uterus  and  vagina.  Persistence  of  the  canals  of 
(jiirtner  sometimes  gives  rise,  later  in  life,  to  cysts  of  the  vagina,  and  persist- 
ence of  the  ducts  of  the  Wolffian  body  may  «levelop  into  parovarian  cysts. 

Nmuerous  cases  of  cystic  tumors  of  the  ovaries  existing  at  birth  have  l;een 
recordetl,  but  there  are  still  controversies  concerning  the  embryonic  origin  of 


304 


AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 


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these  tiimoi's,  some  assuming  that  all  cystic  ovarian  tumors  are  already  formed 
in  the  embryo  (Poz/i).  This  origin  applies  especially  to  the  dermoid.  J,  Bland 
Sutton,  who  has  devoted  much  time  to  the  study  of  fetal  ovaries,  says :  "  I 
have  never  succeeded  in  detecting  an  ovarian  dermoid  at  birth,  neither  can 
I  refer  the  reader  to  a  trustworthy  case." 

Malformations  of  the  Extremities. — Numerical  excess,  supernumerary 
digits  or  toes,  is  another  variety  of  maltbrmations.  The  treatment  for  super- 
numerary digits  is  amputation.  Congenital  union  of  digits  (syndactylism) 
occurs  in  varying  tlegrees,  there  being  sometimes  a  firm  fusion  of  the  two  adjacent 
members,  at  other  times  a  webbed  condition.    The  fusions  are  treated  by  incision. 

Club-foot  is  only  a  modification  of  a  ]>hysiological  position  in  utero.  Too 
small  an  amount  of  amniotic  fluid  tends  to  produce  chilnfoot,  the  foot  being 
pressed  against  the  breech  ;  this  long-continued  pressure  of  the  soft  ])arts 
tends  to  shortening  of  the  bones  by  I'ctarding  the  progress  of  growth ;  thus 
the  position  becomes  fi.xed  (Ivanderer).  This  congenital  malformation  usually 
produces  talipes  varus  or  equino-varus.  There  is  usually  moi'c  or  less  ])aresis, 
and  sometimes  paralysis  of  the  nniscles  of  the  aft'ected  side  and  tonic  contrac- 
tion of  their  ()j)ponents.  The  treatment  consists  in  ])roper  bandages,  which 
should  be  applied  as  soon  as  the  deformity  is  discovered. 

Malformations  of  the  Circulatory  Apparatus. — Malformations  of  the 
heart  are  very  common,  esj)ecially  persistence  of  the  foramen  ovale.  Fetal 
endocarditis,  with  its  consequent  valvular  lesions  and  transposition  of  the  aorta 
and  jndmonary  artery,  also  occurs.  Sometimes  there  is  but  a  rudimentary  sep- 
tum between  the  ventricles.  As  this  system  resembles  the  arrangement  of  the 
heart  of  the  lower  forms  of  life,  it  is  called  "  reptilian  heart."  Persistent 
cyanosis  is  the  most  marked  symjitom  of  these  malformations.  Frequently 
the  fetus  is  not  viable. 

Malformations  of  the  Brain  and  Cord. — Cerebral  hernia,  or  men inr/oceJe, 
is  a  tumor  varying  in  size  from  a  hazel-nut  to  that  of  a  child's  head.  It  occurs 
usually  on  the  occiput,  occasionally  at  the  root  of  the  nose  or  on  one  of  the 
fontanelles. 

Sj)i))a  bifida,  which  is  not  uncommon,  may  o<'cn])y  any  part  of  the  length 
of  the  spinal  colunni.  It  is  a  congenital  malformation  in  which  the  lainiuie 
fail  to  unite  in  one  or  more  of  the  vertebra^  allowing  protrusion  of  a  sac  com- 
])osed  of  the  spinal  cord  or  its  membranes.  If  the  spinal  membrane  only 
protrudes,  it  forms  spinal  meningocele;  if  the  cord  and  spinal  nerves  as  well 
as  the  membranes  ]>rotru<le,  they  form  meningo-myelocele;  if  in  the  latter  pro- 
trusion the  si)inal  canal  is  dilated,  forming  a  sac,  it  firms  syringti-myelocele. 

ExcncephaluH  is  a  deformity  in  which  the  brain  is  present,  but  the  cranial 
bones  are  not  developed.  Pseudeneephalux,  in  which  the  bones  of  the  cranium 
are  absent  or  arc  undeveloped  and  <'ontain  a  rudimentary  bi-ain,  is  a  more 
common  deformity  than  anenrep/iahm,  in  which  there  is  no  brain  and  no 
development  of  the  cranium.  Acep/iafia  and  hemiceplialia  are  deformities 
consisting  in  a  defect  of  the  skull ;  sometimes  the  delect  continues  into  the 
spine.     The  integun)ent  and  nerve-tissue  are  wanting,   and  are  replaced  by 


-:..^; 


THE    PATHOLOGV   OF  PREGXAXC'Y 


305 


some  granulation  tissue.  The  etiology  is  unsettled,  although  several  theories 
exist.  A  fetus  with  this  malformation  is  usually  not  viable ;  if  there  is  lii'e  at 
the  time  of  birth,  it  soon  ceases.  These  deformities  may  occur  successively  in 
several  pregnancies.  Mk-rovcphalla  is  a  monstrosity  with  a  very  small  skull. 
The  forehead  is  flattened  and  receding.  Monstrosities  of  this  class  may  be 
viable;  if  so,  they  are  imbecile.  Tiny  may  live  for  some  time,  and  may 
even  attain  great  age. 

Excessive  Development. — Excessive  development  of  the  whole  fetus 
occasionally  occurs,  in  which  the  fetus  has  weighed  from  fourteen  to  eighteen 
pounds  (A.  Martin,  Beach,  Meadows) ;  the  more  freiiuent  cause,  when  the 
excessive  development  is  not  very  great,  is  prolongation  of  pregnancy  ;  other 
causes  are  multiparity  and  excessive  size  of  one  or  both  parents ;  again,  there 
are  cases  in  which  the  fetus  as  a  wliole  does 
not  exceed  in  weight  the  normal  limits,  but 
there  is  an  excess  of  development  in  some 
particular  member  of  the  body,  especially 
one  of  the  extremities.  In  such  hypertro- 
])hies  of  the  fingers  and  toes,  if  the  de- 
formity is  sufficiently  pronounced  to  prove 
a  hindrance,  am])utation  is  indicated. 

Double  Formations.  —  Authorities  do 
not  yet  fully  agree  concerning  the  cause  of 
formation  of  homologous  twins  and  double 
monsters.  It  is  generally  accepted  that  both 
originate  from  one  blastula  of  the  yolk.  It 
is  still  a  question  of  dispute  whether  the 
])lastoderm  membrane  presents  two  germ- 
i  native  areas,  which  later  fuse  more  or  less 
into  one  being,  or  one  area,  which  becomes 
more  or  less  divided. 

As  union  may  take  place  in  the  cephalic,  the  median,  or  the  caudal  ex- 
tremity of  the  embryo,  one  of  these  forms  of  monstrosities  may  result 
(Miiller).  They  are  accordingly  named  cephalopagus,  thoracopagus,  ischi- 
opngus,  etc.  Of  these  classes  various  modifications  occur.  Figure  162 
icprcsents  an  interesting  specimen  of  thoracopagus,  exhibited  by  Dr.  W. 
\\ .  .laggard  before  the  Gynecological  Society  of  (Chicago.  If  there  is  an 
uiKHjual  development  of  the  embryos,  one  may  seem  nearly  normal,  while 
tlie  other  is  quite  rudimentary  and  seems  to  form  but  an  appendage  to  the 
loriner.  Such  a  rudimentary  fetus  may  even  become  completely  enclosed  by 
tlic  larger  one  (Miiller). 

4.  MATRRN'ATi  Imphkssions. — There  exists  a  jxipular  belief,  which  was 
Itarticularly  prevalent  during  early  times,  that  the  peculiar  sensations,  emo- 
tions, sights,  etc.  experienced  by  a  ]>regiiant  woman  arc  rre(|uontly  transmit- 
ti'il  to  her  child,  and  if  these  sights  and  imj)rcssions  are  particularly  friglit- 
tul.  they  cause  marks  and   defects  on   the  child.      One  of  the  arguments 

20 


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AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


advanced  in  favor  of  this  view  is  that  a  belief  so  universal  and  adhered  to 
through  centuries  is  rarely  entirely  fallacious,  especially  when  the  subject  is 
based  upon  observation.  The  advocates  of  this  theory  adduce  one  of  their 
most  reliable  arguments  from  the  Scriptures  (Gen,  xxx.  37-35)) :  "  Jacob  took 
him  rods  of  green  poplar,  and  of  the  hazel  and  chestnut  tree ;  .  .  .  .  And  he 
set  the  rods  which  he  had  pilled  before  the  flocks  in  the  gutters  in  the  wator- 
ing-troughs,  ....  that  they  should  conceive  when  they  came  to  drink.  Antl 
the  flocks  conceived  ....  and  brought  forth  cattle  ringstraked,  speckled, 
and  spotted." 

At  the  present  time  authors,  practitioners,  and  teachers  differ,  but  up  to 
the  beginning  of  the  eighteenth  century  they  were  nearly  unanimous  in  the 
belief  that  fetal  marks,  deformities,  and  lack  of  development  were  due  to 
impressions  received  by  the  mother.  Wherever  the  truth  may  lie,  it  is  very 
evident  that  manj'  of  the  cases  cited  have  been  taken  from  individuals  whose 
testimony  would  hardly  pass  as  conclusive  in  other  matters. 

During  the  past  forty  years  many  articles  have  been  written  strongly 
opposed  to  the  previously  accepted  theory  of  maternal  impressions.  It  lias 
always  been  extremely  difficult  to  demonstrate  that  any  deformity  or  mark  or 
lack  of  development  in  the  child  was  due  to  an  impression  which  the  mother 
may  have  received  before  its  birth,  inasmuch  as  there  seems  to  be  at  least  one 
unanswerable  argument  in  that  mc  Hnd  no  direct  nerve-connection  existing 
between  mother  and  child. 

The  late  Fordyce  IJarker  has  been  credited  with  demonstrating  the  correct- 
ness of  the  theory  of  "maternal  impressions"  in  a  paper  read  in  1886  befoi-e 
the  American  Gynecological  Society.  He  quotes  freely  from  physiologists 
to  show  that  the  weight  of  authority  must  be  conceded  to  be  in  favor  of  the 
doctrine  that  maternal  impressions  may  affect  the  growth,  form,  and  character 
of  the  fetus.  His  opinions,  however,  were  very  largely  based  upon  references 
and  arguments  adduced  from  older  writers.  Barker,  in  concluding,  quotes 
the  following  from  the  Bnt'iHU-Amerkan  Journal:  "When,  in  the  early 
weeks,  structural  development  is  proceeding  at  no  tardy  rate,  an  interference 
to  luitritiim  of  the  mother  cannot  but  impress  the  fetus  detrimentally,  and  the 
organ  interfered  with  would  be  that  one  in  the  condition  of  the  most  active 
development,  or  that  which  could  less  easily  bear  any  arrest,  however  transient, 
with  inq)Mnity."  Again:  "Then,  too,  although  no  nervous  connecticm  has 
been  demonstratetl  to  exist  between  the  mother  and  the  fetus,  yet  the  latter 
possesses  nerves;  and  alterations  of  the  nutrient  ])ower  of  the  mother  cannut 
but  act  on  the  nerves  that  are  governing,  though  it  may  be  only  to  a  sligiit 
extent,  the  growth  of  the  fetus  itself"  As  a  matter  of  fact,  only  a  few  cases 
— exceedingly  few — of  defective  or  marked  children  are  born  compared  witli 
the  multitudes  of  perfect  ones ;  then,  too,  the  testimony  in  many  of  these  cases 
is  absolutely  worthless. 

One  of  the  ablest  articles  opposing  this  theory  is  written  by  J.  G.  Fischer. 
A  few  of  his  conclusions,  and  those  epitomized,  will  be  given.  Tliey  arr 
briefly  as  follows :     Tiiat  traditional  superstition  has  perpetuated  the  notion, 


^ 


THE  PATHOLOGY   OF  PREGNANCY. 


307 


and  that  the  medical  profession  is  in  no  considerable  degree  responsible  for  its 
continuance ;  that  intense  emotions  and  apprehensions  are  experienced,  and 
malformations  are  expected  by  many  gestating  women,  yet  the  abnormal  births 
arc  extremely  rare ;  that  there  is  no  law  in  the  alleged  result,  and  that  the 
occasional  apparent  relation  of  cause  and  effect  is  due  to  accidental  coincidences. 

There  is,  in  addition,  against  the  theory,  another  argument,  which  is  that 
the  assumed  causes  are  alleged  to  have  operated  upon  the  embryo  subsequently 
to  the  named  period  for  the  evolution  of  the  part  which  is  found  to  be  the 
site  of  the  malformation,  implying  not  otdy  a  formative  process,  but  a  retro- 
formative  power.  This  argument,  it  appears  to  the  writer,  is  particularly 
strong.  For  instance :  a  child  is  born  with  a  profuse  growth  of  hair  upon  a 
spot  of  the  body  whore  it  should  not  exist.  The  mother  and  Ik.t  friends, 
after  considerable  coaching,  remember  that  some  of  the  impression?  somewhat 
similar  to  this  were  received  at  a  certain  time.  As  a  matter  of  fact,  that  time 
occurred  a  considerable  ])eriod  after  or  before  the  period  when,  according  to 
the  study  of  embryology,  we  know  the  hair  to  have  been  developed. 

Several  years  ago  Norman  Bridge  wrote  a  strong  paper  against  the 
theory.  Among  other  things,  he  says :  "  To  endow  the  blood  with  such  a 
weird  intelligence  as  this  would  n^quire  is  too  great  a  load  for  our  credulity. 
There  is  no  philosophy  that  it  so  acts.  There  is  possibly  enough  in  this  theory 
s(j  that  we  should,  on  account  of  the  comfort  of  the  pregnant  woman,  advise 
her  not  to  indulge  in  violent  emoiions,  or  to  see  peculiar  sights,  or  to  do  any- 
thing which  is  outside  of  the  proprieties  of  life."  It  is  desirable,  in  the 
writer's  judgment,  to  give  this  advice  to  all  pregnant  women. 

Many  cases  have  been  brought  forward  that  seem  almost  to  prove  tiie 
position  assumed  by  both  parties  in  this  controversy.  In  the  writer's  judg- 
ment, nothing  is  really  established,  and  we  must  continue  to  believe  that  if  a 
pregnant  woman  sees  a  sight  and  gives  birth  to  a  marked  baby,  it  is  usually 
only  a  coincidence.  We  must  still  regard  the  relation  of  cause  and  effect  as 
largely  an  accidental  coincidence  bearing  in  mind,  however,  the  fact  that, 
exceptionally,  very  profound  emotion  can  and  does  in  some  unknown  manner 
influence  the  growth  and  developin(>nt  of  the  fetus. 

5.  Intua-itterine  Diseases  of  the  Bones. — RaohUh  of  the  new-born 
occurs  in  two  distinct  forms — the  fetal  and  tie  congenital.  Although  rachitis 
as  it  occurs  in  early  childhood  was  recognized  by  the  ancients,  it  is  only  recently 
that  the  existence  of  the  fetal  form  has  been  fully  recognized  and  described. 
Since  Bohn  and  Winckel  described  these  two  forms  the  investigations  of  Vir- 
cliow,  H.  Mliller,  and  others  have  given  support  to  this  classificaiion.  Both 
i'nrnis  originate  in  the  pre-natal  state,  but  in  the  fetal  form  the  disease-process 
is  fully  develoi)ed  at  birth  ;  in  the  congenital  form  it  continues  to  develop. 

Petal  rachitis  (Fig.  KiJJ)  has  been  characterizcci  as  a  disease  of  the  periosteal 
cartiliige,  giving  rise  to  an  active  growth  in  tiie  w  roiig  dircctictn  ;  at  the  same 
time  there  is  a  deficiency  in  the  deposit  of  calcareous  matter.  In  rachitis 
the  cartilaginous  and  subperiosteal  cell-growth  is  excessive  and  irregular, 
wliilc  the  process  of  ossification  itself  is  also  irregular  and  sometimes  wanting 


(?('.' 


■JL.r 


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I,  *. 


308 


AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 


(Fig.  1 64).  The  line  of  ossification  between  the  epiphyses  and  diaphyses  is  irregu- 
lar, likewise  is  the  zone  of  calcification ;  newly-formed  bone-  and  marrow-cavities 
may  be  in  the  midst  of  cartilag  ,  and  masses  of  cartilage  may  take  the  place  of 
bony  tissue.  At  the  same  time  there  is  an  excessive  proliferation  of  cells  on  the 
inner  layer  of  the  periosteum  ;  these  various  abnormal  processes  lead  to  bony 
deformities.  The  long  bones  develop  more  laterally  than  longitudinally ;  the 
extremities  are  short,  thick,  and  usually  curved  ;  the  skull-bones  are  thick  ;  the 
ribs  show  nodular  enlargement  (beaded  ribs) ;  deformities  occur  in  the  spinal 
column  and  pelvis,  and  the  thorax  shows  the  "  pigeon  breast."  There  is  a 
general  disproportion  between  different  parts  of  the  body.  The  head  is  often 
large,  the  neck  thick  and  short,  tiie  abdomen  large.  Associated  with  these 
characteristics  we  may  find  hydrocephalus  and  enlargement  of  the  thyroid  gland. 

Rofei-ence  has  already  been  made  (page 
300)  to  the  frequent  occurrence  of  in- 
trauterine fractures  in  cases  of  con- 
genital rachitis. 

There  are  other  conditions  which 
affect  the  growth  of  the  skeleton  in 
ntrro,  and  which  resemble  rachitis — 
Schmidt's,  Bidder's,  and  Miiller's  dis- 
eases. 

Bidder's  Disease. — In  Bidder's 
disease  (osteogenesis  imperfecta)  the 
lines  of  ossification  are  normal ;  tlio 
epiphyseal  cartilage    is    normal,   but 


Fig.  163.— Fetal  rachitis. 


Fig.  104.— Skvill  (front  view)  in  fotal  racliitis; 
ubsL'iice  (if  frontal  bone. 


ossification  does  not  fully  take  jilaco  either  in  the  epiphysis  or  in  the  diaphysis. 
Tiie  bono-production  from  the  jieriostetmi  is  commoiu'od,  but  in  the  dia])hysis 
tiic  ('((mpact  portion  is  imperfectly  developed  ;  in  the  marrow-cavities  tiiero  is 
no  d<'j)(»sit  of  calcaroous  sub.stancc.  The  bones  remain  short  and  ])liablo  ;  tlie 
sagittal  suture  remains  broad.  The  bones  of  the  face  and  skull  are  particu- 
larly apt  to  be  affln'ted.  Sometimes  this  condition  affects  in  a  slight  degree  tlic 
bones  of  the  skulls  of  infants  wlio  are  otherwi.se  perfectly  developed. 

Schmidt's  disease  is  charMctc'rized  by  great  ])redisposition  to  fracture  nl' 
the  bones.  The  jteriosteum  and  the  epiphyseal  cartilages  are  normal,  but  (he 
bony  canula;  do  not  j)resont  the  concentric  arrangement  which  normally  exists. 


THE   PAT/IOLOOV   OF  PREGNANCY. 


309 


The  bone-corpuscles  are  large,  and  usually  remain  empty.     The  spongy  sub- 
stance contains  much  connective  tissue  and  many  undeveloped  cells. 

Miiller's  disease  is  a  diseased  condition  of  the  cartilage.  The  embryonic 
development  of  cartilage,  which  normally  extends  chiefly  in  a  longitudinal 
direction,  expands  in  all  directions ;  at  the  same  time  the  development  of 
bony  structure  from  the  periosteum  continues.  This  action  leads  to  the  pro- 
duction of  thick,  short  bones.     The  skull-bones  are  also  very  thick. 

6.  Intra-utkrine  Diseases  op  the  Skin,  Connective  Tissue,  and 
Serous  Membrane. — Diseases  of  the  skin,  the  connective  tissue,  and  the 
soi\/US  membrane  that  manifest  themselves  in  the  pre-natal  state  are  usually 
due  to  fetal  syphilis.  Cases  of  congenital  ichthyosis,  pemphigus,  and  other 
eruptive  diseases  have  also  been  observed. 

Pemphigrus. — Pemphigus  neonatorum  in  its  epidemic  form  is  considered 
on  another  i)age ;  it  must  not  be  confounded  with  the  congenital  form.  Al- 
though the  pemphigus  is  usually  syphilitic  when  present  at  birth  (Roeser  says 
always),  still  some  cases  of  non-syphilitic  pemphigus  have  been  observed. 
Erysipelas  has  been  observed  to  be  transmitted  to  the  fetus  in  utero. 

Anasarca. — Under  this  head  belong  hydrothorax,  ascites,  and  hydro- 
cephalus. These  conditions  often  produce  mechanical  obstruction  to  delivery. 
Occasionally  anasarca  is  seen  in  connection  with  dropsy  of  the  mother.  This 
condition  is  frequently  due  to  obstruction  of  the  umbilical  veil  accompanying 
syphilis.  Excessive  distention  of  the  body  may  result  from  ascites  and  hydro- 
thorax.     Ascites  is  often  due  to  syphilis ;  also  to  organic  lesions  of  the  heart. 

Tumors. — Among  congenital  tumors  of  the  skin,  nevus  is  the  most  com- 
mon. Although  not  always  noticed  at  the  time  of  birth,  the  nevus  is  prob- 
!il)ly  always  present  at  that  time.  These  tumors  belong  to  the  angiomata. 
Hairy  and  pigmented  moles  often  occur  congenitally. 

Peritonitis. — Fetal  peritonitis  is  usually  due  to  syphilis.  It  manifests  no 
symptoms  at  this  period,  but  if  not  destructive  to  the  life  of  the  fetus,  it  is 
likely  to  produce  some  constriction  of  the  bowel.  It  also  occurs  in  infants  in 
connection  with  puerperal  fever,  especially  in  lying-in  hospitals.  The  path- 
(tlogieal  conditions  correspond  with  those  found  in  similar  cases  in  adults. 

Pericardial  and  endocardial  inflammations  rarely  occur,  and  the  latter  is 
more  often  located  in  the  right  side  of  the  heart,  and  may  leave  lasting  val- 
vular changes. 

7.  Struma. — Struma  of  the  thyroid  gland  must  not  be  confounded  with 
edonia  of  that  structtu'c.  While  edema  occurs  as  a  traumatic  injury,  true 
struma  is  an  hypertrophy  of  the  thyroid.  Edema  results  from  face  presenta- 
tion ;  hypertrophy  may  produce  the  same.  Struma  may  be  complicated  with 
('(lonia,  which,  however,  will  only  be  temporary. 

8.  Intra-uterine  i/isEASEs  OF  THE  Xervous  System. — There  are  of 
the  brain  a  uund^er  of  defects  which  are  congenital  in  their  origin,  and  which 
Inter  manifest  themselves  as  some  forms  of  deaf-niutism,  cretinism,  idiocy, 
and  otiier  forms  of  ])artial  or  complete  loss  of  development.  Hypertrophy 
ul"  tlie  brain  sometimes  occurs,  associated  with  rachitis. 


m 


If  r   ill   •"  ' 


310 


AMERJi'AN    TEXT-nOOK    OF    OBSTETRICS. 


i  I 


r; 


Hydrocephalus. — Fetal  hydrocephalus  is  not  common  and  its  etiology  is 
not  understood.  According  to  Meigs,  it  is  due  to  an  inflammation  of  the 
lining  of  the  ventricles.  Jt  often  ])r(xluces  a  hideous  defornuty,  due  to  pro- 
trusion of  the  eyes  and  ])rojection  of  the  Ibrehead  (see  page  259). 

Cretinism  is  endemic  in  some  mountainous  districts  of  Europe.  It  is  often 
associated  with  eniargement  of  the  thyroid  gland. 

Syphilitic  Idiocy. — Manifestations  of  syphilitica  idiocy  are  recognized  after 
the  period  of  infancy. 

9.  Dkath  iw  THE  Fetus. — In  presenting  this  subject  a  repetition  of  what 
has  been  said  under  Abortion  (page  259)  can  hardly  be  avoided. 

The  causes  resulting  in  death  of  the  fetus  before  maturity  may  be  consid- 
ered under  the  following  heads  : 

(1)  In  the  father, — alterations  of  semen,  as  in  phthisis,  albuminuria,  etc. 

(2)  In  the  mother, — general  diseases,  excitability  of  the  uterus,  and  marked 
lesions  of  the  same. 

(3)  In  the  fetus — or  faulty  development. 

(4)  In  the  annexes  of  the  fetus — membranes,  placenta,  cord. 

(5)  External  violence. 

(1)  Causes  resuU'my  from  the  Father. — Conditions  producing  great  debility 
in  the  father  are  liable  to  manfest  themselves  in  a  low  degree  of  vitality  in  the 
oflfspring,  and  often  before  the  time  of  birth  ])roduce  death  in  the  embryo. 
Old  age  in  the  father,  chronic  poisoning,  albuminuria,  and  phthisis  are  likely 
to  be  followed  by  this  residt,  but  the  most  frequent  cause  from  the  parental 
side  is  the  transmission  of  syphilis  from  the  father.  The  embryo  may  show 
signs  of  this  disease  without  the  mother  being  infeoted. 

Death  of  the  fetus  is  explained  in  various  ways.  The  fetus  itself  may  be 
of  low  vitality,  or  the  membranes  may  become  affected  in  a  way  to  interrupt 
life.  Syphilis  may  produce  hypertrophy  of  the  villi  of  the  chorion  (Schroedor), 
jiroducing  sufficient  pressure  on  the  maternal  vessels  to  render  imperfect  tlic 
interchange  of  nutrition  between  mother  and  fetus.  The  more  recent  the  infec- 
tion of  the  parent  the  more  likely  is  it  to  produce  death  of  the  fetus  and  abor- 
tion. Rupture  of  one  of  the  viscera  may  cause  death  of  the  fetus.  J.  W. 
Ballantyne  cites  three  cases  in  which  rupture  of  the  spleen  was  the  immediate 
cause  of  death  within  two  days  of  delivery.  One  case  occurred  during  Prof. 
A.  II.  Simpson's  service,  and  the  post-mortem  examination  was  made  by  tlic 
writer;  death  occurred  two  days  after  labor.  The  second  case  is  one  reported 
by  Charcot  (1858),  in  which  a  stillborn  infant  had  been  resuscitated  and  lived 
half  an  hour.  The  third  case  was  reported  by  Kleinwiichter  (1872) :  a  pre- 
maturely born  infant,  weighing  four  and  a  half  pounds  died  in  four  honis. 

2.  Cmm:s  reuniting  from  the  Mother. — The  influences  from  the  mother  lead- 
ing to  death  of  the  fetus  are  numerous.  Acute  infectious  diseases  of  the  motliei 
come  under  this  head.  It  has  been  demonstrated  that  high  temperature  and 
anemia  of  the  mother  are  liable  to  interrupt  gestation  by  premature  uterine 
otrntraetion.  Tuberculosis,  carcinoma,  nephritis,  and  diabetes  of  the  motlier 
often  cause  peculiar  excitability  of  the  embryo;  the  nervous  system  of  the 


THE   PA'nH)lA)(iY    OF  PRKUNANVY 


311 


motlier  will  likewise  bring  about  this  comlition,  the  motor  nerves  responding 
to  very  slight  irritation  and  setting  tip  uterine  contraetion.  IMithisis  of  the 
mother  sometimes  produces  premature  labor,  sonietimes  abortion.  Death  of 
the  fetus  on  account  of  tuberculosis  of  the  mother  is  not  usual,  but  frequently 
the  child  is  poorly  developed,  and  if  it  survives  remains  feeble.  Wliether  this 
feeble  condition  is  due  to  lack  of  resistance  or  to  intra-uterin<  jr  latent  disease 
cannot  now  be  decide<l. 

Conditions  of  the  uterus  and  its  immediate  surroundings  n.  ,  uterrupt  preg- 
nancy ;  especially  is  this  true  of  endometritis  and  all  iuHammatory  conditions 
of  the  parenchyma.  Conditions  which  interfere  with  the  expansion  of  the 
uterus,  such  as  versions,  flexions  and  adhesions,  and  neoplasms,  also  some- 
times interrupt  pregnancy,  but  usually  the  uterus  ov(!rcomes  the  resistance  by 
degrees.     The  presence  of  uterine  fibroids  is  more  likely  to  interfere. 

3.  Causes  resulting  from  Fault}/  Development  of  the  Fetus. — As  regards  the 
fetus  itself,  anasarca  sometimes  results  from  disease  of  the  mother,  sometimes 
indejwndent  of  the  same ;  it  may  cause  })remature  birth  and  expulsion. 

4.  llie  Anncven  of  the  Fetus. — Membranes,  placenta,  and  cord,  degener- 
ations of  the  placental  villi,  extravasations  and  effusions  of  blood  into  the 
placenta  and  membranes,  will  more  or  less  interfere  with  the  nutrition  of  the 
embryo,  causing  jiartial  or  complete  separation  of  the  placenta.  Amyloid  and 
fatty  degenerations  of  the  placenta  will  ])roduee  the  same  result ;  likewise  any 
condition  which  interrupts  the  circulation  of  the  cord  must  be  disastrous  to 
the  nutrition,  and  eventually  to  the  life,  of  the  fetus. 

Dropsy  of  the  amnion  (hydramnion),  or  an  excessive  amount  of  fluid  in  the 
amniotic  cavity,  is  not  uncommon.  Wiicn  it  exists  in  a  marked  degree,  it  will 
])roduce  death  of  the  fetus,  though  the  latter  may  have  advanced  to  maturity. 
Knots  in  the  umbilical  cord  may  produce  sufficient  change  in  the  circulation  to 
materially  affect  the  fetus  (Fig.  1G5).  Lefour,  who  (,'xperiinented  with  refer- 
ence to  knots  of  the  umbilical  cord  cm  the  fetus,  concludes  tiiat  "  the  influence 
of  mere  knots  a])art  from  compression  is  slight.  When  the  intravascular  com- 
])ression  increases  the  cord  becomes  turgescent  and  tends  to  loosen." 


Fi(i.  IfiS.— Knotted  oiinl. 

AVhen  death  of  the  fetus  occurs  in  successive  pregnancies  the  term  *'  habit- 
ual death  "  is  applied.  Some  authors  apply  the  term  only  to  those  cases  in 
wliich  abortion  occurs  repeatedly  at  the  same  stage  of  pregnancy.  Schrocder 
Mould  apply  the  term  only  to  cases  occurring  repeatedly  at  about  the  same 
])eriod  and  assoeiatetl  with  no  apparent  anatomical  changes  in  the  mother,  the 
embryo,  or  the  membranes — that  is,  when  the  interruption  is  brought  about 


'&,1   fi 


ilii: 


i  I       it 


V 


1 1         '  t 


312 


AMTUilCAN    ri'LXT-liOOK    OF    OliSTETRK'S. 


.  ;»:. 


merely  throngli  excessive  irritability  on  the  part  of  the  mother.  Most  authors, 
however,  give  as  causes  for  habitual  death  of  the  fetus,  lirst,  syphilis,  the  most 
common,  then  maternal  anemia  and  uterine  disease. 

5.  External  Violence. — The  dilferential  diagnosis  betwceu  death  produced 
by  external  violence  and  that  produced  by  natural  causes  is  oi  medico-legal 
interest,  but  does  not  properly  belong  to  this  work. 

10.  Post-mortem  Changes  of  the  Fetus  in  Utero. — The  changes 
produced  in  the  fetus  by  pre-natal  death  are  characteristic,  and  usually  an; 
markedly  different  from  those  protluced  after  birth.  A  number  of  post-mor- 
tem changes  may  take  place ;  in  the  main,  the  changes  vary  somewhat  with 
the  period  of  development.  If  pregnancy  is  interrupted  during  the  first  few 
weeks,  the  embryo  is  usually  not  much  altered,  is  small,  and  is  generally  sur- 
rounded by  very  little  fluid. 

If  the  fetus  dies  during  the  first  months  of  gestation  and  the  ovum  is  not 
expelled,  some  weeks  afterward  the  latter  may  be  found  containing  no  trace 
of  the  embryo.  The  total  absorption  of  the  fetus  assumed  by  many  writers 
is  doubtful ;  according  to  Midler,  it  does  not  occur  frequently,  and  probably  is 
possible  only  at  a  very  early  period  of  development.  He  assumes  that  in  many 
cases  where  no  trace  of  the  fetus  is  found  it  has  either  passed  previous  to  the 
expulsion  of  the  membranes,  or  has  been  liquefied  and  is  passed  in  a  state  of 
dissolution.  The  membranes  may  show  signs  of  decomposition  or  may  con- 
tain extravasations  of  blood.  If  the  vitality  of  the  chorion  has  been  retained 
for  several  weeks  or  months,  it  will  result  in  a  "  mole  pregnancy." 

After  the  fourth  month  of  gestation  the  possibility  of  unobserved  escape 
of  the  fetus  or  that  of  liquefaction  no  longer  exists.  At  this  period  the  fetus 
is  either  retained  without  change  or  it  undergoes  one  of  the  following  changes : 
1.  Maceration  ;  2.  Saponification  ;  3.  Mummification  ;  4.  Putrefaction  ;  5.  Sup- 
puration ;  6.  Calcification. 

Maceration  (Fretus  sanguinolentus,  E.  Martin)  is  the  most  eonmion  of  the 
post-mortem  changes  of  the  fetus  aflter  the  fifth  month ;  it  rarely  occurs  at  an 
earlier  period  of  dcvelojiment.  The  fetus  is  usually  discolored,  brownish,  and 
livid  ;  some  of  the  epidermis  shows  bulla; ;  these  may  contain  a  yellowish  fluid, 
or  if  ruptured  the  red  corium  is  exposed.  The  thoracic  cavity  is  usually  small, 
the  abdomen  large,  containing  bloody  fluid,  and  all  tissues,  muscles,  and  bones 
are  softened.  The  umbilical  cord  is  dark,  and  Wharton's  jelly  is  distributcnl 
irregularly.  The  placenta  is  also  softened  and  saturated  with  bloody  serum  ; 
the  chorion  and  decidua  show  necrosis.  In  some  cases  occur  the  characteristic 
changes  of  syphilis,  osteo-chrondritis  syphilitica  being  especially  marked  in 
the  lower  epiphysis  of  the  femur.  Associated  with  this  may  be  a  condition 
designated  by  Buhl  "  lipoid  degeneration."  Tjiterature  contains  but  one  case 
of  this  change,  it  being  fully  described  by  Buhl.  In  this  case  the  muscular, 
adipose,  and  bony  structures  were  unchanged,  but  the  cavities  were  lined  with 
a  thick  caseous  matter,  which  in  microscopic  examination  showed  crystals  ol' 
margarin.  According  to  Buhl,  this  process  must  not  be  confounded  with  that 
of  "  saponification." 


I 


77//;  PA  mo:  )gy  of  pregnancy. 


313 


Saponifloation. — The  process  of  "  suponitication,"  describe<l  in  older  books, 
comes  probably  iiiider  the  head  of  niuniniification. 

Mummification. — Tliis  change  may  be  regarded  as  the  typical  post-mortem 
change  of  the  fetus  when  death  takes  place  between  the  third  and  the  sixth 
month.  The  fetus  is  shrivelletl,  the  tissues  are  dried,  the  skin  is  gray  and  shows 
the  outline  of  the  skeleton.  If  such  a  fetus  has  been  retained  for  a  long  period 
and  is  subjected  to  pressure,  it  sometimes  becomes  desiccated  and  flattened  like 
a  sheet ;  such  a  change  is  designated  by  the  term  Jdm  papp'aceua.  Twin 
pregnancy  is  most  likely  to  produce  such  a  change  when  one  embryo  dies  and 
the  other  continues  to  live  and  develop.  The  placenta  is  also  dehydrated,  and 
there  is  no  amniotic  fluid.  This  fluid  has  either  been  drained  off  or  has 
been  absorbed  by  the  chorion.  Mummification  is  more  likely  to  occur  in  cases 
where  the  cord  is  twisted  about  the  neck  of  the  fetus.  If  the  fetus  attains  the 
age  of  several  months  before  death  takes  plaa^,  it  is  likely  to  undergo  one  of 
the  two  changes,  putrefaction  or  suppuration.  Both  these  changes  are  due  to 
the  entrance  of  germs,  which  is  more  liable  to  occur  after  the  rupture  of  the 
membranes,  so  that  germs  are  admitted  from  without. 

Putrefaction. — The  process  of  putrefaction  differs  from  that  of  maceration. 
It  is  characterized  by  the  presence  of  a  foul  odor  and  by  the  production  of 
gas — sometimes  in  great  amount  (phy.sometra  or  tympanites  uteri). 

Suppuration  is  often  associated  with  putrefaction.  The  changes  which 
the  fetus  undergoes  in  ectopic  gestation  have  been  referral  to  under  that  head. 

Calcification. — A  dead  fetus  remaining  in  the  uterus  or  in  e.xtra-uterine 
cysts  for  a  longer  period  may  become  infiltrated  with  calcareous  matter  until 
it  resembles  a  stone.  Such  a  fetus  is  termed  a  lif/iopedion  (p.  283).  Cases 
are  on  record  where  the  fetus  has  been  retaine<l  in  this  state  for  many  years. 
Lusk  cites  a  case  in  which  the  woman  was  supposed  to  be  pregnant,  and  labor 
ceased  with  the  expulsion  of  a  child.  Thirteen  years  later  Lusk  removetl  a 
calcified  fetus. 


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,   ll'l     _J 

m 


ir 


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I   ; 
I   I 


314 


AMEIilVAN    TEXT- HOOK    OF    OltSTKTIirCS. 


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39.  Thomson :    Deiilnrhe   mecUcinische    Wochen- 

Kelirifl,   1SS9,   No.  44.  Cu. 

40.  I'olaillon  :  ArrhiivH  de  Tocologie  et  de  Gyne-     08. 

cologie,  xix.  p.  729. 

41.  Ruge :    CentralbUitt  f.    Gymikolnc/ie,    1890,  I  69. 

No.  30.  ...  I 

42.  Schroeder,    Olshausen,    and    Flaischlen :     70. 

Zeitxchnft   /.     Geburtshulfe,    1894,    Rd.     71. 
29. 

43.  Dsirne :  Archie  f.  Gyncikologie,  Rd.  42,  .S.     72. 

41."). 

44.  Manj^iagalli  ;    Berliner    klininche    Wochen-  i  73. 

xchrifi,   1894,   No.  21.  j 


.Vcconci  .  "I)ei  cistotne  ovnrici  in  rap- 
porto  allc  funxioni  Ki'"i''''itive,"  Milano, 

Tipiiyr.  Jierhiri,  181S9. 
Terrillon  :    Airhiren    de    Tneologie,    .\pril, 

18SH. 
Klirendorler:    Archie  /.    Gyniikolni/ir,   Rd. 

34,   Hit.  1. 
SiiUKer  :   ( 'enlrnlbliill  f.    (lyniikolni/ie,   1894, 

No.  7. 
Winter  :  Zeitxchri/t  /.  Gebiirtxhiil/e,  Rd.  14, 

Hit.  2. 
Kissman  :   Centralblnll  J.  (lynaki)logie,  1892, 

xxiv.  J).  452. 
Virginin    Mediiol    Monthly,    1888-89,    xv. 

(!7<). 
Martin  :     Dentxehe    medicinixche     Wochen- 

xchrifl,   1889,  No.  39. 
Trenh :    yeilerlondxch    tijdxvhrift    rimr    Ver- 

liixkiiiideen  Gynipcolngie,  Jalirfjf.  iii.  No.  3. 
(cottschalk:  Archie  J\  Gyniikulogie,  Rd.  40, 

Hft.  2. 
Rarl)our:  Edinburgh  Meuicid  Journal,  Kept., 

1894.  • 
Cohnstein  :  Archie  f.  Gynlikologie,    Rd.  33, 

Hft.  1. 
Renckiser:  CentridblattJ.  Gynlikologie,  1887, 

No.  51. 
Davis;    InlernationnI  (linicx,   1894,  vol.  3, 

S.  4,  p.  275. 
Trantenrotli  :  Zeitxchri/t  f.  Geburtxhiilfe  mid 

Gynlikologie,  1894,  15(1.  30,  lift.  1. 
Fischer  :   I'rager  inedirinixehe  Wochenxchrift, 

1892,  No.  17. 

Scluuita  :  Internationak  klinixche  Itnndxi'limi, 

189-\  No.  27. 
Meyer :  Zeitxchri/t  /.  Gebiirtxhid/e,  Rd.  Ill, 

lift.  2. 
Laiitos :    Archie  /,    Gyniikulogie,    I'l'..    32, 

Hft.   3. 
Herman  :   Lancet,  .Jan.  13,  1894. 
Roudin  :    Journal   de   Medecine   de    Paris, 

1893,  No.  22. 

Kol)liUick  :  Zeitxchri/t  /.  Gynlikologie,  1894, 
Rd.  29,  S.  208. 

Rerlieroft':    Vnich,  1893,  No.  10. 

A'oituriaz  :  Archieex  de  Tocolngie,  1890,  No. 
12. 

Randolph  :  Bulletin  Johnx  Ilopkiux  Jlns- 
pital,  1894,  vol.  v.  No.  41. 

I'^chroeder  :  Lehrlmeh  der  Geburtxhiilfe,  IS'.ll. 

Gow :  Edinburgh  Medical  Journal,  18.SS, 
part  ii. 

Storer  :  Boxton  Medical  and  Surgical  Jour- 
nal, 1892,  cxxvii.  pj).  377,  379. 

Jardrin  :  Glaxgoie  Medical  Journal,  1892, 
xxxvii.  417,  422. 


TITK   rATHOLOaV   OF   PREaXANrV 


.315 


71.  Sutii)fiii  :   ZfilMhriJI  J.    (ieburtMlfr,    xxiv.      103. 

|>.  *2M(I. 
75.    ISiulin  :   Pmirh  Midirtile,  1888,  Nos.  2,  .'<•      104. 
70.    Kiiliiiow  ;  Airhir  f.    (lyHahtlmjii',    15(1.   ;<•'), 

lift. ;«.  lor). 

77.  I)rivfr:    limttm  Mfrlintl  iiiiil  Siirfilrnl  Jintr- 

mil,  St'pt.  1"),  1887.  100. 

78.  DiilirsHi'ii :  Archil'  /.  (hjudkohijii;  Ikl.  43, 

lilt.  3.  107. 

79.  Budiii  :    Iai  Neimine  Mfilicnk,  1893,  No. 

.\ix.   p.  141.  108. 

80.  Cliiiriionticr:   ArckireA  ik  Tornhr,i,;   181)2,      lO'.l. 

No.  2. 

81.  Prutz:  Zeilwhri/lf.  Gehnrlshiilf,;  IM.  xxiii.      110. 

lilt.  1. 

82.  I'illiot  and  Delimsornu' :   liiilhlln  tie  In  So-  |  111. 

rit'le  Aimhmuiiiic  ili-  J'nri^,  1802,  No.  8.  '  112. 

83.  Fisi'liiT  ;  PriKjer  iin'ilieinixchf  Worlifnxrhrijt, 

1892,  No.  17.  113. 

84.  IMiuic;  Lnoii.1  Medicali;  18<)0,  No.  38. 

8"),   Piipillon  iiixl  Aiuinin  :    Hiilhiin   de  la  Sii-  114. 
riele  Aiidinmique  di'  I'lirlx,  1891,  vol.  vi.  I 

p.  303.  I  11. -J. 

80.   KofltT    and     Ktiiulrat  :      Wlfiiir    klinkche  \ 
Wiirh'UHvhnfl,    18111,    No.  xx. 

87.  (ierdcs:    Mihivhrner   inrdifiiii.irln'    Wiichen-  110. 

schri/l,   1892,   No.  xxii.  I 

88.  Tarnier    and    ('liaml)rc'lont  :     Aiimden    di- 

(lijiivciiliKjii',  Nov.,    1892.  117. 

89.  LauK :   Arrhiivn  dr  Tnrohf/ie,  1892,  No.  xi. 

90.  Herman:  ^lincricdii  Jiiiini<il  nf  the  Medical     118. 

Scicncfs,   Nov.,    189],   p.  48."). 

91.  Davis:    Aiin'rinin   Joiirmd  of  tin'    Mi'dical     119. 

Sciriic's,   Feb.,   1894,   p.  147. 

92.  (tustav  Hraun  :    Wiener  mediciiiiKchf  I'lrKxr,  '  120. 

1888,  No.  19. 

93.  Blanc:  AiiiKdex  de  Gi/iieeiil(i(jie,   1891,  vol.      121. 

30,  p.  1.').  ! 

94.  Blanc;   /.i/-»h.s  JAV/kk/c,.  1890,  No.  .38.  122. 
9.').    Van    Santvoord:    Medirid    Jlee„rd,    1891, 

vol.  40,   p.  197. 
9(1.   Thomson  :    Deiilni'he    iiiedieiiii.iehe    Woeheii-     123. 
xeliri/t,    1889,    No.  44. 

97.  Kocttnitz  :  Cenlridhlatt /.  (Iijnlikolnfjie,  1888,      124. 

No.  48,   p.  778. 

98.  Neidcn :     MotinlMnll    f.     Aiif/enheilkunde,     125. 

1891,   xxix.   ]).  3.")3.  120. 

99.  Fonrnicr ;    L(i    Jhillelius  Midiade,   vi.    p. 

1170.  ;  127. 

100.  Ilektoen:  Joiirmd  of  the  Ainerirnn  Mediad  ' 

AxMtcidtinii,    1892,    vol.   i.    No.   1,   pp.      128. 
0-12.  ' 

101.  Mc('al)c:   Trannactionn  New  York  Mcdiccd     129. 

Sncieti/,  1892,  p.  200.  i 

102.  Horroeks  :  Tmnmctions  London  ObMetrical  ^  130. 

Society,  1891,  xxxiii.  3,  p.  201.  ( 


Chnnihri'lent :     Animlen    de    (iijnirnlnfiif, 

IVI>.,    I8,S1I,    p.  IM). 
NapiiT  :  yorth  Carolina  Medical  Journal, 

March,  1888. 
Mackav  :    Lomlon   Lancet,   1891,   vol.   ii. 

p.  1.388. 
Braxton  ilicks:   Tranmctinn*  London  Ob' 

Hletrirnl  Sorietij,  1811],  xxxiii.  p.  48(), 
McCann:   Triiiinaetionn  Lomlon  Obnletrical 

Societji,  1891,  vol.  xxxiii.  pp.  413-48.'). 
( towers  :   IHxeaM's  of  the  Xernniit  Si/steni. 
Ilandlield -Jones :     TrannaetionK    London 

ObMetrical  Societij,  1889,  vol.  31,  p.  243. 
Bue  :    La   Prenne  Mi'dicale,  Sejjt.  1,  1894, 

p.   279. 
( lairdner  :  (llaMi/oir  Medical  Journal,  1870. 
I'antzer:   Cenlralblatt  f.  llyniikoloijie,  1890, 

No.  xxxii. 
Shoot :  yederlamlKcli,  tijdxchrifl  voor  Genees- 

kinide. 
SolowieiF:     Ccntralhlalt    f.     Gyniikologie, 

1892,   No.  xxvi. 
Matthews    Unncan :    Traumctionn    Obxtet' 

rical  Society,  1882,  vol.  xxiv.  pp.  250- 

285. 
( )ddi    and    Vicarelli :    Lo    Sperimeutale, 

Fitseicolo  No.  2,  1891,  Memoire  Origi- 

nali. 
Fry  :    J'ranKactioun  American  Gynecological 

Society,  1891,  vol.  xvi. 
Ilehir:    Indian   Medical   Gazette,    March, 

1892. 
Feinl)erg :      Centralblull  f.      G yniikolof/ie, 

1890,    No.   vii. 
Davis:      7V((/i.s(/W/o».s    American     Gyneco- 

logical  Society,    1S1I4,   vol.  19,    p.  110. 
Lindcnmann  :    ( 'entralblutt  f.    I'athologie, 

1892,    No.  XV. 
Copeman  :   "A  Novel  Treatment  of  Obsti- 
nate Vomiting  in  l'ref;nancy,"  liritiKh 

Medical  tlourual,   May  15,    1875. 
(irant:   Montrrid  Medicid  Journal,    1891, 

vol.   xix. 
Koland  :    Xourellex  Archiren  d'ObKlitrique 

el  lie  (lynceoloijie,    1893,   No.  vi. 
Blanc:   Archirexde  Tocoloi/ie,  No.  vi.  193. 
Kinjrman  :    lio.slon   Medical  and  Surgical 

Journal,  vol.  77,   p.  427. 
.Mdt'eld  :   Cenlralblatt  f  Gyniikologic,  1891, 

No.  17. 
(innther:  Cenlralblatt  f.  Gyniikologic,  1888, 

No.  29. 
Siinger  and   Ilennina;:    Miinrhencr  medi- 

cinisehe    Worlien^chrift,    1888,   No.  28. 
Florentine:  American  Gynecological  Jour- 
nal, 1892,  vol.  ii.  p.  149. 


J 


316 


AMERICAN   TEXT- BO  OK   OF   OBSTETRICS. 


,    ! 


I     r 


131.  Clay:  Chim<jo Medical Siandard,  1801,  p. 29. 

132.  Johnston  :  Virriinin  Mvdiad  Monthh/,lSiii\ 

vol.  XV.  J).  140.  See  also  Lomer,  "  Ueber 
die  Bedeutung  des  Icterus  (.Jravidarurn 
fiir  Mutter  und  Kind,"  Zeitschrijt  /. 
Gehurtslnilfe,  Kd.  xiii.  lift.  1,  8.  ICi). 

133.  Matthews  Duncan  :    Lccturen  on  Diseases 

of  Women,  3d  edition,  p.  2i)5. 

134.  Winter :  Transactions    Washington  Obstet- 

riml  Society,  1889-90,  vol.  iii.  p.  1. 

135.  Robert  Koch :    .SV.    Peterxburgcr  medicirir 

ischc   Wochcmchrift,  1893,  No.  x. 

136.  Mixter :    Boston    Medical    and   Surgical 

Journal,  1891,  No.  27. 

137.  Lantos :   Archiv  f.   Gyndkologic,   Bd.  32, 

Hft.  3. 

138.  Thomson  :  Deutsche  medicinische  Wochen- 

schrift,  1889,  No.  44. 

139.  Koettnitz :  Deutsche  medicinische  Wochen- 

schrift,  1889,  No.  44. 

140.  Elliott :     Birmingham     Medical    Review, 

1892,  vol.  32,  p.  1. 

141.  Haberlin :     Centralblatl    f.     Gyndkologic, 

1890,  No.  26. 
1 12.   Dudner  :  Miinchcncr  medicinische  Woclien- 
schrift,  1890,  Nos.  31  and  32. 

143.  Narse :    Deutsche  Archiv  f.    Gyndkologic, 

X.  315. 

144.  Winckelinann :    Inaug.   Dissert.,  Heidel- 

berg, 1888. 

145.  Schroeder :  Archiv  f.   Gyniikologie,   1890, 

Bd.  39,  Hft.  2. 

146.  Meyer :  Archiv  f.  Gyndkologic,  1887,   Bd. 

31,  lift.  1. 

147.  Ingersled':     Ccntralblatt    f.     Gyndkologic, 

1879,  No.  26. 

148.  Fehling  :  Verhandlungcndcr  DcntschcnGe- 

sellschaft,  18S(i,  I.  sitzung. 

149.  Meyer  :  lor.  cit. 

150.  (iiisserow:    Archiv  f.    Gyndkologic,    1871, 

ii.  218. 

151.  BischoH'and  Bieriner  :  Corrcspondenz-blatt 

fiir  Srhweizcr  Arrztc,  1872. 

152.  t'anienm  :  American  Journal  nf  the  Med- 

ical Sciences,  .Jan.,   1888;  Nov.,  1890. 

153.  Siinger :    Archie  f.    Gyndkologic,    Bd.   33, 

Hft.  2. 

154.  Davis:     IVanmetions    American    Gyneco- 

logical Society,   1891,   vol.  16. 

155.  Lautienherg  :   Arrhirf.  (r'y;i(7W()(/(V',  1891, 

Bd.  12,  lift.  3. 

156.  PliilliiiHi    Tran.taclions  London  ()bstetric(d 

Society,    1891,   vol.  ;):i,   p.  390. 

157.  Kaezniarsky  :   Klin.  Mitt,  aus  der  f,  (le- 

burtshillfe  Klin.,  Budapesth,  1884,  S. 
178. 


158.  Dohrn:  Archiv  f.  Gyndkologic,  1874,  Bd. 

6,  p.  486. 

159.  Osier  :  Boston  Medical  and  Surgical  Jour- 

md,  Nov.  8,  1888. 

160.  Istria  :  "  l)e  la  grossesse  considdrde  eoninie 

cause  de  I'endocardite  chroniciue," 
T/iftsc,  Paris,   1876. 

161.  Marshall :   "  Du  retrdcis,sement  mitral,  sa 

frequence  plus  grande  chez  la  femnie 
que  chez  I'liomme,  I.,"  Tlilse,  Paris, 
1879. 

162.  Macknesa :    Edinburgh  Medical  Journal, 

1890,  p.  123. 

163.  Merklen :    La   Semaine   Medicale,    1892, 

vol.  12,  p.  274. 

164.  Martin  :  Medical  Press  and  CirctUar,  1886, 

vol.  ii.  p.  328. 

165.  Robertson :  London  Lancet,  1891,  p.  487. 

166.  Schauta :    Internationale    klinische    liund- 

sehan,   1892,  vol.  6. 

167.  Hirigoyen :    Memoires  el   Bulletins  de  la 

Societe  de  Medecine  el  de  Chirurgie  dc 
Bordeaux,   1886,   15,  p.  335. 

168.  Besnier  :  Journal  de  Medecine,  Nov.,  1890. 

169.  Findlay  :  Obstetrical  Gazette,  1889,  vol.  12. 

170.  Giglio:    CentndblaU  f  Gyndkologic,  1890, 

No.  46. 

171.  Boyd  :  Annals  of  Gynecology  and  Pirdiat- 

ric",  1891,  vol.  V. 

172.  Smith :    Transactions    Washington    Obstet- 

rical Society,   1889-90,  vol.  ii. 

173.  Cohn :    Ccntralblatt  f.   Gyndkologic,   1888, 

No.  48. 

174.  Lomer :   Ccntralblatt  f.  Gyndkologic,  1889, 

No.  48. 

175.  Gautier :    Annales  de    Gynecologic,    187!>, 

p.  321. 

176.  BallaiityneandMilligan  :  Edinburgh  Med- 

ical Journal,  July,  1893. 

177.  Meyer  :  Zeitschrift  f  Gelmrtshiilfc.  M.  14, 

lift.  2. 

178.  Remy:   Archives  de  Torologic,  18^4,  No.  (!. 

179.  Mann;   London  Lancet,  1891,  p.  610. 

180.  Wallich  :    Annales  de  Gynecologic,  June, 

1889,   p.  439. 

181.  Klaiitsch  :   Miiuchener  medicini.ichc   Worh- 

ensehrift,   1892,   No.  48. 

182.  \  iiiay  :   Archives  de  Toeologic,  1893,  No.  3, 

183.  ^larkus :      Prayer    medicinische     Wochch- 

schrift,   1890,   No.  xxi. 

184.  Dakin  :     Transactions    Jjondon    Obstetrical 

Society,   vol.  33,   p.  163. 
18.5.   Stocker:   Centralblatf  f  Gyndkologic,  \S\t2. 

No.  .32. 
186.    Flaischlen :     Ccntralblatt   f.    Gyndkologic, 

1892,  No.  10. 


THE  PATHOLOGY   OF   PliEGXANCV. 


317 


187.  Dsirno :    Archiv  f.   Gyniihtlmjie,    lid.   4;5,     200. 

lift.  3. 

188.  Polaillon :      IhiUelin    dc    I'Academie    ile     201. 

Mdecine,  Paris,   1892,  vol.  28,  p.  14(). 
ISit.   Kreutznuiii :    Occidental    Medical    TiniCK,     202. 
Aug.,   1892.  203. 

190.  Doran :     Transacliom   London    Obstetrical 

Society,   1891,  vol.  33,  p.  112.  204. 

191.  Tiffany  :    Transact iom  American  Surgical 

Associntion,  1888,  vol.  C.  205. 

192.  Beliii:  JMletin  MMical  du  Nord,  1878, 

vol.  17. 

193.  Richard:  BiUletin  Medical  du  Nord,  1878,     20(). 

vol.  17.  207 

194.  Harris :    American  Journal  of   Obstetrics, 

vol.  20,  j).  t!73.  208. 

195.  (,'orcy  :  American  Practitioner,  ^i\\)t.,  1S78. 

19().   Rydygier:  Proceedinys    Congrens    Go-vian     209. 
Suryeon-s,   1887,  No.  12.  210. 

197.  Petit:   Thesis,  1876. 

198.  Keelan:    lirilish  Medical  Journal,   1887,     211. 

p.  825.  I 

199.  Prozowsky  :   Vrach,  St.  Petersburg,  1879,     212. 

No.  6.  I 


IJancroft :  Medical  and  Surgical  Reporter, 

187t),  vol.  34. 
Lihotzky :     Centrnlblatt    /.     Gyniikologie, 

1892,  No.  xxiv.  489. 
Milner :  Medical  Xews,  Ixi.  24.3,  244. 
Neugebauer  :    Centralblatt  f.    Gyniikologie, 

1890,  p.  88. 
Fancoii :    Journal  rftvf  Sciences  Medicates 

de  Lille,   1883,  p.  241. 
Tift'auy :   Transactions  Medical  and   Chi- 

rurgical   Faculty   of  Maryland,    April, 

1884.  . 

Tiffany  :  Medical  News,  Ajiril  l(i,  1887. 
Hint:  American  Journal  of  the  Medical 

Sciences,   vol.  81,  p.  18(>. 
Pilclier :      Provincial     Medical     Society, 

King's  Co.,  1879,  vol.  3. 
Keen  :  Medical  News,  March  2(),  1892. 
Rasch  :  Zeitschrift  f.  Geburtshiilfe  u.  Gynii- 

kologie,  \k\.  25,  Hft.  2. 
Vickory :    Boston    Medical    and    Surgical 

Journal,   1890,  p.  413. 
(jerilcs  :  Centralblatt  f.  Gyniikologie,  1890, 

No.  45. 


w    \- 


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Ill 


.    I 

i  I 


II  m 


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1 

l^ww 

1 

1 

1'     ^! 

■        ■  If 

III.  LABOR. 


V 


\i% 


I.  THE  PHYSIOLOGY  OF  LABOK  * 

Definitions. — Labor  is  the  complex  process  by  which  the  ovum  is  severed 
from  its  connection  witli  the  motlier  and  extruded  or  extracted  from  the  ma- 
'  ternal  oriranisifi.  The  term  normal  hibor  (eutocia)  may  be  restricted  to  labors 
with  normal  factors  that  are  terminated  by  the  natural  forces,  or  it  may  be 
narrowed  down  to  include  only  vertex  presentations  in  anterior  positions  under 
right  conditions.  Di/Kfocia,  or  ditticult  labor,  includes  all  forms  of  abnormal 
or  complicated  deliveries  near  term.  Premature  labor  refers  to  the  premature 
birth  of  a  fetus  which  has  reached  the  period  of  viability  or  of  sufficient  de- 
velopment to  live  independently  of  the  mother.  Mm-arr'uKjc,  or  inunature 
delivery,  is  usually  restricted  to  the  expulsion  of  the  fetus  from  the  third 
month  until  viability,  although  it  is  often  used  as  a  synonym  of  abortion,  and 
is  the  lay  term  for  that  event,  "abortion  "  to  the  layman  denoting  criminal 
intent.  The  word  abortion  is  reserved  for  the  expulsion  of  the  ovum  in  the 
first  three  months. 

Causes  of  Onset  of  Labor. — What  constitutes  maturity  or  ripeness  we  do 
not  know,  and  in  the  indetiniteness  of  our  knowledge  "  we  refer  the  matter  to 
a  law  of  the  organism — a  law  the  cause  of  which  we  do  not  know." 

The  termination  of  j)regnancy  is  due  to  some  combination  of  conditions,  no 
one  of  which,  singly,  will  account  for  the  occurrence  of  labor  at  two  hundred 
and  eighty  days  after  the  date  of  appearance  of  the  last  menstrual  period. 
Briefly  stated,  the  chief  fiictors  are — 

1.  Increasing  irritability,  witli  strengthening  intermittent  contractions. 

2.  Changes  in  the  decidua — loosening,  thinning,  and  thrombosis. 

3.  Excess  of  COo  and  lessened  oxygen  in  the  placental  blood  acting  on  the 
motor  centre  for  the  uterus  in  the  medulla. 

4.  Increasing  tension  on  fully-developed  muscular  walls. 

0.  Stronger  fetal  movements  in  more  confined  space. 
G.   Partial  relaxation  of  the  cervix. 

7.  Menstrual  periodicity  (tenth  period). 

8.  Habit  and  heredity. 

9.  Exciting  cause — exercise,  sM'<in,  emotion. 

1.  A  steadily  increasing  irritability  is  probably  the  rule  during  gestation. 
At  certain  menstrual  epochs.  >^uch  as  the  second,  third,  and  seventh,  it  is  espe- 
cially marked,  and  there  is  evident  disturbance  both  of  the  neighboring  nerves 
and  of  uterine  ganglia  in  the  first  and  last  trimesters. 

InteraiitteuL  contractions  occur  regularly  in  the   non-gravid  uterus,  they 

*  The  ifiiprrior  fifiiires  ( ' )  occurring  tlirougliout  the  text  of  this  section  refer  to  the  bibliog- 
riipliy  givt'ii  nil  ]i;ige  ;i40. 
.318 


tht 


THE  PHYSTOLOGY   OF  LABOR. 


319 


arc  distinct  from  the  very  boginniiig  of  pregnancy,  tliey  stcatlil)'  gain  in 
strength  daring  its  progress,  and  at  its  end  hardening  and  prominence  during 
contractions  may  always  be  found.  The  dividing-line  between  contractions 
and  true  labor-pains  is  not  easily  drawn,  and  as  soon  as  the  ovum  becomes  a 
ibreigu  body  by  beginning  separation  more  vigorous  action  is  ensured. 

2.  The  changes  in  the  decidua  arc  well  epitomized  by  Lusk:'  "The  re- 
searches of  Friedliinder,  Kundrat,  Engelmann,  and  Ijcopold  have  demon- 
strated that  the  decidua  vera  of  pregnancy  is  distiuguisiiable  into  an  outer 
dense,  membranous  stratum,  comj)oscd  of  large  cells  resembling  pavement  epi- 
thelia,  probably  mctainorphos(!d  cylindrical  cells,  and  an — in  appearance — 
underlying  mesliwork,  ibrmed  from  the  walls  of  the  enlarged  decidual  glands. 
It  is  in  this  spongy  layer  that  the  separation  of  the  decidua  takes  place,  the 
fundi  of  the  glands  persisting  even  after  the  expulsion  of  the  ovum.  By  many 
a  fatty  degeneration  of  the  cells  of  the  decidua  has  been  observed  toward  the 
end  of  pregnancy,  but  Leopold,  Dohrn,  and  Ijanghans  have  shown  that  this  is 
not  of  constant  oceuirrencc.  The  traljcjcuke  w'hich  enclose  the  spaces  of  the 
network  diminish  in  size  with  the  advance  of  pregnancy.  Thus,  while  they 
measure  at  the  fourth  month  about  j,^  of  an  inch  in  thickness,  they  become 
gradually  reduced  in  the  subsetpient  months  to  -^-^  of  an  inch — a  change 
which  materially  facilitates  the  peeling  off  of  the  decidual  surface. 

"From  the  fourth  month  onward  large-sized  cells  make  their  appearance 
in  the  serotina,  especially  in  the  neighborhood  of  thin-walled  vessels.  The 
largest  of  the  so-called  giant-cells  contain  sometimes  as  many  as  forty  nuclei. 
Though  a  physiological  product,  they  resemble  for  the  most  part  the  so-called 
specific  cancer-cells  of  the  older  writers.  They  are  of  special  obstetrical  inter- 
est from  the  fact,  observed  by  Friedliinder  and  confirmed  by  Leopold,"  that 
they  penetrate  the  uterine  sinuses  from  the  eighth  month,  and  lead  to  coagula- 
tion of  the  blood  ami  to  the  formation  of  young  connective  tissue,  by  means 
o!"  which  a  portion  of  the  venous  sinuses  becomes  obliterated  before  labor 
besrins.  The  subtraction  of  these  vessels  from  the  circulation  tends  to  increase 
the  amount  of  the  venous  blood  in  the  intervillous  spaces  of  the  placenta." 

;3.  Brown-Se(piard  found  by  experiment  that  an  excess  of  COg  circulating 
in  the  blootl  of  a  gravid  aninutl  excited  uterine  contractions,  ami  he  claimed 
that  this  excess  of  the  gas  was  the  pi-oximate  cause  of  labor.  His  theory  lacks 
conclusiveness,  however,  because  it  does  not  explain  why  the  COj  postpones  its 
irritant  action  until  the  end  of  the  ninth  month.  Lcopohl  believes  that  the 
excess  of  Qi).,  in  the  placental  blood  is  the  result  of  venous  hyperemia  of  the 
placenta,  produced  by  the  spontaneous  thrombosis  in  the  veins  of  the  placental 
site  at  the  end  of  pregnancy,  while  Flassc  credits  it  to  certain  changes  in  the 
circulation  of  the  fetus — chiefly  in  the  crossing  blood-currents  of  the  right 
auricle  and  shrinkage  of  the  ducius  venosus  and  arteriosus.  Spiegclbcrg 
tcaciics  that  at  maturity  the  fetus  rc(pii:'"s  some  new  sub.-tance  not  supi)lied 
by  the  ]»lacenta,  and  that  it  dies  (as  in  extra-uterine  ])regnancy)  if  it  does  not 
obtain  it.  wliile  chemical  substances  no  longer  required  accumulate  in  the 
l)lood  and  act  as  irritants  to  the  spei'ial   nervous  centres. 


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AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


4.  Power  iu  1819  called  especial  attention  to  over-distention  of  the  uterus 
as  a  causative  factor  iu  labor ;  it  can  admirably  be  demonstrated  by  analogy. 
As  the  over-loaded  stomach  or  the  rectum  rejects  its  burden,  so  the  over-dis- 
tended uterus  rebels  and  expels  its  contents  by  the  contractions  of  labor  when 
the  mouth  of  the  organ  begins  to  be  distended.  The  occurrence  of  ])rematuro 
labor  iu  hydraninion  aud  multiple  pregnancy  sustains  this  theory,  but,  on  the 
other  hand,  it  does  not  account  for  labor-pains  in  extra-uterine  pregnancy. 
The  extensibility  of  the  uterine  wall  has  a  limit,  and  when  this  is  reached  the 
ovum. in  its  growth  presses  more  and  more  upon  the  iuternal  os.  This  })ressure 
excites  a  special  set  of  nerves  and  brings  about  uterine  contractions,  just  as  the 
contact  of  the  drop  of  urine  at  the  neck  of  the  distended  urinary  bladder  ex- 
cites contraction  snd  evacuation  of  that  organ. 

A  theory  of  this  nature  brings  up  the  question  of  the  innervation  of  the 
uterus.  Through  what  set  or  sets  of  nerves  does  the  uterus  receive  its  motor 
impulses  during  labor?  The  nerve-supj)ly  is  largely  from  the  hypogastric  and 
ovarian  plexuses  of  the  sympathetic  system.  The  cervical  ganglion  receive:-!, 
in  addition  to  its  extensive  connections  with  the  lympathetic,  filaments  from  the 
second,  third,  and  fourth  sacral  nerves.  Rut  Lusk  and  Jacquemart  report 
cases  of  successful  labor  in  patients  sutf'ering  with  paralysis  of  the  lower  ex- 
tremities, retention  of  urine,  and  incontinence  of  feces — a  state  of  affairs  which 
would  lead  one  to  discount  the  imjjortance  of  the  rdle  ])layed  by  the  filaments 
from  the  sacral  nerves.  On  the  other  hand,  the  experiments  of  Schlesinger'^ 
argue  against  the  exclusive  source  of  motor-supply  resting  with  the  symi)a- 
thetic,  for  he  was  able  to  elicit  reflex  movements  of  the  uterus  by  stimulation 
after  severiiiLT  all  the  branches  of  the  aortic  plexus.  Whether  he  may  not 
have  overlooked  some  of  the  slender  nerve-filaments  in  cutting  the  branches 
of  the  aortic  plexus  is  a  question  worthy  of  consideration,  and  the  possibility 
of  such  an  error  detracts  from  the  value  of  his  experiments  and  the  weight  of 
the  conclusions  to  be  drawn  from  them.  The  uterine  ganglia  have  a  certain 
independence  of  action,  such  as  the  cardiac  ganglia  possess,  since  rhythmic  con- 
tractions by  both  may  be  kept  up  after  separation.^  Brandt  has  shown  that 
massage  of  no  part  of  the  pelvic  contents  will  prodMc<  contraction  in  the  non- 
gravid  uterus  so  rapidly  as  manipulation  of  the  (supravaginal)  cervix,  and  the 
writer  has  demou«+rated  this  for  the  early  weeks  of  pregnancy.'^ 

Whatever  the  chainiels  of  nerve-force  may  be,  there  has  been  ])roved  to  ex- 
ist in  the  medulla  oblongata  a  motor  centre  for  contraction  of  the  uterus  that 
may  be  excited  to  action  by  COj  in  the  blood,  by  anemia,  and  perhaps  by  tlic 
toxic  substances  retained  in  the  blood  of  one  suffering  from  nephritis.  At  full 
term  something  stimulates  this  centre  to  acdvity,  with  a  complex,  co-ordinated 
.set  of  muscular  contractions  as  the  resultant.  Moreover,  it  is  supjwsed  l)v 
Schat/ (hat  the  uterus  possesses  an  inhibitory  centre  which  is  active  throughmit 
j)regnancy,  but  wliicli  for  some  reason  ceases  to  ad  at  term. 

G.  A  diminished  resistnnce  in  (lie  lower  birth-canal  is  to  be  noted.  The 
cervix  is  fully  softened,  the  pelvic  floor  is  edematous  and  relaxed,  and  (he 
uterus  and  its  contents  often  sink  low  in  the  pelvis. 


THE   PHYSIOLOGY   OF  LABOR. 


321 


7  Tlift  tlioory  udvuiioed  hy  Tylur  Smith  to  the  olfwt  that  the  tenth  period 
of  ovarian  excitement  incites  the  nervous  ap|)aratus  of  the  uterus  to  activity  is 
of  some  force,  since  prej^naney  is  often  interrupted  at  menstrual  epochs ;  but 
it  is  open  to  the  same  objection  as  that  just  mentioned,  for  it  does  not  make 
phiin  wily  the  nintli  or  eleventh  j)eriod  iliils  to  effect  the  same  result.  ^lore- 
over,  single  ovariotomy  has  been  jx-rformed  many  times,  and  double  ovariotoiny 
a  few  times,  during  pregnancy,  without  perceptibly  influisncing  its  course. 

8.  Many  multiparie  tbllow  the  same  rule  in  a  series  of  pregnancies.  Tu 
other  cases  great  variations  are  seen. 

9.  Filially,  with  all  things  ready,  an  unimportant,  i)erliaps  accidental, 
occurrence,  such  as  slight  increase  in  intra-abdominal  [>ressure  from  walking, 
stair-climbing,  coughing,  or  straining  at  stool,  as  well  as  any  mental  irritation 
(anxiety,  care,  anger),  may  be  the  exciting  cause. 

We  iiuve  been  dealing,  then,  with  deteriiiining  causes,  factors  in  a  phe- 
nomenon, noiK^  of  which  can  establish  a  claim  to  be  considered  singly  and 
absolutely  causative.  Wiiickel  sums  up  by  saying  that  labor  is  the  total  of 
several  causes  which  may  enter  into  different  combinations  to  accomplish  the 
same  result.  liusk  takes  substantially  the  same  ground,  and  Barnes  observes 
that  the  determining  causes  act  synergetieally,  not  singly. 

The  fetus  is  mature,  ready  to  undertake  the  complex  acts  of  respiration  and 
digestion  ;  the  imperceptible  uterine  contractions  of  several  weeks  have  loos- 
ened the  attachments  of  the  decidua,  whose  trabecuhe  have  grown  much  thin- 
ner and  capable  of  easy  rupture  ;  the  uterus  by  distention,  pcrhaj)s  by  increas- 
ing pressure  of  the  fetus  oi>  the  internal  os,  has  grown  very  irritable,  the  lusty 
inmate  augmenting  this  condition  by  the  force  and  frequency  of  its  movements. 
The  maternal  blood  contains  an  increased  (juantity  of  C"()^;  venous  thromboses 
in  the  uterine  wall  near  the  serotina  and  in  the  si'rotina  itself  obstruct  the  cir- 
culation and  cause  stasis  of  the  maternal  l)lo(,(l  reMirning  from  the  ])Iacenta ; 
the  cervix  uteri  becomes  soft  and  dilatable  ;  the  advent  oi"  the  tenth  menstrual 
(late,  with  increased  congestion  and  irritability  of  all  the  generative  organs  as 
a  conse(iuence,  adds  fuel  to  the  pile  ;  the  unknown  factor  deposits  the  spark  at 
the  centre  of  uterine  contraction  in  the  me(lulla,  and  lal)or  has  be  juii. 

The  Phenomena  of  Normal  Labor. 

The  ])hysiology  of  the  processes  concerned  in  the  expulsion  of  the  fetus 
includes  a  stutly  of  the  action  of  the  uterine  walls,  the  uterine  ligaments, 
the  abdominal  muscles,  and  the  vagina;  the  changes  induced  by  labor  in  the 
cervix,  in  th(>  lower  uterine  -(•gment,  and  in  thf  IxmIv  of  the  uterus;  the 
viuiations  in  the  |)resenting  pouch  of  membranes;  and  the  character  of  the 
li(jiior  anuiii,  the  formation  of  the  caput  succcdanenin.  and  the  ciianges  in  the 
|H'lvi(^  floor.  Then  the  t-linical  character  of  the  three  stages  of  labor  will  i)e 
ciinsidered,  leaving  i[iic>tions  of  mechanism  and  management  for  later  sections. 

Uterine  Contractions. — The  uterine  ciintriictions  of  labor  go  by  the  name 
III' "pains"  in  all  language-^,  including  tiie  speech  of  the  scienti.st,  because 
111'  the  sulfering  iiiscjiarably  associated  with  tiicin.     The  <'nnxr  of  this  sulf'criiif/ 

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is  the  coinprcssiuii  of"  the  uterine  nerves  hetween  the  contracting  nuiscular 
fibres,  the  tension  of  tiie  external  os  and  lower  uterine  segnjcnt,  the  stretching 
of"  the  nterino  ligaments,  and  the  pressure  of"  the  advancing  fetus  on  the  nerves 
of  the  vagina,  the  vulva,  and  the  neighboring  structures.  ^Moreover,  hyper- 
emia of  the  lower  end  of  the  cord  and  its  envelopes  is  jirobably  in  part  respon- 
sible for  the  distress. 

The  looaVion  of  the  ^)nm  is,  at  first,  in  the  hunbo-sacral  region,  and  later 
in  the  abdomen  or  down  the  thighs.  The  most  severe  degree  of  ])ain  is  felt 
at  the  vulva  as  the  head  passes.  The  onset  of  the  contraction  is  more  ra])i(l 
than  the  decline.  The  pain  begins  suddenly  a  few  seconds  after  the  beginning 
of  the  contraction — as  may  be  seen  by  the  bulging  foi'ward  of  the  fundus  or 
be  felt  by  the  examining  hand — reaches  and  retains  f"or  a  f((w  seconds  its  acme 
of  intensity,  and  then  gradually  subsides.  If  each  pain  l)e  divitled  into 
])eriods  of  increase,  acme,  and  decrease,  the  acme  will  occu])y  the  greatest 
length  of  time  of  the  three  divisions,  the  total  duration  of  a  pain  being  about 
one  minute.  The  suffering  is  commoidy  more  severe  in  very  young  or  in 
elderly  priniiparje  than  in  those  in  the  prime  of  ]>liysical  life.  Susceptibilitv 
to  pain,  and  general  vigor,  have  nnich  to  do  with  the  anunuit  of  anguish 
experienced,  it  being  among  serene  women  and  dull-witted  and  sturdy-limbed 
hospital  patients  that  we  oftenest  see  quiet  labors.  Painless  deliveries  have 
been  reported,  but  they  are  rare. 

The  muscular  fibre  of  the  uterus  is  non-striated,  and  the  contractions,  as  in 
all  organs  of  like  histological  stri'.cture,  are  pcrif<f>i/(i(\  invninntavy,  and  intrr- 
mitfcnt.  Contractions  sweep  over  the  uterus  in  a  peristaltic  Avave,  probably 
travelling  from  the  opening  of  the  Fallopian  tubes  down  to  the  cervix,  reaching 
a  swift  acme,  and  subsiding  within  twenty  or  thirty  seconds.  Waves  in  both 
directions  have  been  observed  in  the  uteri  of  .some  of  the  lower  animals. 
Though  mainly  controlled  by  the  sym])athetic  system  of  nerves,  and  hence  inde- 
])endent  of  the  will,  the  pains  are  nevertheless  influenced  to  some  extent  by  the 
brain — a  fact  demonstrated  by  the  ef!"ect  of  fright  or  of  excitement  in  retarding 
or  even  in  stopping  labor.  The  pains  last  from  thirty  to  ninety  seconds,  and 
the  peristaltic  action  from  twenty  to  thirty  seconds  ;  the  interval  is  about  thirty 
minutes  at  first,  whereas  at  the  end  of  labor  it  is  but  two  t(j  three  mimites,  and 
nearly  disappears  as  the  head  emerges.  Symmetrical  pains  often  occur  in 
groups,  f"ollowed  by  shorter  or  almost  abortive  pains.  As  to  tho  force  exerted. 
the  pressure  during  the  height  of  a  pain  never  exceeds  100  millimeters  (4 
inches)  of  mercury,  the  average  being  60  millimeters  ('JJ|  inches  ;  Schat/), 
TiCaman  measured  the  force  with  which  the  head  atlvanced  (r^ot  the  force  with 
Mhich  it  was  proju'lled),  and  found  a  high  pressure  to  be  five  jiounds.  Forcep- 
was  required  where  it  did  not  exceed  two  and  a  lialf  pounds.''  The  force  of 
the  pain  remains  about  th.e  same  during  the  entire  labor,  or  it  may  increase  by 
a  fourth,  and  this  with  no  regard  to  weariness  on  the  part  of  the  patient.  Tin 
force  does  not  increase  with  the  resistance  offered,  but  the  ]>ains  sinqdy  beconi" 
niore  frequent  and  last  longer.  The  type  of  the  pains  is  nearly  constant  in  \\\v 
same  patient  (Schatz). 


anc 


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THE   PHYSIOLOGY   OF  LABOR. 


323 


Fui.  ICC).— Pulpntion  of  the  cervix  before  la- 
bor. The  two  rintrs  ure  shown,  with  tlie  tinner-ti)) 
toueliiiif;  wlmt  iiiay  lie  called  clinieally  the  "  iii- 
ternnl  os  "  (one-lialf  natural  size). 


The  amount  of  force  exerted  by  the  pains  \s  sui)p().>^o(l  to  riiii<re  between  soven- 
teeii  and  eiglity  pounds.  Our  methods  of  niearfurinjr,  however,  are  defective. 
Duncan  and  I'oppel,  who  studied  the 
force  rccpiired  to  rupture  the  mem- 
branes, found  that  in  ea.sy  cases  it  was 
hardly  more  than  tlie  weiolit  of  the 
chiM,  and  only  in  severe  cases  did  it 
rise  to  fifty  pounds.  Sehatz"  passed  a 
rubber  bag  into  the  uterus  during-  labor 
and  connected  it  with  a  gauge,  rcgi>;ter- 
iiig  tifty-Hve  pounds  as  the  maxinnun. 
An  ob.stctrician  knows  that  all  the  nni,<- 
cidar  ])ower  he  possesses  is  sometimes 
insufficient  to  prevent  rapid  expulsion 
of  the  head. 

The  changes  in  shape  in  the  uterus 
during  contraction  are  markei].  In  the 
quiescent  state  it  re.sts  against  the  spinal 
column,  ovo'd  in  shape,  the  transverse 
exceeding  the  antero-posterior  diameter. 
During  contraction  these  diameters  be- 
come about  e(pial,  the  titerus  assumes  an  ovoid  or  somewhat  cylindrical  form, 
and  by  means  of  this  increase  of  «^he  antero-posterior  diameter  and  the  con- 

ti'actile  action  of  the  broad  anil  round 
ligaments  the  fundus  is  forced  forward 
ay-ainst  tlie  abdominal  wall.  At  the 
same  time  the  uterus  becomes  longer  at 
the  expense  of  the  lower  uterine  seg- 
ment and  the  cervix  (Fig.  23(5,  p.  42")). 
Action  of  the  Ligaments. — The 
uterine  ligaments — the  round  ligaments, 
the  lower  part  of  the  broad  ligaments, 
and  the  utero-sacral  bands  —  contain 
much  muscular  tissue  which  is  directly 
continuous  with  that  of  the  uterine 
wall.  Contraction  of  this  muscular 
ti.ssne  occurs  with  each  pain,  and  serves 
to  fix  or  to  .steady  the  uterus  in  position 
at  the  brim,  and  to  a.ssist  in  lifting  and 
liolding  it  at  an  angle  favorable  for  exi)ulsion  of  the  fetus  (Fig.  211,  p.  38S). 

Action  of  the  Abdominal  Muscles. — Next  to  the  uterine  contractions 
the  force  of  the  abdominal  muscles  is  the  important  expulsive  agent.  We 
include  all  those  nuLscles  that  fix  the  thorax  and  pelvis  or  narrow  the  abdom- 
inal cavity.  The  resultant  of  the  forces  ofthe.se  muscles  lies  parallel  with  the 
axis  of  the  superior  strait   (Winckel ;  see  Fig.   211,   p.  38S).     The  action 


BiX'>"">'.^'  i/iiattition 
of  intiriiiil  OS, 


Flirt Iwr  liilatation 
of  iutt'yniil  os. 


Conif*lcte  fj^tiLCtitt'nt 
of  inti'riuil  os,  iK'ith 
sharp  t'xtt-rnal  os. 


£-o 


Fifi.  1(')7.— Diagram  showing;  the  sensation  to 
the  exaniininn  linger  of  wiileninj.'  and  elliiee- 
iiii'nt  of  the  internal  os  dnriiin  dilatation  of  the 
iervi.\,  and  the  knife-like  eil^e  of  the  external 
OS  (one-liulf  natural  size). 


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AMERICAN   TEXT-BOOK   OF    OJiSTETRIVS. 


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on  tlic  part  of  the  woman  is  V(jluntarv  at  first,  bnt  bocKMios  loss  so  as  labor 
advance's,  as  sliown  by  her  inability  to  withlioUl  strong  prcssnro  at  the  time 

when  tlie  pelvic  floor  is  endangered. 


.i/,-(///' 


y.  n,\iili<,t. 
'^      ' J^',Lf>;vrr  uterine 
se/;ment. 


'ostmor 
vaciutil  'vail. 


Fid.  If*.— Secliuii  ul'  iiTvix  at  torin  (Wiil- 
deyer).  Tlii'  iiTfuuliir  hlutU'il  lilack  marks  with- 
in till'  ciTvical  canal,  riiiiiiiii!,'  to  tlii'iiii'inliraiies, 
(li'iKito  iiiiiciiiis  iiiciMliraiu'  nf  cervix  ;  llio  dc- 
ciiliia  runs  in  a  wavy  line  bcnc.Uli  tlic  nieni- 
branes. 


Such  assistance  to  the  uterus  is  not 
absolutely  necessary,  for  labor  nuiy 
be  accomplished  in  the  absence  of 
the  action  of  these  external  forces, 
as  in  paralysis  ;  but  when  the  head 
lies  in  the  pocket  Ibrmed  by  the 
curve  of  the  sacrum  and  the  partly 
stretched  |)elvic  floor,  having  to 
turn  nearly  a  right  angle  in  its 
course,  the  power  brought  to  bear 
by  the  abdominal  muscles  is  of 
very  great  moment.  From  the 
atrophy  of  the  truidv-museles  due 
to  corset-wearing,  failure  of  force  at  this  crisis  often  calls  tor  forceps  extraction. 
The  uterus  is  raised  by  the  round  ligaments  so  that  abdominal  pressure  acts 
to  better  advantage.  The  uterus  is  compressed  from  all  sides,  is  supported  by 
the  pelvic  walls,  and  is  arrested  in  attempts  to  slip  downward  by  the  utero- 
saeral  and  brt»ad  ligaments  and  the 
sacral  ciu've,  while  its  contents  are 
j)ressed  out.  The  increased  tension 
on  all  the  contents  of  the  trunk 
sends  blood  to  the  extremities  and 
flushes  the  face  of  the  patient.  Be- 
low the  pelvic  brim  the  pressure 
is  not  brought  to  iu'ar,  and  conges- 
tion produces  edema  ;ind  softening 
of  the  cervix  and  pelvic  ilonr.  At 
times  the  child  is  expelled  with 
considerable  force  by  means  of  this 
added  power,  and  the  uterus  may 
even   be  inverted   by  these  ettbrts  of  the  external   nuiscular  structures. 

Action  of  the  Vagina. — At  first  the  vagina  opposes  some  obstacle  to  the 
advancing  head.  When,  however,  a  large  circumference  has  passed,  any 
onwai'd  motion  may  receive  slight  aid  from  contractions  of  the  vagina.  Figiue 
185  (p.  l)-'»())  shows  how  the  vaginal  walls  are  smoothly  fitted  to  the  ehikl  even 
after  the  exit  of  the  head  has  <>i'eatly  distended  the  passage. 

Changes  in  the  Cervix  during  Labor. — Although  palpation  of  the  exter- 
nal surfiice  of  the  cei'vix  may  give  the  impression  of  a  smooth  ex])ause  of 
stretched  rubber  around  the  opening,  yet  when  the  finger  is  passed  within  tli<' 
cervical  canal  as  far  as  the  membranes,  is  hooked  forward,  and  then  slowly 
withdrawn,  one  detects  two  well-defined  rings  with  a  1-  to  2-inch  (.'?.5-  to  "i- 
centimetcr)  pas.sage  l)etween  them,  and  fiiuls  that  this  pa.ssage  has  yielding  siili; 


Viis^lna. 

Kiii.  liv.i.— Cervix  of  multipara  at  bcu'liiniiii.' 
of  lal)(ir;  the  internal  us  is  at  llio  edge  of  the 
crater  (frozen  section,  Winter). 


THE    PIIYSlOLOfiY   OF  LAIiOJi. 


325 


Rt-jU'i  tt'ti  iiitttihyaiu's. 


posttrior   \~     V 


Ktxtunt, 


Fi(i.  170.— Cervix  of  five  iind  a  hnlf  months'  primipara  in 
•lilatation  period,  witli  marliiMl  irregularity  in  i>ro(;ress  of 
tlilatalion  ol"  posteri<jr  and  anterior  lips,  the  posterior  lieiiiR 
nejirly  llattened  (Winter;  frozen  section,  five-eii.'htlis  natural 
size).    Compare  wideniuK  funnel  or  crater  with  I'iKUre  K'.h 


walls  (Figs.  166,  1G7,  174).  Whether  thi.s  inner  ring  1k>  the  trne  iiitornal  os, 
or  only  the  ui)per  limit  of  the  vaginal  jjortion  of  the  cervix,  we  may  he  allowed 
to  call  it,  for  dinicjil  pni- 
poscs,  the  internal  os,  since 
we  need  to  watch  it.s  be- 
havior during  the  dilatation 
.stiige. 

At  the  beginning  of 
labor  in  the  primipara  the 
cervix  i.>;  barely  pa.-<sable  by 
the  Hiiger-tip.  Dilatation 
of  the  internal  o.s  occurs 
first,  and  it  may  open  rather 
widely  before  the  external 
OS  begins  to  gape  (Fig.  1G7). 
In  this  case  the  cervix  thins 
out  to  a  flat  ring  over  the 
watch-glass  niend)ranes,  and 
the  external  os  r.iay  form  a 
.sharp,  parchment-like  edge 
as  the  internal  os  merges  with  the  lower  uterine  .segment  and  the  mend)ranes 
or  the  presenting  part  is  applied  directly  to  the  external  os.  At  other  times 
the  two  rings  draw  back  iu  less  marked  .sticcession  (Figs.  169,  170).     In  nuil- 

tipara  the  more  open  canal 
]\hit.  OS.  freely  admits  the  finger  dur- 
ing the  la.st  month,  and  the 
condition  is  suggestive  of 
labor  b(>guii.  But  an  inner 
edge  may  u.-^ually  be  distin- 
guished (Fig.  170)  until  the 
early  labor-])aius*  or  the 
threat e n  i  n  g  preliminary 
pains  begin.  The  effect  of 
such  early  pains  in  com- 
mencing the  dilatation  of 
the  cervix  in  certain  cases  is 
shown  in  Figure  175.  In  multipara;  labor  is  likely  to  pull  back  the  whole 
cervix  bodily,  but  with  .some  thinning  and  with  a  somewhat  irregular  edge, 
(iradually  the  circle  widens  until  it  merges  imperceptibly  into  the  uterine  wall, 
leaving,  as  a  rule,  to  represent  the  external  os,  a  slightly  raised  encircling  ring 
in  the  wall  of  the  curved  birth-tube  3  millimeters  (3,  inch)  in  thickii(>ss,  located 
against  the  back  of  the  symphysis  in  front  and  halfway  up  the  sacrum  behind 
(Fig.  134).  The  wall  of  the  cervix  is  then  2  millimeters  (^\  inch)  in  thick- 
ness, and  the  cervix  is  said  to  be  ctlaccd.  The  anterior  lip  may  be  nipped  betv  een 
the  bony  ring  (pelvis)  and  the  ball  of  bone  (fetal  head)  and  become  elongated 


Fin.  171.— Dilatinj;  cervix  of  eitilit  months'  primipara,  with 
Iironouneed  thinninK  of  posterior  lip  (Winter ;  frozen  section, 
two-thirds  natural  size). 


;^- 


i 


m 

1 

326 


AMKRIVAX    TKXT-IiOOK   OF    OBSTETRICS. 


aiul  odt'iiiatous,  even  to  the  cxtt'iit  of  ivppoariui;  at  the  vulva  <liirin<;  dclivory 
or  of  liantj;iii<!;  without  it  afterward.  lu  paticius  witli  contraeted  inlets  the 
external  os  ofti'U   remains  at   or  ni'ar  the  brim  after  full  dilatation. 

The  dilatation  is  estimiUed  either  l)v  j^uessinj;  the  eoin  it  seems  to  resemble 
in  size,  or  by  stating  the  inches  of  its  diameter,  or  the  number  of  fingers  which 
the  elastic  ring  will  admit.  The  cervix  may  not  be  found  greatly  dilated, 
and  yet  may  be  dilatable  to  a  large  size,  as  determined  by  the  introduction 
of  four  fingers  or  the  whole  hand.     The  eommou  error  of  the  beginner  is  to 


Fiif.  17J.— Cervix  cumpresscd  bi'twcpii  the  head  nnd  tlic  pelvip  floor,  nt  the  hoRlnningof  Inbor  in  a 
Vl-piini  (Hurt,  iini'-tliinl  uatiiriil  sizei.  Tlic  ciTvix  exti-mls  fmin  the  tiiherosily  uji  to  the  riKht-hiunl  n  ■ 
tile  viiniiiii  is  shown,  mill  also  the  ureter  ami  the  tmse  of  the  broad  litjauient ;  the  area  on  the  sl<le  not 
covered  with  periloiieiiiu  being  the  shaded  space  (a,  a,  a). 

believe  that  the  cervix  is  nuich  more  widely  opened  than  it  is  in  fact.  He  is 
sometimes  deceived  into  thinking  the  cervix  has  gone  by  the  exceeding  thin- 
ness of  the  tissue  stretched  taut  over  the  head  (Figs.  167,  210;  p.  385),  or, 
again,  by  the  softness  of  the  yielding  edges.  The  cervix  may  remain  in  a 
stationary  anil  partly  dilated  condition  for  hours,  or,  in  rare  cases,  for  days.  It 
may  close  after  partial  dilatation — even  fnmi  the  size  of  three  fingers. 

The  mechanical  factors  effecting  dilatation  are  discussed  on  pages  424-430. 
The  active  agents  are:  (1)  Coiu'raction  of  the  longitudinal  fibres  of  the  uterine 


Till':  rnv.siOLoar  or  laiior. 


327 


bmly,  piilliiijT  the  cervix  up  over  the  ovum  ;  (2)  liyth'ostatie  pressure  of  the  bag 
(»f  waters  ;  (o)  \ve(l^e-aeti(»n  of  the  preseutin^  part  ;  (4)  softening  of  tlie  cervix. 

'i'iiere  is  tension  on  all  the  other  uterine  vessels  during  a  eoutraetion,  hut 
the  unsupported  eervieal  vessels  helow  the  pelvic  hrini  l)econie  engorged  and 
the  lyni[»hati(;  interspaces  are  intiltrated  with  serinn  and  looseiujd  ;  thereliv  the 
torce  of  cohesion  is  lessened.  Were  it  not  s»»,  the  elastic  cervix  woidd  dose 
down  on  the  siioulders  after  the  })assage  of  the  head.  "  Indeed,  the  conditions 
of  an  elastic  tube  are  not  infre((Uently  realized  in  versions  wlu-re  an  attempt  is 
made  to  extract  tiie  fetus  through  an  i m per I'ectly  dilated  os ;  in  which  ease, 
after  the  disengagement  of  the  shoulders,  the  cervix  is  apt  tt)  close  ui)on  the 
neck  and  arrest  the  delivery  of  the  after-coming  head.  That  this  complication 
does  not  hap[)en  as  a  rule  is  due  to  the  fact  that  in  natural  labors  the  mechan- 
ical expansion  is  associated  with  certain  organic  changes  which  render  the;  cer- 
vix soft  and  distensible,  and  which  at  the  same  time  diminish  its  retractility."" 

To  bring  the  cervix  to  a  circle  of  a  diameter  of  5  centimeters  (2  inches) 
frequently  demands  two-thirds  of  the  total  time  recpiired  for  full  dilatation. 
Irregular  dilatation  is  not  infrecpient,  wherein  the  posterior  lip  is  further 
etfaced  than  the  anterior,  or  inversely,  but  the  former  is  more  common.  From 
the  frozen  sections,  the  first  process  would  seem  to  be  constant  in  occurrence 
and  most  marked  in  character  (Fig.  170). 

Location  of  the  Orifice. — The  internal  os  is  foinul  at  the  beginning  of  labor 
and  in  frozen  sections  6.3  centimeters  (2^  inches)  below  the  brim,  being  a  little 
lower  than  in  the  nullipara.'"  The  cervix  nuiy  be  high  and  pointing  backward, 
and,  in  practice,  when  there  is  much  difficulty  in  reaching  it  far  up  toward  the 
promontory,  one  may  be  obliged  to  hook  tlie  anteri(»r  lip  downward  with  the 
Hnger  in  successive  sections  until  the  external  os  can  be  caught  (Fig.  356, 
page  556).  A  cervix  at  a  long  distance  from  the  vulva  suggests  false  labor- 
pains  taking  place  at  an  early  period  of  pregnancy,  before  the  occurrence  of 
"sinking"  of  the  uterus,  or  a  contracted  pelvis.  The  cervix  may  be  found 
low  in  the  pelvis,  near  the  vulva,  with  the  head  packed  into  it,  pressing  it 
downward  against  the  pelvic  floor  and  toward  the  vulvar  opening  (Fig.  172). 

Changes  in  the  Lower  Uteruie  Segment. — The  two  beliefs  concerning 
this  portion  of  the  uterus  can  only  be  summarized.  Schroeder  and  his  school 
teach  that  the  lower  uterine  segment  is  that  part  of  the  wall  of  the  body  of  the 
uterus  (Fig.  173)  extending  from  the  coutr(iction-ri)i(/  i\hn\c — the  level  at  which 
the  peritoneum  is  found  firmly  adherent — to  the  internal  os  below  ;  that  it  is 
constituted  of  more  loosely  adherent  nniscular  layers  than  the  wall  higher  up; 
and  that  it  is  relatively  passive  during  labor.  By  its  anatomical  structure  and 
l)v  the  epithelial  C(  'cring  of  its  nmcous  mend)rane  the  lower  uterine  segment 
is  diiferentiated  fr  n  the  cervix  in  both  the  pregnant  and  the  puerperal  uterus, 
hi  pregnancv  th  •  internal  os  may  be  found  by  its  forming  tlu;  upper  end  of 
the  closed  cervical  canal.  With  this  point  the  denser  structure,  with  its  con- 
nective-tissue appearance,  the  character  of  mucous  membrane  and  its  junction 
with  the  decidua  above,  and  the  upper  limit  of  the  arbor  vita>,  usually  coincide. 
The   lower  segment  dilfers  distinctly  from   the   upper,  to  which    it   belongs 


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IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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WEBSIIR.N.Y.  145S0 

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328 


AMERICAN   TEXT- HOOK   OF   OBSTETRICS. 


anatomically,  in  possessing  loosely  connected  muscular  layers  which  are  easily 
separated,  whereas  the  rest  of  the  body  of  the  uterus  is  made  up  of  inseparably 
interlaced  bundles  which  can  only  be  dissected  from  one  another,  even  iu  tiie 
thinnest  layers,  by  destroying  the  structure  (Hofmeier)."  "  The  physiological 
behavior  of  the  lower  uterine  segment  during  labor  is  essentially  passive,  as 
opposed  to  the  remaining  portion  of  the  uterus,  which  is  sharply  contrasted 
with  it  by  contractions."  The  difference  between  the  two  is  palpable,  afler 
vigorous  uterine  contractions,  to  the  hand  within  the  cavity,  the  ring  being 
occasionally  detected  by  the  hand  M'ithout  as  well.  The  term  "  contraction- 
ring,"  though  firmly  seated,  should  yield,  in  the  writer's  opinion,  to  the 
more  correct  "retraction-ring,"  which  is  self-explanatory. 

The  writer  has  given  precedence  to  the  views  of  those  investigators  who 
believe  that  the  cervix  remains  unchanged  until  the  beginning  of  labor.    Only 


Pcliroeilor, 
llofini'ier, 
Miilk-r, 
i>t  al. 


HODY  OF 
UTEKl'S. 


LOWKIi 
ITKHINE    \ 
SKO.MKNT 


Contract  Ion 
ring. 


CEKVIX. 


Internal  n». 

I  (Miillor's  riiij;.^ 

[  External  on. 


/iriiUH, 

A'Ushtt-r, 
Buyer, 
et  al. 


Iiiteriinl  os 

(or  Kiiigof  Bandl). 


(Braun's  isthmus.) 


ExternnX  oh. 


Bony  OF 
urnKus. 


isvHonytiti'its  H'ith 
/,>-,ivr  uterine  sef- 
Hunt). 


Fi(i.  17:!.  — Dingrnin  illustratiiiK  the  two  ti'BchlnKs  luicnt  tlio  lower  ulorine  si'Knicnt  and  the  cervix 
Oil  tlie  left  side  nil  iiiteriial  os  has  l)een  added  for  the  sake  of  eleariiess,  althuiigh  in  tlic  frozen  sections 
of  women  with  full  dilatation  it  is  rarely  apparent  macroscupically  (one-third  imtiirul  size). 

the  briefest  outline,  however,  t)f  the  voluminous  controversy  ^^  can  be  given, 
and  the  opposite  side  stated.  The  older  theory  held  that  toward  the  end  of 
pregnancy  the  upper  portion  of  the  cervix  was  expanded  and  drawn  up  to 
form  part  of  the  general  uterine  cavity,  leaving  only  the  small  vaginal  por- 
tion of  the  cervix  below.  Braun,  whose  section  is  given  in  Figure  134, 
l)elieves  that  the  semicircular  ledge  with  the  large  vein  (Kranzvcne)  is  the  in- 
ternal OS,  10  to  11  wntimeters  (4  inches)  above  the  external  os;  Bandl  confirms 
this.  He  now  believes,'^  with  Kiistner,  that  in  first  labors  the  mucous  nvm- 
brane  of  the  dilated  portion  of  the  cervix — the  lower  uterine  segment — becomes 
torn  or  stripped  off,  and  subsequently  there  is  formed  upon  the  denuded  surface 
a  new  membrane  not  distinguishable  from  that  of  the  corpus,  which  in  future 
pregnancies  is  capable  of  forming  a  tlecidua.     Bayer  '^  concludes  that  "  the  ex- 


,  'II 


THE  PJIYSIOLOGY   OF  LABOR. 


329 


Closely 
iMlerwdfen  \ 
layers. 


« 

:? 


Limit  of 
firmly  ail- 
hereHt  peri- 
toneum. 


I 

6;  (3 


RetriUtion-ring. 


<< 


Easily 
sepa  ral'le 
layers. 


cessivcly  tliin  decidna  of  the  lower  uterine  segment  pusses  into  eervical  mucous 
membrane  on  the  jiosterior  wall  of  that  segment,  and  that  the  lower  uterine 
segment  and  supravaginal  cervix  are 
one  and  the  same  thing.  It  envelops 
the  presenting  part  during  labor,  it  is 
thinne<l  out,  distende<l,  paralyzed,  while 
the  thick,  contractile  muscle-mass  of  the 
corpus  lies  above,  where  the  phenomena 
of  contraction  oct;ur  with  their  expul- 
sive effect  upon  the  uterine  contents." 

Practically,  the  lower  uterine  seg- 
ment interests  us  as  the  common  seat 
of  rupture  of  the  uterus.  During  long 
labors,  or  where  obstruction  is  asso- 
ciated with  vigorous  contractions,  ex- 
treme thinning  occurs  at  this  level,  and 
in  such  cases  the  retraction-ring  can 
sometimes  be  felt  as  a  baud  or  ridge  in 
the  vicinity  of  the  navel  to  serve  as  a 
danger-signal. 

The  thickness  nf  the  hirer  vterine 
seijment  was  measured  by  the  writer  on 
such  of  the  frozeii  sections  as  wotdd  ad- 
mit of  study.  In  5  cases  at  the  eighth 
and  ninth  months  of  pregnancy  the 
average  thickness  of  the  wall  was  G  mil- 
limeters (J-  inch),  the  extremes  being  5 
and  10  millimeters  (y^  to  ^  inch).  In 
5  cases  in  the  stage  of  dilatation  the 
average  thickness  was  3.6  millimeters 
{\  inch),  the  extremes  being  2  and  5 
millimeters  {^  to  y^  inch).  In  6  cases 
in  the  expulsion  stage  the  average  thickness  was  3.5  millimeters  {\  inch),  the 
extremes  being  2  and  7  millimeters  (^  and  ^  inch  plus).  The  remarkable 
thing  in  this  series  is  that  there  are  so  many  instances  where  a  measurement 
close  to  2  milimeters  {-^  inch)  was  found,  in  some  sections  of  the  wall,  either 
in  the  first  or  the  s(x;ond  stage — namely,  in  seven  different  patients.  Thus  we 
may  say  that  before  labor  the  wall  of  the  lower  utei'ine  segment  is  6  millimeters 
(]-  inch)  thick,  and  durinrf  labor  3.5  millimeters  [\  inch).  Anterior  and  poste- 
rior walls  are  rarely  equal  in  thickness,  but  the  sections  are  nearly  equally 
dlvidcil  on  thimier  anterior  or  thinner  posterior  walls. 

Changres  in  the  Body  of  the  Uterus. — Thickening  of  the  wall  of  the 
upper  uterine  segment  is  a  somewhat  cttustant  factor.  It  is  especially  marked 
in  long  or  obstnicted  labors  (Figs.  134,  185,  2H8).  The  average  thickness  of 
the  uterine  wall  at  term  is  the  same  as  during  the  early  dilatation  stage,  as 


'ej; 

1 

r^ 

—  ^ 

•st 

ts 

=«^ 

'n 

ijjk) 

s'^ 

0 

-J 

Internal  os. 

%i 

« 

^ 

C 

1-^ 

H 

;^ 

ft  t 

•^ 

5  ;* 

65 

l'>v 


External  os. 

V'a^itta.^ 

Kifi.  171.— Section  (if  tlie  waU  of  tlio  pregnant 
utiTiis  (UiifnifRTi.  The  (HtViTonco  in  Icxtnre  bo- 
twt'i-n  <'L'rvix  and  lower  uterine  segment,  aecortl- 
ing  to  Hofnieier,  is  clearly  shown,  as  well  as  the 
loose-meshed  and  close-meshed  muscle-layers  of 
the  vipper  and  lower  uterine  segments. 


^'■1- 


:kn 


— 'i\ 


330 


AMERIVAy    TEXT- BOOK    OF   OliSTF/TItlCS. 


measured  on  eight  frozen  sections — namely,  7  millimeters  (^  inch).     Toward 
the  close  of  the  expulsion  stage  it  is,  on  five  sections,  from  9  to  18  millime- 
ters (\  to  J  inch),  averaging  1 
,, ;  ,  centimeter  (^  inch). 

Bag  of  Waters  —  Pore- 
waters. — Through  the  dilating 
cervix  the  fetal  envelopes  are 
tclt,  growing  tense  during  the 
pains  or  just  before  the  sensa- 
tion of  suffering  comes.  The 
ovum  is  being  peeletl  off  the 
lower  uterine  segment  and  pro- 
truded. We  note  the  amount 
of  tension,  the  shape  of  the  pro- 
truding sac,  and  its  volume,  and, 
later,  the  location  of  the  tear. 
The  tension  is  usually  intermit- 
tent, as  above  stated.  At  times 
we  detect  a  permanent  lesion 
and  look  out  for  hydramnion 
or  twins. 

The  shape  of  the  sac  depends 
on  the  shape  or  size  of  the  pre- 
senting part,  the  elasticity  of  the 
membranes,  and  the  amount  of  liquor  anuiii.     It  may  be  (1)  Flat;  (2)  watcii- 
glass — this  is  usual  with  vertex  presentations  (Fig.  176);  (;i)  hemispherical — 
it  may  bulge  fidl  and  round  (Fig.  177)  ;  (4)  glove-finger — it  may  be  elongated 


Fi*;.  17'i.— Ppotinn  of  primipiira  of  twcnty-iiiiith  week, 
slioHliin  beKiiiniiiK  (liliitutiuii  of  the  eeivix  in  the  iit)sem'e 
of  paiiilul  oontractions  ■  mi>,  luiicous  jiIiik;  i",  internal  os, 
with  attachment  of  membranes  (Ahlfeld;  burdcneil  prepa- 
ration, une-thirU  natnrul  size). 


I"i(i.  ITii.— rorm  of  nienihianis  iluriuK  ililala 
tliin,  WHtchnhiss  I  Varnien  tlie  presenliiiti  partis 
lari;e  and  tills  the  cervix  lonesixtli  natural  sizei. 


Fl(i.  177  —Form  of  membranes  with  less  elll- 
cieiit  lillin^riif  cervix  and  pelvis,  and  larger  iiimii- 
titv  of  f(jre -wiiters  imodifled  from  Varnier). 


in  shape  when  the  cervix  is  narrow  and  the  ])resenting  part  does  not  fill  it,  as 
in  knee  or  shoulder  presentations  (Fig.  178);  (o)  pear-shapctl  (Fig.  179),  as 


Tine  riiYsioLoay  of  labor. 


331 


whore  the  fetus  is  dead  and  niaeoratcd  ;''  (({)  double,  as  with  twins — but  very 
rarely. 

The  membranes  are  slightly  permeable  tnider  pressure  (Tarnier  and  Pinard), 
and  at  times  the  amnion  will  leak  into  the  chorion,  jriving  a  double  pouch. 
Some  of  the  vajrinal  flow  ha.--  been  eredi*^e<l  to  this  source. 

The  cervix  and  lower  uterine  segment  are  drawn  up  over  the  prot»'udal 
ovum.     The  chorion  often  separates  fron«  the  decidua.     The  attachment  of 


Kiii.  1T.H.— filovo-tiiiBcr  furni  wluTO  tho  proscntint; 
(iiirt  iMsniiill  (iiiciililU'il  fnnu  Variiii'ri. 


Km.  IT'.t.— renr-shnpi'il  pourli  sci'ii  with  some  ciikl'S 
of  iiiai'L'riiti'il  fttiis  (iiKHlitk'd  .''r(im  Vtiriiier). 


the  membranes  initil  the  beginning  of  labor  is  at  the  internal  os,  or  upper 
limit  of  the  apparent  cervix.  In  normal  eases'*  the  coverings  of  fetal  origin 
are  not  se|>arated,  nuUcrnal  and  fetal  membranes  parting  at  the  level  of  the 
lower  pole.  In  certain  cases  before  rupture  the  chorion  jind  amnion  may 
already  be  separated  throughout  or  far  up  on  the  cord. 


X/tCENTA 


TnBRANO 


I"l(i.  1811.— riiicoiitii  ninl  iiu'iiiliniiics  after  ili'IiviTV,  tn  sliow  linw  tlu'  rolatloii  of  tin.-  opi'iiiiiK  to  the 
liliict'iita  iiidicatt's  the  site  of  the  hitter:  1.,  htteral  iiiiphmtation  :  II.,  fiiiulal  iniplaiitation;  III.,  placenta 
,  .aviu  marginaliij. 

Xormally  the  membranes  give  way  on  full  dilattition  of  the  cervix  when 
|ti<'ssiiig  on  the  pelvic  floor.  At  times  rupture  occurs  days  or  hours  before 
labor,  from  low  implantation  of  the  placenta.''      In  PouUet's  case  the  mem- 


I 


'ii 


^i»*ll 

':^-. 


'fffipH^ 

|ij^R'>< 

*',VJJ.  -Kf    ^ 

K-'v 

■  ^'1 

<Ik^ 

w^BKb^ 

Wl 

332 


AMERICAN    TEXT-BOOK    OF   OBSTETRTCS. 


li 


l\) 


I  'j; 


M 


m- 


l)ranes  gave  way  six  days,  and  in  that  of  Mattlipws  Duncan  forty-five  days, 
before  labor.  A  ('oj)ioiis  diseliarge  of  fluid  tliat  has  collected  between  the 
ovum  and  the  uterus  and  due  to  a  catarrhal  endometritis,  called  "  hydrorrhd'a 
gravidarum,"  may  deceive  one  into  believing  that  the  amniotic  sac  is  empty. 
A  more  common  cause  of  error  is  the  gushing  of  (nlorless  hysterica'  urine. 
At  times  rupture  is  delayed  until  the  membranes  btdge  through  the  vulva. 
In  rare  instances  the  child  is  born  enveloped  completely  in  the  unbroken 
sac ;  this  is  the  "  caul." 

The  chorion  usually  gives  way  first,  having  a  firmer  attachment,  as  the 
amnion  can  loosen  over  most  of  its  surface  and  slip  downward  and  out.  The 
seat  of  rupture  may  not  correspond  with  the  opening  of  the  cervix.  If  it  is 
on  the  side  wall,  the  waters  may  leak  more  slowly,  but  this  slow  flow  of  the 
fore-waters  is  not  very  often  seen,  although  discharge  of  the  hind-waters  in 
jets,  as  the  presenting  part  recedes  from  its  tight  fit  in  the  cervix  during  a 
contraction,  may  simul.ate  it.  Frequent  gushes  of  so-called  **  liquor  amnii  " 
arc  often  only  urine.  After  rupture  the  waters  may  come  away  with  a  forcible 
gush  or  may  leak  slowly.      On  examination  after  delivery  the  position  of 


Fici.  181.— Locntton  of  the  caput  succedniioum,  iiinl  its  liniicutiDii  of  the  oriRinal  position  of  a  verti'x 

])rfseiituti<iii. 

the  tear  in  the  membranes  shows  the  location  of  the  placenta  in  the  uterus 
(Fig.  180).  An  opening  opposite  the  after-birth  would  denote  implantation 
in  the  fundus  ;  a  tear  close  to  the  niargin  of  the  placenta  woidd  indicate  pla- 
centa prtevia  ;  and  one  of  the  intermediate  degrees  is  also  shown. 

Character  of  the  Liquor  Amnii. — Ordinarily  the  waters  have  a  slightly 
turbid,  yellowish  color.  At  times  the  amniotic  fluid  is  thick  with  greenish  or 
brownish  meconium,  due,  perhajis,  to  undue  pressure  on  the  child,  and  some- 
times indicative  of  danger,  except  in  breech  presentations.     Flakes  of  skin 


THE  PiivsioLoay  of  lab  or. 


333 


and  a  niiuUly  consi.stencv  siig«^cst  a  macerated  fetus.  Bright  blood  in  any 
quantity  within  tlie  membranes  indicates  prcmatiuc  separation  of  the  placenta 
with  leakage  into  the  amniotit;  sac,  but  is  very  rare. 

Formation  of  the  Caput  Succedaneum. — The  caput  succedanenni  is  an 
edematous  swelling  that  clevelops  on  the  presenting  part  of  the  child  as  the 
cervix  expands.  The  cervix  makes  pressure  all  over  the  presenting  part  dur- 
ing uterine  contractions,  except  at  one  spot,  and  here  serous  infiltration  develops 
a  doughy  prominence.  The  si/e  of  this  swelling  varies  with  the  duration  of 
the  labor.  If  it  occurs  on  the  face,  the  grotescjue  disfigurement  alarms  the 
family,  but  the  swelling  subsides  in  a  day.  The  scrotum  may  assume  large 
dimensions  in  breech  labors.  On  the  scalp  the  position  of  the  edema  serves  to 
indicate  the  position  in  which  the  head  enters  the  pelvis,  provided  too  long 
delay  in  the  lower  birth-canal  has  not  occurre<l.  The  tumor  is  located  on  that 
end  of  the  head  and  that  side  of  the  head  opposite  in  name  to  the  position. 
Thus  in  the  left  occipito-anterior  position  it  is  found  to  the  right  posteriorly  ; 
in  right  occipito-postcrior,  to  the  left  and  front  (Fig.  181). 

Clinical  Course  of  Labor. 

Signs  of  Beginning  Labor. — From  eight  to  fourteen  days  before  labor 
"siidving"  or  "  lightening"  occurs  in  a  considerable  number  of  patients.  The 
uterus  drops  lower,  the  fundus  falls  forward,  the  head  engages  or  descends  to 
lie  on  the  pelvic  floor  (Fig.  172),  and  as  a  consequence  the  patient  experiences 
a  sense  of  relief,  breathes  more  freely,  digests  better,  and  has  looser  waistbands. 
This  may  never  occur  in  a  given  patient,  or  it  may  happen  two  days  or  four 
weeks  before  delivery.  In  half  the  primigravida;  Bruhl  examined  he  foimd 
the  greatest  circumference  of  the  head  beneath  the  brim  at  the  end  of  preg- 
iianev  where  the  inlet  was  roomv,  whereas  in  onlv  one-third  of  the  nudti- 
gravidic  was  this  condition  seen,  owing  to  the  laxer  state  of  the  abdominal 
wall  after  first  pregnancies.  On  the  other  hand,  irritability  of  the  bladiler 
and  venous  obstruction  in  the  legs  or  the  labia,  with  more  difficulty  in  walk- 
ing, may  result  from  the  intrapelvic  pressure.  At  the  time  of  subsidence  the 
intermittent  contractions  may  begin  t(>  be  painful,  so  that  labor  is  supposed  to 
be  under  way,  the  pains  often  being  grouped  in  certain  parts  of  the  day  or 
night,  and  being  most  commonly  seen  among  multipara\  Late  in  pregnancy 
tile  vagina  and  the  vulva  are  relaxed,  a  glairy  mucus  lubricating  them  and 
facilitating  internal  pelvic  measurement  and  examination. 

The  only  certain  method  of  determining  whether  labor  is  under  way  is  by 
digital  exploration  of  the  cervix.  JJy  passing  the  finger  within  the  cervix  and 
iiooking  it  forward  we  may  determine  whether  the  internal  os  is  widening  or 
•  lisappearing  (Fig.  166),  and  the  whole  tubular  canal  of  the  cervix  is  being 
thimied  and  drawn  up ;  for  we  must  remember  that  in  over-distention  of  the 
uterus,  as  in  cases  of  hydrainnion  or  twins,  or  in  the  relaxed  state  of  some 
iiiultiparous  uteri,  or  where  there  has  been  wide  laceration,  the  cervix  gapes  in 
the  last  month,  and  that  a  low  i)osition  of  the  fetus  flattens  the  cervix  between 
tile  head  and  the  pelvic  floor  (Fig.  172). 


i  i 


1534 


AM/:/i'/(A.\    Ti:XT-li(KtK    OF    OllSTKTRH'S. 


n : 


Wo  are  warned  that  labor  is  actiiallv  under  wav  l)v  the  foUowint;  sijjns  : 

1.  Irritahility  ol"  the  bhuhh-r  and  the  reetuni  l)ee(in)in<i;  more  marked  than 
before,  micturition  beinj;  particuhu'ly  affected. 

2.  The  "show" — an  escape  of  blood-streake«l  nuicus,  due  to  slight  lacera- 
tions of  the  cervix.     This  sign  is  not  constant, 

?>.   Expulsion  of  the  mucus  plug  fntm  the  cervix — a  sign  not  often  detected. 

4.  Increased  secretion.  Jioth  cervical  and  vaginal  mucus  is  jwured  out  in 
such  a  manner  that  when  the  passages  seem  soaked  and  softened  with  free 
mucilaginous  discharge  we  may  expect  to  find  cervical  dilatation  making  good 
progress. 

0.  Rhythmical  uterine  pains.  The  most  conclusive  symptom  of  beginning 
labor  is  the  occurrence  of  regularly  recurring  pains,  with  lessening  intervals 
au<l  increasing  force,  and  the  most  conclusive  sign  is  that  stated  above — 
namely,  beginning  dilatation  of  the  cervix. 

Stages  of  Labor. — The  jirsi  stage,  better  called  the  dlMnWon  stage,  ends 
with  the  complete  canalization  of  the  utero-cervical  zone.     The  second  stage, 


•/ 


Fiii.  IW.— IVlvlc  11(1(11-  liofdrc  (listoiitidii  (iiKidiliLMl  fniiu  a  fidzcii  section  by  I?riuin  nnil  Zwcifol,  (Hic 
third  nntiinil  sizf) :  tlii'  fdfiiin  mid  tliicki'iiiiit;  st'uiii  oxci'sslve,  but  Webster's  iiieiisurements  show  that 
this  lloor  is  ratlier  thinner  than  the  average. 

the  Nt(U/e  of  expufnion,  ends  with  the  birth  of  the  child.     The  third  or  placental 
Hhiffc  ends  with  complete  evacuation  and  lasting  retraction  of  the  uterus.'*' 

Tlie  First  S(a(/e,  or  (fie  JHlatntion  Star/e. — When  labor  is  fairly  started  the 
contractions  of  the  uterus  assume  a  certain  regidarity,  characteriztnl  bydecreas- 


Tin:    I'JfVSI(J/J)GV   OF   LAJiOli. 


335 


ill}?  intervals  aiul  by  incmising  furco  aiid  ikuiiI'iiIiu-ss.  Occurring  at  Hrst  about 
every  half-hour  and  only  slightly  discoinforting,  with  sonic  sense  of  ]>ressiire, 
the  contractions  gradually  run  closcrtogcther  until,  toward  the  end  of  dilatation, 
they  give  but  momentary  intervals  of  relief.  The  pain  is  located  as  a  rule  in 
the  sacral  region,  and  later  extends  to  the  lower  abdomen  or  down  the  thighs. 
The  patient  is  restless,  standing,  sitting,  moving,  tossing,  wringing  her  hands, 
seizing  on  a  support,  calling  for  pressure  against  the  sacrum,  or  begging  for  re- 
lief. Her  outcry  is  invohmtary,  high-pitched,  or  apologetic,  an  impatient  pro- 
test, or  a  plaint.  She  can  be  persuaded  with  difliculty  that  any  progress  is 
being  made  by  such  colic,  seemingly  futile.  Her  cries  are  not  like  those  of 
the  second  stage,  which  is  marked  by  a  transition  to  the  groan  or  grinit  of  efl'ort 
as  she  closes  the  glottis  and  strives  to  expel  the  child.  The  maternal  jiulse 
increases  in  fre(|uency  during  a  uterine  contraction,  while  the  fetal  pidse  is 


Kin.  I8H.~FuIly-<listondcil  pclvir  floor  (over  onotliird  lifo  size). 


retarded  at  the  acme  of  the  j)ain.  The  temperature  in  normal  labor  rarely 
rises  1°  F.  Urine  is  freely  secreted  during  this  stage,  and  attacks  of  shiver- 
ing or  vomiting  may  occur  toward  its  end.  With  each  pain  the  cervix  grows 
tense,  the  border  becoming  sharp  and  the  mendiranes  protruding,  to  retreat 
again  as  the  edges  relax.  Gradually  yielding  and  softening,  with  abundant 
luucus-.secretion,  the  retreating  edges  permit  the  mendiranes  to  re,<t  broadly  on 
the  pelvic  floor.  When  the  opening  measures  7.0  centimeters  (3  inches)  the 
bag  of  Avaters  usually  gives  way  and  the  "fore-waters"  escaj)e, clear  or  milky, 
with  particles  of  vcrnix  caseosum,  while  the  bulk  of  the  amniotic  fluid  is  hold 
back  by  the  ball-valve  action  of  the  head.  After  a  ])ause  pains  recur  and  the 
head  descends,  and  the  im  of  the  cervix  is  pushed  back  against  the  pelvic 
walls  until  its  edges  are  hardly  j>erceptible,  the  cervix  being  flattened  against 
and  practically  continuous  with  the  vaginal  walls. 

The  duration  of  the  stage  of  dilatation  varies  from  two  hours  to  several 


m  n 


H 


-■>^^a 


AMKRHAX    TKXT-nOOK   OF   OUSTETJilCS. 


(lavri.  Ill  tlu>  priniipiini  twenty-ioiir  lunirs  is  not  iiiicuinnion,  and  tlie  length 
incroasos  with  the  patient's  ajje,  avera{j;ing  over  thirty  hours  at  forty  years 
(I)octerliii).  To  j;ive  a  figure  lor  the  student  to  remember,  we  say  that  tiie 
averanc  duration  in  the  primipara  is  fifteen  hours,  in  the  multipara  ei<j:lit  h(»urs. 
The  Secniid  Star/r,  or  the  Stage  of  Ex/tutttioii. — We  are  not  here  coneerned 
witli  the  mechanism,  wliieh  will  bo  treatwl  later  (p.  430).  The  patient  has 
a  fully-<lilated  cervix,  ruptured  membranes,  and  a  fetal  head  resting  on 
the  pelvic  floor.     The  character  of  the  pain  changes ;  it  is  no  longer  teasing 


fUllydustended 


Flu.  IW.— nitinniiii  iif  tile  iiclvic  tloor  liofurc  iiri'l  (luriiit;  thi- proci'ss  of  thiniiiiiKor  strotchinn-    It  will 
bo  sfoii  that  tlR'  stnicturu  is  thiiiiit'd  riitlKT  tliiiii  drivi'ii  furwurd  (uiio-tliinl  natiiritl  size). 


iV 


JsM 


I        (^ 


and  inefficient  ;  the  impulse  to  drive  out  the  great  mass  that  presses  toward 
the  outlet  l)rings  about  an  effort  by  the  diaphragm  and  abdominal  muscles 
with  closed  glottis;  steadying  herself  or  pulling  hard  on  sheet  or  assistant, 
she  .strains  to  bring  all  her  strength  to  bear;  instinctively,  as  in  the  savage 
races,  she  takes  the  seini-recund)ent  posture  that  brings  the  uterus  upright ; 
and  her  outcry  is  the  groan  of  great  etfort  or  the  moan  of  endetl  exertion. 
With  each  pain  the  pelvic  floor  bulges  and  then  recedes;  the  vulva  gapes 
and  the  head  appears;  the  parts  behind  the  outlet  grow  thinner  and  more 
dangerously  tense  ;  the  acme  of  suffering  has  arrived.  As  the  head  protrudes 
through  the  opening  the  pains  grow  stormy,  and,  reckless  of  injury,  the  mother 
drives  out  the  tortin'iug  obstructi(m.  The  fourchette  slips  back  over  the  face 
and  is  snugly  a])plied  to  the  neck  or  shoulder  (Fig.  185).  Xow  occurs  a  pause 
of  from  one  to  five  miinites.  The  child  may  grow  dusky,  or  may  attempt 
to  breathe,  thus  drawing  into  the  air-])assages  fluids  taken  into  the  mouth. 


Tin:  I'JiYsioLoav  or  i.Anoii. 


.•}:J7 


IJsimlly  the  iioxt  pain  oxpcis  the  tnink,  wliidi  is  fnllowcd  l)y  a  jjiisli  of  liquor 
ainiiii,  with  s(»mc'  bloctd.  Tlie  ihimfioii  oj  the  r.ry>»/.s/o«  .v/m/r  varies  from  ten 
iiiiiiiitos  t(»  six  hours.  In  priniipanu  tlic  avcrajjc  is  t\v(»  lioiirs,  in  tniiltipanc 
on(>  hour. 

Chaneres  in  the  Pelvic  Floor. — Tho  polvic  floor  is  the  fleshy  diaphrafrin 
dovetailed  int()  the  bony  outlet  of  the  pelvis,  ft  is  about  o  eentinioters(2  inehes*) 


Fi(i.  185.— Pelvic  floor  nftcr  the  escupe  of  the  head  (one-thinl  naturitl  size);  eoiistruoted  from  the 
/vM'ifel  frozen  section  to  show  tlie  pusliinn  forwiinl  of  tlie  anterior  vulvar  eomniissiire  also,  and  the 
rciimrl^ahle  way  in  which  llie  child  is  paelied  into  tlie  liirtli-eanal.  Tlie  passage  of  tliis  liead  tlirough 
111!'  pelvic  cavity  mi(,'ht  well  result  in  rupture  of  tlie  uterus. 

ill  thickness,  concave  above  and  covered  with  peritoneum,  and  convex  in  shape 
(111  its  lower  skin-surface.  Between  these  surfaces  lie  fascia?,  muscles,  coinieetivo 
tissue,  and  fat,  named  in  tho  order  of  their  physiological  importance.  Through 
tlio  floor  run  three  slits,  the  urethra,  the  vagina,  and  the  rectum-anus.  The 
axes  of  these  openings  are  oblique  (Fig.  1H4),  so  that  direct  pressure  from  above 
22 


i! 


1 1' 


;WH 


AAfKItlCAX    TEXT-noOK    OF    OJtSTKTIilCS. 


teiuls  to  diet!  tlio  openings  by  prt'ssinij  their  walls  tojj;etlier.  Ordinarily  tlieir 
capacity  for  distention  is  limited,  but  the  remarkable  character  of  the  |M'lvic 
floor  is  that,  whereas  the  chief  function  of  this  nni<|iie  strnetnre  is  to  form  a 
Holid  and  luibroken  support  for  the  or<;ans  above  it  under  all  conditions  uf 
strain,  at  certain  moments  it  nnist,  without  injury,  etl'ace  its<'lf,  and  ojm'u  up 
to  the  size  of  its  entire  length  and  bn'adth.  Wc  shall  consider  the  change- 
that  bring  about  this  rcsidt. 

Hart,  studying  fr»»zen  sci'tions  maiidy,"  observed  that  the  vaginal  slit  <livides 
the  structure  intct  an  anterior  part,  which  he  named  the  pnh'ir  styinnit,  triangu- 
lar in  shape,  com|)ose<l  of  retropubic  fat,  bladder,  urethra,  and  anterior  vaginal 
wall,  attached  (loosely)  to  the  ptibcs  ;  and  a  much  larger  and  stronger  |M>sterior 
part,  the  mivritl  nq/mnit,  between  the  rear  vaginal  wall  and  the  |M»stcrior  Imiuv 
wall,  including  the  anus  and  part  of  the  rectum.  Symington'*  considers  flmt 
the  rectum  and  bladder  and  the  upper  vagina,  like  the  uterus,  should  not  lie 
regarded  as  parts  of  the  flo(»r,  but  as  organs  resting  u|»on  it.  Webster'"  hulcU 
that  the  bladder  is  indM>dde<l  in  the  pelvic  floor,  and  that  the  vagina  and  (-ervix 
are  parts  of  it,  together  with  the  rectum  from  the  coccyx  down.  In  the  illustra- 
tion (Kig.  ^M),  ibr  obviotis  reasons,  the  bladder  and  cervix  have  been  ojuiitcij. 

Late  in  pregnancy  the  changes  that  belong  to  the  j)clvic  floor  arc  relaxation 
from  edema,  moderate  increase  in  thickness,  and  a  l«»w  <lrtM)p  or  "  Imlging 


peivic 


Y-iooi 


Ki(i.  IHt').— IVlvic  tliiiir  si'cii  ill  iixial  coronal  section  (nuxiificd  from  Hart). 

downward."    All  these  changes  favor  the  stretching  that  is  to  come.    The  main- 
tenance of  .";s  former  axis  by  the  vagina,  its  distance  from  the  symphysis,  tlic 
sliiip<'  of  the  pelvic  floor  at  this  time,  and  the  low  j)ositi(»n  before  it  is  opcncii 
lip  into  an  oblique  hernial  canal  are  shown  in  Figures  182,  184,  and  186. 
During  labor,  in  the  dilatation  stage  the  parts  anterior  to  the  vagina  aiv 


li^' 


""•■  '■"y-'oi.'xn-  or  ,..,„„,<. 

I'osfmiiicfl  /n.m  Im.;,,,,  ,i,.:,.       ,         .  •^•^•* 

:;.:;■■;■  ";•■  ■; --  ™  Ti^zx:;  r™' .-.:.."  ^.<- .:,.. „■ , 

,' '.'•/"■'■"■'■-""I  l-...'l.  .(  |H.,i„  „.      i  '"  ""■":"•  '->■  ""•  'I."".,,,!;,,,;  |„, 

'  Tt;^XL:ir;!:r'  '"■■'  '■''--'' """ " "-  '"""■"' 

"    '  ',-•  '■'■  "■<•"  t"  2  ,„illi„„.,,,..  (  4   „-,"".'",  ""-"""I  l'.v™...i-l  i,  „„„„. 

/ ''°  "'■' » '"".v  '"•  ^ X.I ::  ,;t!:!':i'  '""•''"'■■xi'v.  ..4, ,,, ,,, ,° 

Tliickiiess  of  die  n,.!..;,,  n       ■     „ 

"  "        ".!"  "?:"•  '"  '^-'X  <•<•  -lu-  anus,  in  „.,,.•„,,„  ,,..  .        ^     *>■.'..„..,..«.    ,„,.„.. 

'■■■"- ■'^-'■-".";'^:;:;r'";:-  ■■-■:::::::'J     \ 

„       ■■"  «'"<-'-''U's|  (lislfiili,,,,  .7  .), 

"""■  ""■■«'"».  «  <lo,„.|„  ,„■  ,,„,    '■   "'•    \"y  ■"'x'-ralo  sti„,„li_,s„,|,  ,,     , 

*  The  fi,,„ros  „sod  in  thi  ■  d"         •  '"'  '"''''  '''^f*^'"'"'. 

---:^.:r':;;d?r='?"-^^^  ^ 


^§n 


■I 


340 


AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 


The  average  duration  of  the  placental  stage  is  from  twenty  to  thirty  min- 
utes. The  placenta  may  follow  the  rhild  at  onee,  or  it  may  remain  two  hours. 
After  that  time  the  ease  belongs  under  the  head  of  Pathology. 

Duration  of  Labor. — The  length  of  labor  varies  within  very  wide  limits, 
and  our  definite  statements  of  averages  do  not  claim  accuracy.  The  exact  hour 
of  the  onset  of  labor  is  often  impossible  to  fix.  Labor  is  usually  longer  in  the 
primipara  than  in  the  pluripara,  on  account  of  the  greater  I'esistance  of  the 
soft  parts  during  the  first  delivery.  It  is  longer,  as  a  rule,  in  the  very  young 
and  in  the  elderly  primipara,  and  in  the  stout  than  in  women  of  slighter  build. 
Spiegelberg's  506  cases  are  commonly  quoted,  wherein  the  three  stages  in  the 
primipara  are  averaged  respectively  at  fifteen  hours,  two  hours,  and  half  an 
hour,  with  a  total  of  about  seventeen  hours,  while  the  multipara  is  listed  at 
eight,  one,  and  one-half,  the  total  being  given  as  eleven  hours.  Many  of  the 
text-books  are  non-committal.  The  majority,  however,  estimate  the  duration 
of  labor  in  the  multipara  at  eight  hours — not  varying  greatly  from  Spiegel- 
berg's figures  in  other  respects. 

Table  of  Average  Duration  of  Stages  of  Labor  in  Iloum. 


Primipara 
Multipara 


Dilatation 
Stage. 

Expulsion 
Stage. 

I'lacontal 

Stago. 

15 

8 

2 
1 

i 

Total. 


17 
9 


Spiegelberg  ^^  states  that  labor  most  frequently  begins  between  10  and  12 
o'clock  in  the  evening,  and  the  end  of  labor  occurs  twice  as  often  between  9 
P.  M.  and  9  A.  M.  as  in  the  other  twelve  hours.  West^''  found,  in  2019  cases, 
40  per  cent,  delivered  between  11  p.m.  and  7  a.m.,  and  the  most  favored 
time  is  between  midnight  and  three  in  the  morning.  A  larger  lunnber  of  rapid 
labors  are  said  to  occur  in  summer  than  in  winter  (107  :  100). 


REFERENCE    LIST. 


1/ 


1.  Liisk:  Midwifery,  1892,  p.  124. 

2.  Archivfilr  Gyniikologie,  Bd.  xi.  p.  49. 

3.  Wiener  mediciiiigeke  Jahrbuch,  1872,  1873. 

4.  Colinstein :    Archiv  fUr   Gyniikologie,    Bd. 

xviii.  p.  394. 

5.  New  York  Journal  of  Gynecology  and  Ob- 

Htetrics,    June,    1892,    and    Asovember, 
1893. 

6.  Parvin  :   ObxIetricK,  1890,  p.  362. 

7.  Ceiifrnlblalt  far  Gynilknloyie,   1884,  p.  648, 

and  1885,  p.  625. 

8.  Winter:  Zirei  Medianschn.,  Berlin,  1889. 

9.  Lnsk;  Midwifery,  1892,  p.  138. 

10.  Barbour  and  Webster:  Edinburgh  Lab.  Re- 

ports, vol.  ii.,  1890,  p.  31. 

11.  Schroeder  :  Srhwangere  und  Kreissende  Ute- 

rus, 1886. 

12.  A  clear  epitonu' with  partial  bibliography 


is  given  in  Jaggard's  section  of  Hirst's 
A  merican  System  of  Obstetrics,  p.  333. 

13.  Arrhivfiir  Gyniikologie,  Band  xv. 

14.  "  Ziir  Phys.  u.  Path,  niorphol.  d.  ( iebfir- 

nuitter,"  Oyn.  KUnik,  1885,  p.  398. 

15.  Ribeniont-Dessaigri.-:s-Lepage:  PrecLid'Oh- 

stetricide,  1894,  p.  332. 

16.  Pinard  and  Varnier:  Anatomie  Obstctricuk. 

17.  Precis  d' Obstvtricale,  p.  33"). 

18.  Jewett:     Outlines   of    Obstetrics,    Saunders, 

Philadelphia,  1894,  p.  109. 

19.  Structural    Anatomy  of    the    Pelvic    Floor, 

Edinburgh,   1880. 

20.  Edinburgh  Medical  Journal,  March,  1880. 

21.  Researches  in  Female  Pelvic  Anatomy,  189!i. 

22.  Lchrbuch,  1891,  p.  147  ;    Monatsschrijt  fUr 

Giburtshiilfe,  18(18,  p.  279. 

23.  American  Medical  Journal,  1854. 


THE    CONDUCT  OF  NORMAL   LABOR. 


341 


II.  THE  CONDUCT  OF  NORMAL  LABOR. 


L'l- 


IlirstV 

Is. 


1.  Antisepsis. 

Nowhere  do  we  find  more  striking  proofs  of  the  value  of  the  antiseptic 
system  tlian  is  shown  in  the  diminished  puerperal  mortality  and  morhidity 
in  hospitals  since  the  introduction  of  antisepsis  into  obstetric  practice. 
Jk'foro  the  advent  of  Listerism  the  usual  death-rate  from  childbed  fever 
in  lying-in  hospitals  was  from  2  to  10  per  cent.,  and  in  so-called  "  epidemics" 
this  limit  was  often  exceeded.  In  the  women  who  survived,  feverless  childbeds 
were  comparatively  infrequent.  Under  antiseptic  methods  the  mortality  from 
sepsis  in  well-managed  institutions  is  less  than  1  in  200,  and  the  morbidity 
does  not  exceed  10  per  cent. 

A  few  examples  will  suffice  to  show  what  is  possible  under  the  present 
perfected  system  of  aseptic  obstetrics.  Professoi's  Groth,  Netzel,  and  Sonders 
of  Stockholm  report'  17,8(52  births  under  their  direction  (1880-89),  with  1 
death  in  344,  or  .29  per  cent.  In  Copenhagen  (1888-89),  in  1218  hospital 
deliveries  the  death-rate  was  .24  per  cent.  Slawiansky  *  tabulates  the  results 
of  176,646  deliveries  in  fii'ty-thres  hospitals  of  Russia  (1881-89),  showing  a 
morbidity  of  8.57  and  a  mortality  of  .38  percent.  Leopold^  records  3089 
cases  (from  May,  1885,  to  May,  1887)  without  a  death  from  septic  infection. 

The  Boston  Lying-in  Hospital  (1891)  recorded  550  deliveries  with  no 
death  from  septic  causes.  In  1892  there  were  515  continements  with  but 
1  fatal  case  from  septicemia — a  mortality  of  less  than  0.1  per  cent,  for  the 
two  years.*  In  the  Sloane  Maternity,  New  York  City,  there  has  been  thus 
far  but  1  septic  death  in  3000  deliveries.'  In  the  New  York  Maternity 
Hospital  957  women  were  delivered  during  the  three  years  ending  Oct.  1, 
1893,  without  a  death  from  sepsis.® 

While  in  pre-anti septic  times  the  puerperal  mortality  was  many  times  greater 
in  public  institutions  than  in  private  practice,  to-day  the  pauper  delivered  in  a 
hospital  is  exposed  to  less  risk  than  are  the  well-to-do  classes  who  are  confined  in 
tlieir  own  homes.  Insurance  reports  show  that  of  all  deatlis  in  women  between 
the  ages  of  nineteen  and  twenty-nine  more  than  18  per  cent.,  and  between 
twenty-nine  and  thirty-nine  years  more  than  13  per  cent.,  are  due  to  puerperal 
causes.  From  65  to  75  per  cent,  of  puerperal  deaths  are  attributable  to  sepsis. 
It  is  fair  to  assume  that  these  statistins  have  to  do  almost  wholly  with  a  class 
wiio  are  delivered  outside  of  hospitals.  This  indicates  a  mortality  that  is  truly 
ap])alling,  especially  when  one  reflects  that  it  iidls  upon  women  in  the  prime 


'  Verhnndlitntien  <les.  X.  Internationakn  ^ft'(^.  Con;/.,  ]\.  Ill, 

*  Deiitschf  med.  H'   hemchrifl,  vol.  xiii.  No.  2o. 

*  Comninnicntion  to  the  writer  from  Dr.  Charles  M,  Green,  Sept.,  1893. 

*  Personal  letter  from  Prof.  J.  W.  Me  Lane,  Oet.,  IS'.tli. 

*  Peraonnl  eomnuinieation  from  Dr.  Hohert  A.  Murray,  Oet.,  1893. 


Ibid. 


1    i 


PM 


!     ■ 


\! 


\:\  t 


342 


AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 


r 


of  life  and  tiscfulncss,  aiul  is  tlie  result  of  a  preventable  disease.  Yet  the 
disastrous  effects  of  puerperal  infection  are  not  represented  by  the  mortality 
alone.  Thousands  of  invalid  mothers  owe  their  impaired  health  to  the  milder 
grades  of  sepsis  in  childbed.  Xo  stronger  evidence  could  be  oft'ered  than  is 
afforded  by  the  foregoing  facts  of  the  need  for  improvement  in  the  obstetric 
methods  of  the  general  practitioner. 

Obstetric  antisepsis  dates  from  1847.  To  Ignatius  P.  Senunelweis,  a 
young  Hungarian  wiio  at  that  time  held  the  position  of  assistant  in  the  lying-in 
department  of  the  Vienna  General  Hospital,  belongs  the  credit  of  first  demon- 
strating its  efficacy.  The  obstetric  service  of  the  hospital  was  divided  into  two 
sections,  in  one  of  which  instruction  was  given  to  midwives,  in  the  other  to 
nietlieal  students.  It  was  with  the  latter  that  SemmeUvcis  was  connected.  The 
students  in  this  department  were  at  the  same  time  actively  engaged  in  the  pur- 
suit of  practical  anatomy  and  pathology.  The  women  were  delivered  by 
students  who  for  a  considerable  portion  of  their  time  were  occupied  with  the 
operations  of  the  dead-house  and  the  dissecting-room.  They  took  no  precau- 
tions to  cleanse  themselves  except  to  wash  tlieir  hands  with  soap  and  water, 
and  they  made  examinations  ad  libitum.  The  death-rate  was  excessive,  reach- 
ing nearly  10  per  cent,  of  the  Momeu  delivered. 

Horrified  at  this  frightful  mortality,  Seininelweis  bent  his  energies  to  find- 
ing the  cause.  He  was  struck  with  the  fact  that  in  the  midwives'  clinic  the 
death-rate  was  little  more  than  3  in  every  100  woujiMi  confined.  The  records 
showed  also  that  women  delivered  before  admission  nearly  all  escaped.  It 
appeared,  too,  that  prolonged  labors  in  the  students'  clinic  were  almost  invari- 
al)ly  followed  by  death,  while  in  the  midwives'  section  the  length  of  the  labor 
made  little  difference  in  the  mortality.  Daring  the  time  that  Semmelweis  was 
engaged  in  his  investigations  Prof  Kolletschka,  one  of  his  associates,  lost  his 
life  by  a  dissection-wound.  The  symptoms  of  his  colleague's  illness  were 
entirely  similar  to  those  of  the  fatal  malady  which  was  raging  in  his  own 
wards.  Impressed  with  the  identity  of  the  two  diseases,  it  dawned  upon  him 
that  the  cause  of  the  deadly  scourge  was  to  be  fijund  in  the  infected  iiands  of 
the  students  who  attended  the  labors. 

In  May,  1847,  he  established  the  order  that  students  before  taking  charge 
of  a  labor  case  should  wash  their  hands  in  eidorin-water  or  in  a  solution  of 
chlorinated  lime,  and  he  restricted  the  number  of  examinations.  The  result 
was  an  immediate  fall  in  the  death-rate.  In  six  months  it  had  dropped  ihnw 
nine  or  ten  to  three  per  hundred,  and  in  the  second  year  of  the  new  r6gime  it 
did  not  exceed  1.5  per  cent.  No  proof  could  be  clearer  of  the  correctness  of 
his  views,  yet  they  were  bitterly  opposed  by  the  profession.  He  struggled  in 
vain  for  the  acceptance  of  his  theories.  He  was  ridiculed  and  despised,  and 
finally  died  insane,  the  victim  of  continued  persecution.' 

Soon  after  its  introduction  into  surgery  by  Sir  Joseph  Lister  in  1866  anti- 
sepsis began  to  gain  a  permanent  foothold  in  obstetrics.     First  adopted  in 

'  For  niuny  of  these  facts  the  writer  is  indebtwl  to  an  address  by  C  T.  Culllngwortli,  M.  D., 
F.  R.  C.  P.,  entitled  Piurpenil  Fever  a  Preventabk  Disium. 


THE   CONDUCT   OF  NORMAL    LABOR. 


343 


liti- 
in 

I), 


1870  by  Stadfeklt  of  Copoiihagen,  it  was  taken  up  by  the  principal  maternities 
ot'Pjiirope,  and  to-day,  with  many  ini[)rovements  in  the  technique,  it  is  univer- 
sally practised  in  the  lying-in  hospitals  of  the  world. 

Practical  Rules  for  Disinfection. 

Indrumcntii,  Utcimli^,  and  Drcmm/n. — The  most  efficient  of  all  germicidal 
agents  is  heat.  For  instruments,  utensils,  sutures,  and  dressings  that  will  not 
be  injured  by  high  temperatures  heat  attbrds  the  best  means  of  disinfection. 
Either  of  three  methods,  dry  heat,  boiling,  or  steaming,  may  be  employed. 

])rif  Heat. — For  metallic  instruments  and  f(jr  most  utensils  exposure  in 
an  oven  is  a  convenient  and  effective  method  of  sterilizing.  It  is  necessary, 
on  the  one  hand,  to  make  sure  that  the  temperature  reaches  at  least  234°  F., 
and,  on  the  other  hand,  that  it  docs  not  exceed  400°  F.,  at  which  point  the 
temper  of  steel  instruments  would  begin  to  suffer  impairment.  F(»r  greater 
accuracy  in  regulating  the  temperature  a  tiiermometer  specially  made  for  the 
purpose  may  be  used.  As  some  time  will  be  require<l  to  bring  the  instru- 
ments to  the  necessary  degree  of  heat,  the  exposure  shordd  be  maintained  for 
at  least  fifteen  minutes  to  ensure  proper  sterilization. 

IloUimjf. — A  ready  means  of  sterilizing  most  instruments  is  by  boiling  them 
half  an  hour  in  water.  The  addition  of  1.5  per  cent,  of  washing  soda  to  tiie 
water  helps  to  remove  greasy  matter  and  prevents  steel  instruments  from 
rusting.  The  soda  should,  if  possible,  be  chemically  pure.  This  method  has 
the  advantage  tliat  it  is  available  in  any  household.  All  that  is  needed  is  a 
vessel  large  enough  to  hold  the  necessary  instruments  and  appliances  and  a 
range  fire,  gas  stove,  or  even  a  large  alcoliol  lamp.  In  emergency  no  more 
elaborate  apparatus  is  requircil  than  a  common  disii-pan.  Place  in  it  the 
instruments,  silk  sutures,  sponge  compresses,  and  other  materials  to  be  steril- 
ized, cover  thetn  with  water,  and  boil  for  the  requisite  length  of  time.  Turn 
off  the  water,  and  the  pan  serves  as  an  .aseptic  instrument-tray. 

Steaminr/. — Sterilization  by  steam  retpiires  special  apparatus.  Numerous 
appliances  arc  to  be  had  for  the  purpojic,  one  of  the  most  economical  of  wliich 
is  the  Arnold  steam-cooker.  This  process  is  available  for  practically  all  instru- 
ments, dressings,  and  utensils  not  too  bulky  to  be  containetl  in  the  sterilizer. 
It  is  well  to  place  the  articles  to  be  sterilized  in  a  wire  basket  or  a  cloth  bag  in 
which  they  may  be  lowertnl  into  the  steam-chamber.  This  facilitates  handling 
and  makes  it  possible  to  remove  the  instruments  promptly  on  opening  the 
sterilizer.  If  allowed  to  remain  in  tlie  steam-ehamber  for  even  a  few  seconds 
after  air  is  admitted,  the  instruments  become  wet  with  condensed  steam 
and  polished  steel  surfaces  are  liable  to  tarnish.  The  time  required  tor 
sterilization  is  from  thirty  tninutes  to  an  hour,  according  to  the  Itulk  and 
character  of  the  materials.     Dressings  need  the  longest  exposure. 

In  the  labor  ward  of  a  hospital  a  steam-sterilizer  may  be  kept  in  operation 
•luring  the  labor,  and  the  instruments,  compresses,  sutures,  and  dressings  may 
be  taken  direct  from  the  Rteam-cbamber  as  th(>y  are  wanted  for  use. 

Chemical  Antiseptics. — Among  the  chemical  agents  most  commonly  em- 


mv- 


V  ' 


;  ■  1 


Eii- 


i/'i 


JM 


'  :  !' 


344 


AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 


ployed  for  obstetric  antisepsis  are  the  mercuric  chlorid  dissolved  in  water,  in 
.strength  of  from  1  :  2000  to  1  :  500,  the  mercuric  iodid  in  similar  proportion, 
the  peroxid  of  hydr(»gen '  (lo-volume  solution),  the  liquor  sodoe  ehlorinatse 
diluted  with  9  volumes  of  water,  a  2  ])er  cent,  creolin  mixture  (in  water),  a 
2  to  5  per  cent,  solution  of  carbolic  acid,  and  a  1  :  1000  solution  of  hydro- 
naphthol.  The  order  in  which  they  are  named  is  substantially  that  of  their 
germicidal  potency. 

The  j)ractical  efficiency  of  mercuric  chlorid  (corrosive  sublimate)  is  greatly 
increased  by  the  addition  to  the  solution  of  five  parts  of  hydrochloric,  tartaric, 
or  acetic  acid  for  each  ])art  of  the  sublimate,  since  in  neutral  solutions  of  that 
salt  the  mercury  is  preeipitatetl  as  an  albuminate  on  contact  with  blood  or 
with  other  albuminous  liipiids.  The  acid,  moreover,  serves  to  protect  the 
solution  against  impairment  of  strength  by  contact  with  the  alkaline  fluids  of 
the  tissues.  The  mercuric  chlorid  is  decomposed  by  alkalies.  The  mercuric 
iodid  (biniodid  of  mercury),  recpiires  the  addition  of  on  equal  weight  of 
the  iodid  of  j)otassiura  to  render  it  freely  soluble.  With  this  salt  no  acid 
ia  required.  Neutral  solutions  of  the  mercuric  i(xlid  yield  no  precipitate 
M'ith  albumin.  The  chlorinated-soda  solution,  the  ])eroxid  of  hydrogen,  and 
the  creolin  mixture  have  the  advantage  of  being  practically  non-poisonous,  and 
they  are  therefore  more  suitable  to  be  trusted  to  the  nurse  than  the  mercurial 
preparations. 

The  Obdeti'ician. — The  obstetrician  should  always  be  clean ;  especially  must 
Jiis  hands  be  clean,  and  he  should  wear  clean  clothing.  It  is  well  to  avoid  con- 
tact with  ])athological  material  and,  so  far  as  possible,  with  other  sources  of 
wound-infection.  Yet  attendance  on  post-mortems  and  contagious  diseases  is 
not  necessarily  inconsistent  w-ith  the  safe  conduct  of  confinements,  provided  a 
rigorous  antiseptic  cleansing  be  always  observed  as  a  preliminary  to  the  care 
of  the  obstetric  patient.  After  a  septic  exposure  an  entire  change  of  clotiiing 
and  repeated  and  conscientious  use  of  disinfectants  nnist  be  practised  before 
taking  charge  of  a  case.  The  writer  has  repeatedly  attended  a  prolonged 
labor,  has  delivered  by  forceps,  and  has  repaired  perineal  rupttu-es  within  one 
or  two  hoiu's  after  having  the  hands  bathed  in  offensive  pus,  witiiout  infect- 
ing the  patient.  Repeated  scrubbings  with  hot  water  and  soap  and  with  dis- 
infectants, including  the  final  use  of  the  permanganate  method,  will,  if 
properly  executed,  ensure  complete  asepsis  of  the  hands  within  an  hour 
after  the  worst  exposure. 

When  summoned  to  a  case  of  labor  immediately  after  a  septic  contact, 
besides  the  usual  care  in  disinfection,  in  simple  labor  all  internal  examina- 
tions may  be  avoided.  In  addition  to  this,  it  is  possible,  if  thought  necessary, 
to  manage  the  birth  even  without  contact  with  the  external  genitals  of  tlio 
patient,  tlie  required  manipulations  being  conducted  through  the  intervention 
of  a  fresh  towel  well  saturated  with  the  antiseptic  solution. 

It  is  impossible,  however,  to  lay  down  rules  which  alone  will  make  an 
aseptic  practitioner.  The  obstetrician  must  be  ])ossessed  of  an  aseptic  instinct, 
'  The  l)e8t  j)roparation  of  tlip  jieroxid  of  liydrogen  is  pyrozone. 


10 

In 
In 


THE   CONDUCT   OF  NORMAL   LABOR. 


,'J45 


and  this  is  a  matter  wliich  comes  of  training  and  a  keen  appreciation  of  the 
])ossible  sources  and  modes  of  infection. 

In  liospital  practice  the  obstetrician  should,  during  attendance  upon  a  hibor, 
wear  a  fresh-laundered  gown  or  a  clean  ai)ron  large  enough  to  prevent  contact 
of  his  hands  with  his  clothing.  His  hands  and  forearms  arc  to  be  cleansed 
thoroughly  and  disinfectetl  before  the  first  examination,  and  before  each  subse- 
quent contact  with  the  genitals  if  they  have  in  the  mean  time  touched  anything 
that  is  not  aseptic. 

For  the  disinfection  of  the  hands  the  following  method,  which  is  substanti- 
ally that  of  Fiirbringer,  is  reconuuenoled  : 

1.  Clean  the  nails  dry. 

2.  Scrub  the  hands  and  forearms  for  not  less  than  three  minutes  with  a 
hand-brush,  with  soaj)  and  water  as  hot  as  can  be  borne.  Special  care  must 
be  taken  in  brushing  the  nails  and  finger-tips,  and  the  water  should  be  changed 
two  or  three  times. 

3.  Soak  well  with  alcohol  (not  below  80  per  cent.)  and,  before  it  evaj)orat('s, 

4.  Immerse  for  three  minutes  in  a  hot  solution  of  mercuric  iodid  or 
chlorid  (1  :  2000  to  1  :  500),  or  in  a  3  })er  cent,  solution  of  carbolic  acid. 

Undoubtedly,  the  most  essential  step  in  the  process  is  the  soap-and-water 
scrubbing.  It  not  only  removes  the  greater  part  of  the  offending  material, 
but  it  is  also  indispensable  to  the  proper  action  of  the  antiseptic  solution. 
The  latter  can  penetrate  the  skin  only  after  the  oily  matter  has  been  removed 
and  after  the  skin  is  thoroughly  wet.  The  use  of  alcohol  helj)s  the  action  of 
the  chemical  solution  by  dehydrating  the  skin  and  rendering  it  hygroscopic, 
thus  favoring  penetration  of  the  solution. 

Welch,  of  the  Johns  Hopkins  Hospital  at  Baltimore,  recommends  the  fol- 
lowing procedure,  which  is  known  as  the  pennanr/anate  method.  By  it  tlie 
hands,  it  is  claimed,  may  be  rendered  practically  sterile  to  culture  tests  : 

1.  The  nails  are  cut  short  and  carefully  cleaned. 

2.  The  hands  and  forearms  are  serul)t)ed  for  three  minutes  with  soap  and 
water.  The  brush  before  using  is  sterilized  by  steam,  and  the  water,  which  is 
as  hot  as  can  be  borne,  is  frequently  changed.  The  soap  is  rinsed  off  with 
plain  walor. 

3.  The  hands  are  next  immersed  in  a  warm  solution  of  permanganate  of 
potassium  and  are  scrubl)ed  with  a  sterilized  swab.  Distilled,  or  at  least 
boiled,  water  should  be  used  for  the  solution,  w'hich  should  be  saturated. 

4.  The  hands  are  next  held  in  a  warm  saturated  solution  of  oxalic  acid  in 
boiled  water  until  the  permanganate  stain  is  entirely  discharged. 

5.  After  rinsing  in  sterilized  water  the  hands  are  immersed  for  two  minutes 
in  a  1  :  -500  mercuric-chlorid  solution. 

The  Nurse. — The  nurse  should  be  no  less  careful  than  the  obstetrician  in 
the  observance  of  all  antiseptic  details. 

The  Patient — In  hospital  practice  the  patient  has  a  bath  and  a  change  of 
clothing  at  the  onset  of  labor.  Before  the  fir-it  internal  examination  the 
abdomen,  the  thighs,  and  the  vulva  are  cleansed  by  the  nurse  with  soap  and 


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AMUR/CAN  TEXT-BOOK  OF  OBSTETRICS. 


warm  water.  The  soapy  water  is  rinsetl  off  and  the  parts  are  well  bathed  with 
the  antiseptic  solution.  It  is  a  nseful  precaution  to  cover  the  limbs  of  the 
patient,  when  she  takes  the  1)C<1,  with  a  pair  of  muslin  leggings  fresh  from 
the  sterilizer.  The  leggings  should  be  closed  below,  so  as  completely  to 
envelop  the  feet.  In  addition  to  this,  the  patient  and  the  entire  cot  may  be 
covered  with  a  sterilized  gauze  sheet.  During  the  first  tage  a  vulvar  dress- 
ing saturated  with  Thiersch's  solution  may  be  worn. 

Similar  precautions  are  not  all  practicable  in  private  practice,  nor  are  they 
all  necessary.  The  clr'iij^e  of  clothing,  the  preliminary  cleansing  and  disinfec- 
tion of  the  external  genitals  and  adjacent  surfaces,  and  the  aseptic  cleanliness  of 
everything  that  comes  in  contact  with  the  birth-canal  nujst  always  be  insisted 
upon. 

The  utility  of  prophylactic  vaginal  douches  is  a  question  which  has  pro- 
voketl  much  discussion.  Stetfeck  '  recommends  vaginal  irrigation  during  labor 
with  mercuric-cMorid  solution  at  intervals  of  two  hours,  rubbing  the  antisep- 
tic well  into  the  mucous  membrane  with  the  lingers. 

Doderlein  ^  advises  scrubbing  the  vagina  with  a  preparation  of  creolin  and 
mollin,  followed  by  a  ten-minutes'  douching  with  the  creolin  solution. 

Hofmeier^  favors  preliminary  disinfection,  especially  in  maternity  hospitals 
where  students  are  allowed  to  examine  the  patients  during  labor.  He  concludes, 
from  a  comparison  of  the  records  of  the  Wiirzburg  clinic  with  the  published 
statistics  of  other  like  institutions,  that,  with  preliminary  disinfection  and  the 
carefid  observation  of  all  possil)le  antiseptic  precautions,  instruction  by  means 
of  examinations  during  labor  does  not  necessarily  increase  the  danger  of  infect- 
ing the  patient.  He  further  contends  that  thorough  disinfection  of  the  birth- 
canal  is  not  a  source  of  danger  to  the  mother,  as  has  been  claimed,  but  that  it 
results  in  a  diminished  puerperal  morbidity  and  mortality, 

FrommeP  reports  over  five  hundred  cases  in  which  vaginal  injections  of 
the  corrosive-sublimate  solution  (1  :  2000)  were  en>i  h,  'etl,  and  where  in 
manv  abnormal  ciises  from  sixty  to  seventy  examin?  lL)us  vere  made  during 
the  patient's  stay  in  the  hospital,  the  clinic  being  oiwu  to  about  one  hundred 
students,  and  being  also  used  for  the  training  of  midwives.  In  this  number 
of  patienis  there  were  two  cases  of  sepsis  whose  infection  was  traceable  to  his 
clinic.  The  morbidity-rate  was  from  5.5  to  7.5  per  cent.  In  another  series  of 
cases,  where  external  disinfection  alone  was  praetisetl,  the  morbidity  rose  to 
11.1    per  cent. 

Mermann  ^  reports  the  results  of  seven  hundred  cases  without  the  employ- 
ment of  vaginal  douches  for  preliminary  disinfection.  He  records  a  morbidity- 
rate  of  6  per  cent.,  with  no  deaths  from  septic  infection.  In  the  last  two  hun- 
dred births  there  were  two  cases  of  mild  ophthalmia,  and  in  all  less  than  ten 

'  "  Ueber  Disinfection  des  Weiblichen  Genital  Canals,"  Zeitschrift  /iir  GeburtshiVfc,  vol.  xv. 
p.  395. 

'■'  "  Disinfection  des  Geburts-Canal,"  Archiv  JUr  Gyiidkologie,  vol.  xxxiv.  111. 

'  Deutiichi'  mcd.  Wochcmchrijt,  1S!)1,  No.  49.  ♦  Ibid.,  1892,  No.  10. 

»  Centralblatt  fiir  Gyndkologie,  1892,  No.  99. 


THE    COyOCVT    OF  ^OIi^fAL    LABOR. 


347 


of  conjunctivitis  anionjT  the  children.  Merniann  omits  internal  exaiiiinations 
whenever  practicable,  observing  the  progress  ot"  the  labor  by  abdominal  palpa- 
tion and  auscultation. 

LeopoKl  and  Goldberg'  publish  the  statistics  of  several  thousand  deliveries 
with  and  without  the  eniploynient  of  vaginal  disinfection.  Their  tables  show 
the  best  results  where  the  vaginal  douches  were  not  used.  They  recommentl  the 
employment  of  abdominal  palpation  as  a  means  of  noting  the  progress  of  labor, 
and  th(!  restriction  of  vaginal  examinations  to  cases  of  dystocia,  except  when 
necessary  to  confirm  a  diagnosis  made  by  the  abdominal  method.  They 
advise  douches  in  operative  cases  and  in  all  others  where  previous  infection 
is  suspected. 

Fischel  in  an  experience  of  880  births  at  the  Prague  Maternity  lost  nine 
women  from  sepsis  with  the  employment  of  preliminary  disinfection.  After 
sto|)ping  the  use  of  the  irrigations,  iu  a  scries  of  933  cases  there  were  but  two 
deaths  due  to  infection,  and  a  year  later,  in  521  women  delivered,  there  were 
no  deaths  from  that  cause. 

The  safer  course,  at  least  for  general  use,  is  undoubtedly  the  restriction  of 
internal  examinations  as  much  as  practicable,  and  of  the  preliminary  vaginal 
douche  to  cases  in  which  the  scd'ctions  are  pathological.  In  the  presence  of 
purulent  gonorrheal  discharges  both  the  vaginal  and  cervical  canal,  as  well  as 
the  vulva,  ought  to  be  cleansetl  carefully  with  soap  and  water  and  gentle  fric- 
tion with  the  fingers,  and  subsecpiently  washed  well  with  the  antiseptic  solution. 
In  extreme  cases  the  disinfection  may  be  repeated  at  intervals  of  two  or  three 
hours  during  the  labor.  This  is  required  not  only  in  the  interests  of  asepsis 
for  the  mother,  but  as  a  i)rophylactic  against  ophthalmia  in  the  child.  Mer- 
curials, however,  are  not  suitable  for  the  purpose,  owing  t'>  the  danger  of 
mercurial  intoxication,  Merctuy  has  been  found  in  the  stools  after  a  single 
vaginal  irrigation.  Some  of  the  non-toxic  disinfectants,  such  as  creoliu, 
peroxid  of  hydrogen,  or  the  chlorinated-sotla  solution,  are  to  be  recomnit-nded. 

Doderlein  has  calliHl  attention  to  the  litmus-rea^'tion  as  a  ready  means  of 
distinguishing  healthy  from  morbid  vaginal  secretions.  He  points  out  that 
while  in  health  they  are  strongly  acid,  in  pathological  conditions  of  the  secre- 
tions their  reaction  is  feebly  acid,  neutral,  or  alkaline.  These  observations 
have  been  confirmed  by  Williams  ol  Baltimore.  The  litmus-reaction  of  the 
vaginal  secretions  therefore  affords  a  convenient  guide  to  the  conditions  in 
which  preliminary  internal  disinfection  is  indicated. 

Ant'HepHis  in  the  Use  of  flie  Catheter. — Should  the  patient  require  to  be 
catheteriz(><l  after  labor,  care  will  obviously  be  needed  to  prevent  infection 
of  the  vaginal  wounds  and  abrasions.  But  this  is  not  all.  Cystitis  of  the 
vesical  neck  frequently  results  from  infectious  material  carried  into  the  bladder 
during  the  use  of  the  catheter.  So  common  is  this  accident  that  patients  who 
have  repeatally  been  catheterizcd  by  the  mirse,  even  with  ordinary  precautions, 
very  rarely  escape  some  degree  of  vesical  irritation,  and  they  often  sutt'er  from 
severe  inflammation  of  the  bladder  or  of  the  vesical  neck.     Pyelitis  may  even 

'  Dcutuchc  mad.  Wuchmachn/t,  1892,  No.  13. 


iri 


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348 


AMERICAN  TEXT-BOOK'  OF  OBSTETRICS. 


result  by  extension  of  the  septic  process  from  tlie  vesical  mucosa  through  the 
ureters.  The  strictest  asepsis  must  therefore  be  observed  in  catheterizing  the 
bladder.  The  instrument  should  be  boilitl  in  water  for  fifteen  minutes  imme- 
diately before  using,  and  this  is  pctssible  even  with  soft-rubber  catheters  with- 
out material  injury  to  tiie  instnmient.  It  should  then  be  haiulled  only  with 
hands  that  have  been  previously  sterilized. 

The  patient  lies  \\\wn  the  back  with  the  knees  drawn  apart.  The  labia  are 
to  be  held  apart,  either  by  the  jiatient  herself  or  by  an  assistant,  so  as  to  com- 
pletely expose  the  meatiis  urethra^  and  so  held  until  the  instrument  is  passed. 
The  meatus,  the  vestibule,  and  all  the  surrounding  surfaces  are  to  be  cleansed 
with  soaj)  and  water,  and  subsequently  be  washed  with  the  disinfectant  solu- 
tion. The  catheter,  well  lubricated  with  sterilized  vaselin,  is  then  passed  with 
clean  hands  and  with  the  parts  fidly  exposed  to  the  eye. 

Precautions  must  be  used  to  prevent  urine  from  trickling  over  the  wounded 
surfaces  or  into  the  vagina  as  the  instrument  is  withdrawn.  The  catheter, 
after  using,  should  be  cleanstMl  carefully  with  water.  Care  must  be  taken  that 
irritating  chemical  antiseptics  are  not  carried  into  the  urethra  upon  the  catheter; 
otherwise  a  troublesome  urethritis  may  result. 

2.  Management  op  Normal  Labor. 

Essential  to  the  proper  management  of  childbirth  is  a  watchful  super- 
vision of  the  health  and  habit^  of  the  i)atient  throughout  pregnancy,  and  a 
previous  knowledge,  so  far  as  possible,  of  the  conditions  to  be  dealt  with  in 
each  case  during  labor.  Next  to  Listerian  cleaidiness,  nothing  is  destined  to 
do  more  for  improv  ■  I  results  in  obstetrics  than  the  practice,  now  happily 
growing  with  obstetricians,  of  studying  their  cases  before  labor. 

It  is  desirable,  therefore,  Miat  the  jiregnant  woman  be  under  the  observation 
of  her  physician  from  an  early  period  of  gestation,  and  especially  if  the 
experience  be  her  first.  Much-needed  information  and  advice  may  be  im- 
parted with  reference  to  the  hygienic  requirements  of  pregnancy.  Knowledge 
may  be  gained  of  conditions  likely  to  complicate  the  parturient  or  puerperal 
process,  and  much  may  often  be  done  to  fortify  the  health  and  strength  of 
the  ])atient. 

Dystocia,  if  it  cannot  be  prevented,  is  more  successfully  managed  with  the 
aid  derived  from  previous  knowledge  and  preparation.  I]ven  w'hen  all  is 
normal,  both  jiatient  and  jjliysician  are  amply  rej)aid  for  their  pains  by  the 
increased  confidence  with  which  the  result  of  labor  is  awaited. 

The  patient  should  be  atlvised  with  reference  to  the  selection  of  her  nurse. 
Instructions  will  be  needed  pertaining  to  the  care  of  the  nipples.  Siie 
should  be  directed  to  cleanse  them  daily  during  the  last  month  or  two  of 
pregnancy,  and,  if  they  are  very  small  or  suidven,  to  draw  them  out  with  the 
fingers.  This  manipulation  also  helps  to  inure  them  to  nursing.  Daily 
inunction  of  vaselin  or  of  fresh  cocoa-butter  during  the  same  period  keej)S 
them  supple,  and  is  a  better  preparation  for  suckling  than  the  use  of  astrin- 
gents so  commoidy  practised. 


THE    CONDUCT   OF   NORMAL    LABOR. 


349 


Especially  Important  is  it  tliat  tho  functions  of  tlic  kidneys  he  watched. 
Dnrinji;  the  last  one  or  two  months  before  labor  the  urine  should  be  examined 
weekly.  An  occasional  examination  at  an  earlier  period  is  generally  advisable. 
If  albumin  be  found,  the  microscopic  study  of  the  urine  will  best  reveal  the 
character  and  extent  of  the  structural  chanfjes  in  the  kidneys.  In  doubtful 
cases  the  best  evidence  of  the  manner  in  which  these  or}j;ans  are  performing 
their  functions  is  afforded  by  occasional  quantitative  tests  for  urea. 

Obstetrical  Examination. 

In  the  later  months  it  is  the  duty  of  the  jjhysician  to  make  a  preliminary 
obstetric  examination.  Tlie  most  suitable  time  is  usually  about  the  end  of  the 
eighth  month.  The  object  is  to  determine  the  position  and  presentation  of  the 
child,  the  relative  size  of  head  and  pelvis,  and  the  poi-sible  presence  of  patho- 
logical conditions  that  may  conjplicate  the  mechanism  of  labor.  It  is  to  be 
assumed  that  full  information  has  already  been  obtained,  at  the  time  of  engag- 
ing to  attend  the  patient  in  confinement,  with  reference  to  her  obstetric  history, 
including  the  number  of  previous  pregnancies,  term  labors,  and  miscarriages, 
all  important  facts  pertaining  to  the  character  of  the  pregnancies,  labors, 
and  childbed  period?,  and  particulars  relating  to  the  course  of  the  present 
pregnancy. 

In  hospitals  it  is  the  rule  to  make  an  external  and  an  internal  examination. 
Ill  private  practice  an  internal  examination,  while  always  desirable,  need  not 
in  all  cases  be  insisted  upon.  Usually  all  that  is  necessary  to  know  may  be 
determined  by  the  external  methods.  In  the  presence  of  pelvic  deformity, 
and  in  all  cases  in  which  for  any  reason  the  external  examination  is  not  satis- 
factory, exploration  of  the  pelvic  cavity  should  not  be  omitted. 

It  is  essential  that  the  bladder  and  the  rectum  be  empty.  The  patient  lies 
upon  a  bed  or  a  lounge,  covered  with  a  sheet  and  with  the  limbs  outstretched. 
Her  clothing  is  to  be  loosened  and  the  skirts  drawn  above  the  abdomen.  The 
necessary  manipulations  are  conducted  under  the  sheet  or  through  it,  without 
exposure  of  the  patient.  In  this  maimer  the  abdominal  examination  and  the 
external  measurements  of  the  pelvis  may  be  made  without  causing  discomfort 
or  giving  offense. 

The  hands  of  the  examiner  are  first  bathed  in  warm  water  to  render  the 
skin  soft  and  the  touch  more  acute.  This  precaution,  too,  helps  to  prevent 
reflex  contractions  of  the  abdominal  and  the  uterine  muscles,  which  are  more 
liable  to  occur  when  the  hands  are  applietl  cold  to  the  abdomen. 

The  examination  should  be  methodical.  Errors  of  diagnosis  are  more  fre- 
quently the  result  of  carelessness  than  of  ignorance.  Success  here,  as  in  most 
other  undertakings,  depends  upt)n  a  capacity  for  taking  jiains.  All  manipula- 
tions are  to  be  conducted  gently,  and  need  never  cause  the  slightest  pain, 
except  rarely  when  deep  ])ressure  is  rc«|uircd  to  map  out  the  lower  fetal  polo. 
A  definite  order  of  procedure  is  recommended  in  accordance  with  the  following 
scheme : 


■|i"1 


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a 


3o()  AMi:iiivAy  Thwr-nooh'  of  onsTiyntics. 


1.    DrACNOSIS    OK   TMK    KkTAL    I'KKSKNTATION    AMt    POSITION. 

Lncftfinn  of  the  Dnrxnl  P/inic  initf  Suui/I  Ptirfs, — Tlic  sitiiatinii  of  the  (If)rsal 
plane  and  small  parts  of  tlie  fetus  may,  as  a  rule,  easily  l)e  made  ont  hy  palpat- 
ing; tliealxlomen.  The  palmar  surfaces  of  the  finger-tips  are  applied  with  lij;lit 
iiitermittinj;  touches  (Fig,  1H7).  Heginniiigat  the  lo\v(>r  part  of  the  abdomen,  a 
narrow  zon«'  is  palpatetl  entirely  across  from  one  side  of  the  tumor  to  the  other. 
The  palpation  is  repeated  over  a  similar  area  just  above  the  first,  and  so  on  until 
the  entire  surface  of  the  timior  has  been  explored.  The  situation  of  the  f«'tus 
will  usually  be  learned  by  the  first  t<»uclies.  It  presents  to  the  examining 
fingers  the  feel  of  a  solid  body,  while  elsewhere  over  the  tumor  only  fluid 
is  felt. 

The  location  of  the  child  niav  more  readilv  be  made  out  bv  J)laei'ic:  one 
hand  flat  upon  the  middle  section  of  the  abdomen  and  pressing  firmly  back- 
ward (Fig.  188).  The  licpior  amnii  is  thus  displaced  to  one  side  and  the  child 
to  the  other,  where  it  can  more  easily  be  j>alpated. 


Fic.  IST.— (ii'iicral  palpiitiDii  of  iiliilomcn  for  Icu'iitiiif;  ilcirsal  plimo  ami  small  parts  of  futiis  (from  a 

liliotnuraph). 

The  child's  back  is  identified  by  the  length  and  breadth  of  the  resisting 
j)lane  which  is  offered  to  the  examining  touch,  and  by  the  absencie  of  a  suIcmis 
between  it  and  the  fetal  head.     The  side  of  the  child  presents  a  narrower 


i:it- 

icr. 
iitil 
■tiis 

luid 


otic 


hil.l 


III)'. 


Ivcr 


coNnrcr  ok  nokmai,  kahoh. 


I'l.Mi:  "J.-l. 


KXA.MINATlciS    lii;i()IIK    I,. Midi!:    llxiimilllltinll  (if  IdWtT   I'cllll    |icilf  ilVolll  II  |illnl(,i.'ni|ill 


I 


1 1 


.'I  I  Iter  i( 

lIlC    11)1 

cf  the 


;-; '.  -r «,,  i™:  t;;;,""  :■  -'—  > '- '->  ,1,. 


■'"tt'rior  position  of  the  child'-  I      I 

/'        .  l"j-'ituoi    position 

'"■""'»  «"'  "I«.n  .1,0  alKl.„„c.„  „v,.    ,       w"""-'  "'"  "'""■■■'■'«  fc., .0,1,,. 

^ft"'nit  of  the  iitmis(I'|.2;}). 


'ill.!  "|i,'  ifi ' 

ii 

iil 

'i  111 


l8 


Ii 


I         :i: 


1 


o;'»-2  ami:rivax  text-book  of  obstetrics. 

With    tlio    liaiuls    irstiiij;    upon    the    sitlos    of    the    tumor,    thoir    palmar 


Kii; 


sinks  (U'opiT  in  llic 


,Sll 


rfacrs  nearly    laoiu};  each  otlii-r  and    the   tin<!;er-ti})s   1    or  2  inches  ahovo 


Ki(i.  I'.iii  —  Kxiiiniiiiit 


L'()|l(ll(ll 


tile  level  of  the  piibes,  maintaining  firm  pressure,  the  llnger-tips  are  gently 


(OXDlCr  OF  X 


*»liMAL   LAHon 


Vi. 


vn:  '24. 


I 

Wf 

1 

tl 

!« 

1 

ii 

ll. 

1 

28i 

1 

m 

i:.\ 


^'II^VIInN     lt|:r,,|;|;    I, 


»liiil::   I, 


I'lilii 


" I'll.'llir   I 


'■  ii'i; ill, 


'■"inlrnni 


111. I  |.ll..|,,i;,;,|,h 


■"■'■'liii-  III.'  Umul 


iii'n..s>  II 


I''  Mi|ini 


p 

I  MW 

,     '  r 

.     f 

!    1 

J.       '? 

1    / 

i 

;                               i 

1 

'    r 


r 
t( 

iij 

Ml 
til 

if* 

ill  I 


/ 


i 


I      > 


bri 
diK 

put 
the 
the 

ri<,Wi 

ci'tl 

tlesc 

men 

liciic 

/ 

siiniil 

upon 

tiiwai 

I'llCOU 
pillar  , 

pivs.si: 
l''iii(ll 

•  '.•Itcs  { 

"I'  flio 

I"  fill' 


THE    COX  DUCT    OF  XORMAL    LAliOJi. 


353 


thrust  downward  into  the  hriin  of  tlie  pelvi^i.  Tlie  pelvic  excavation  is  then 
explored  to  learn  if  it  contains  the  presentinjj;  fetal  part.  If  it  is  tilled  before 
labor,  the  i>resenting  ])art  is  the  vertex.  Xo  other  fetal  part  sinks  into  the 
lesser  pelvis  nntil  labor  begins,  and  even  this  sinking  very  rarely  occurs  except 
in  priniipara\  In  the  latter  the  fetal  head  is  normally  always  in  tho  j-.clvic 
brim.  Dnriiig  labor  either  pole,  whether  the  woman  has  previously  borni^ 
children  or  not,  should  be  found  in  the  lesser  }K>lvis. 

The  head  when  it  lies  above  the  lesser  pelvis  is  not  usually  so  accessible  to 
palpation  as  when  in  the  excavation.  A  useful  nianeuvre  for  locating  the 
liead,  if  it  is  not  readily  found  by  direct  palpation,  is  to  i)lace  the 
hands  in  the  usual  position  over  the  sides  of  the  lower  uterine  seg- 
ment and  proceed  as  for  external  ballottement,  bringing  the  hands  more 
;ind  n\ore  nearly  together  initil  the  head  is  found.  The  head  will  be 
ivcognized  as  a  solid  globular  body  which  can  be  tossed  from  one  band 
to  the  other. 

The  cephalic  extremity  is  distinguished  from  the  breech  by  its  greater 
mobility  when  it  lies  above  the  excavation,  by  its  hardness  and  globular  shape, 
and  by  the  presence  of  a  sulcus  between  it  and  the  fetal  trunk.  The  breech 
alone,  is  smaller,  with  the  interior  extremities  larger  than  the  head.  It  lacks 
tlie  hard  and  globular  character  of  the  head,  and  presents  no  sulcus  between 
itself  and  the  trunk.  An  imperfect  ballottement  of  the  heatl  is  frequently 
ol)tainable  when  it  lies  in  the  lower  segment  of  the  uterus  above  the  pelvic 
inlet. 

C('i>haliG  Promiucncc. — When  the  head  is  in  the  excavation  one  side  of  the 
brim  will  be  found  more  completely  tilled  than  the  other  (Fig.  189).  This  is 
due  to  the  fact  that  the  occiput  sinks  deeper  into  the  pelvic  cavitv  than  the  sinci- 
put. On  one  side  the  frontal  portion  of  the  head,  on  the  other  side  the  najie  of 
the  neck,  occupies  the  pelvic  brim.  That  side  of  the  cephalic  tumor  which  is 
the  more  prominent,  therefore,  is  the  sinciput.  Cephalic  prominence  to  the 
right  indicates  a  left,  to  the  left  indicates  a  right,  fetal  position.  The  situation 
of  the  greater  prominence  will  be  observed  in  the  course  of  the  pal|>ation  above 
(lesiribed.  It  may  also  be  made  out  by  arching  the  hand  across  the  abdo- 
men innnediately  above  the  ))ubes  (PI.  24;  Fig.  l!*.'i).  The  cephalic  promi- 
iicni'c  will  be  found  most  marked  in  <K'cipito-posterior  positions. 

Location,  of  the  Anterior  Shonbh')'  in  }'erte.r  J^resentotio)). — The  anterior 
siioulder  may  usually  be  found  as  follows:  While  the  bands  are  stiP  held 
upon  the  abdomen  over  the  sides  of  the  fetal  head,  move  them  upwar<l 
toward  the  fundus  without  ri'laxing  the  pressure.  The  first  obstacle  they 
tiicounter  is  the  anterior  shoidder,  which  may  more  fidly  be  identitied  by  map- 
l)iiig  it  out  with  the  fingers  of  one  hand.  Steadying  the  fetal  mass  by  gentle 
pressure  with  the  other  hand  over  the  breech  facilitates  the  examination. 
I'iiidinir  the  anterior  shoidder  within  1  or  2  inches  of  the  inediau  line  iiidi- 
tales  an  anterior,  and  several  inches  from  tiie  median  line  a  post(>rior,  position 
(if  the  fetus.  In  left  ])ositions  the  shoultler  lies  to  the  left,  in  right  positions 
to  the  right,  of  the  median  line  (Fig.  15>2). 
2:t 


lU- 


%i%\ 


'mm. 


).' 


:  a 


}Sn 


ill    liifeM:  iv.:,.i:'E 


.'. 


/ 


!r 


sr)4 


AMEIIK'AX    TEXT-BOOK    OF   OliSTETRIVS. 


Kxianinntlon  of  the  rjt/tcr  Fetal  Pule. — The  cxaiuiiier  next  faces  the 
mother's  fiioe  and  phu-es  his  hands  over  the  sides  of  the  fnndns  (Figs. 
190,  IDl).  The  finiihil  poh-  of  the  fetus  is  then  examined  hv  palpation. 
The    head    is    differentiated    from    the    breeeh    by    the    characters    ah'eady 


Km.  I'.il.— Kxainiimtinii  df  uiiper  Mai  polo  (from  a  photograph). 

mentioned  and  by  a  more  pronounced  ballotteinent  than  is  usually  pos- 
.sible  when  the  head  presents.  By  reason  of  its  smooth,  globular  shape, 
and  especially  of  its  flexible  attachment  to  the  trunk,  the  head  is  very 
movable,  rebounding  distinctly  under  the  touch  when  in  the  roomy  upper 
uterine  segment. 

Location  of  the  Fetal  Heart-to)ie,s. — The  stethoscope  may  or  may  nol 
be  u.'^ed,  according  to  the  usual  habit  of  the  examiner.  The  point  at 
Mhich  to  listen  first  is  directly  over  the  supposed  location  of  the  upper 
part  of  the  child's  back.  Failing  here,  the  entire  surface  of  the  tunmi 
may  be  .searched. 

The  hen  it -.sounds  are  usually  heard  over  an  area  of  about  3  inches  in 
diameter,  but,  since  they  are  .sometimes  more  widely  diffused,  it  is  importaii! 
to  locate  the  point  of  greatest  intensity.  The  point  upon  the  abdomen  ;i! 
which  they  are  mcst  intense  is  termed  the  j'(tcH.s  of  aniicultafion.  As  a  nil''. 
this  point  overlies  the  fetal  heart.      Exceptionally,  the  sounds  are  most  di- 


Is  vorv 


KT 


upi 


ay  not 
|)int   ill 

tumor 


llies  in 

l>ortan! 

Lieu  ill 

|i  rill''. 

St  (li-- 


THE    COXDiCT    OF  yORMAfj    LAliOli. 


>)i> 


tiiictly  heard  at  some  remote  point,  owing  to  firmer  contact  of  the  i'etus  witli 


Fi<i.  11.12.— Mftppiiig  out  tho  anterior  shoulder  (from  ii  photoKrnph). 

tlio  utorino  wall  at  that  point.     Their  location  usually  serves  to  distinguish 
lelt  from  right,  and  anterior  from  posterior,  positions.     In  a  posterior  posi- 


Kio.  l;i;{.— .Mftliiiil  of  lociitiui;  the  eeiihiilic  proiniMriiee  hy  iir( '.nu','  the  hanil  iicmss  the  suimipuhie 


reKinu 


tioii  the  heart,  if  heard  at  all,  is  found  far  hack  over  one  side  of  the  ahdo- 
iiit'ii ;  frc(|uently  the  cariliac  .sounds  are  (piite  indistinct ;  rarely  they  .uvj 
\vli(»lly  inautlible. 


1: 


I  !■ 


356 


AMKRJCAN    TEXT-nOOK    OF   OliSTETIilVS. 


For  the  diagnosis  of  prosoiitation  the  sitiiutioii  of  the  fetal  heart  is  of 
limited  value  in  women  who  have  borne  ehildren.  Sinee  the  position  of  the 
lieart  is  nearly  midway  between  the  extremities  oi'  the  fetal  ovoid,  tlie  mere 
inversion  of  the  long  axis  of  the  child  makes  little  ditlerence  in  the  location 
of  the  heart-somids.  In  primiparie,  in  whom  the  presenting  pole  sinks  into 
the  excavation  in  vertex,  and  rides  above  it  in  breeeh,  presentation,  the  level 
at  which  the  heart-tones  are  heard  is  of  some  valne  in  determining  the  pres- 
entation. In  first  pregnancies  this  level  will  usually  be  found  below  the 
umbilicMis  in  cephalic,  and  above  it  in  breech,  presentation. 

The  Location  of  the  Fetal  Movements  must  be  taken  on  the  statement  of 
the  mother,  which  statement  as  an  aid  to  diagnosis  is  liable  to  the  usual  fal- 
lacies of  subjective  signs.  It  may  have  some  weight,  however,  in  deciding  in 
what  part  of  the  uterus  the  feet  lie. 

Importance  of  the  Ahdoniinal  Examination  for  the  Diarpioniti  of  the  Fetal 
Presentation  and  Position. — With  all  the  facts  clearly  made  out  it  will  readily 
be  seen  that  the  abdominal  examination  is  of  nK)re  value  for  the  diagnosis  of 
j)resentation  and  ])ositioi!  of  the  fetus  than  the  vaginal  touch.  Every  physi- 
cian, therefore,  shoidd  familiarize  himself  with  the  techni«iiie  of  abdominal 
palpation  and  auscultation  in  its  application  to  obstetric  practice.  It  is  within 
the  ])ower  of  every  obstetrician  to  become  expert  in  obstetric  diagnosis  by  tlu! 
abdomen.  AVliile  the  facilities  afforded  by  a  hospital  service  are  »*f  great 
advantage,  they  are  by  no  means  indispensable  if  j)roper  use  be  made  of  the 
opportunities  which  even  the  general  practitioner  has  at  his  command. 

Patholof/ical  Conditions. 

After  detf  rmining  the  presentation  and  position  of  the  fetus,  the  abdomen 
is  next  to  be  interrogated  for  the  ])ossiblc  existence  of  fetal  or  maternal  anom- 
alies that  may  complicate  the  labor. 

A  pendulous  abdomen  in  a  first  pregnancy  should  suggest  the  possibility 
of  pelvic  deformity.  It  not  infrecjuently  occurs,  however,  in  multipane  in 
whom  the  ])elvis  is  normal,  and  it  may  retard  the  labor  by  hindering  tiic 
engagement  of  the  jjresenting  pole. 

Ilydramnion  is  recognized  by  the  increased  size  and  permanent  tension  of 
the  uterine  tumor,  by  preternatural  mobility  of  the  fetus,  and  by  the  pres- 
ence usually  of  suprapubic  edema. 

The  entire  abdomen  is  exploi'cd  for  the  possible  presence  of  pathological 
growths  of  the  itclvic  or  abdominal  organs. 

The  lo'-ation  of  the  placenta  may  usually  be  made  out  by  palpation  over 
t  bdomen,  except  when  its  implantation  is  mainly  upon  the  posterior  wall 
■  ih'  uterus.  Its  convex  edge  presents  a  resisting  ring,  and  the  ])alpati<iii 
t  tdal  it.'irts  is  partially  obscured  within  the  placental  area.  The  diagnosi> 
of  vicious  i!!.-;ertion  of  the  placenta  is  therefore  sometimes  ])ossible  by  abdomi- 
nal examination. 

A  liydrocephalic  head  of  a  siz(!  sufficient  to  give  rise  to  dif!ieulty  in  delivery 
ought  to  be  recognized  by  external  palpation.     Its  size  may  be  determined 


ksibility 
|)ari«  ill 
|ing  till' 

ision  of 

>logioal 

in  ov<'r 
n-  Nvall 

llpat'uiii 
\gno!?i> 
j[)doini- 

■ 'liven 
huiiu'd 


TIfE    CONDn'T   OF  XORMAL    LA/iO/f. 


i]r>7 


more  accurately  by  moasureincnts  taken  with  calipers  throujfh  the  abdominal 
walls,  and  by  tryin}>;  whether  it  can  be  crowded  into  the  excavation. 

In  twin  pre}i;nancies,  as  in  hydramnion,  the  abdominal  tumor  is  usually 
large  and  persistently  tense,  and  there  is  suprapubic  edema.  Indeed,  multiple 
pregnancies  are  generally  associate<l  with  exi'css  of  licpior  amnii.     Single  feta- 


Kiii.  ini.— Hfliitivc  IdCHtion  nf  tlif  |i(isl(ii(ir  sii)Kri<ir  iliiic  spiius  iind  spiiic  of  liist  liiiiiliar  virti'brn.    The 
liitttT  is  the  second  vortobral  abovt'  tliu  luvol  of  the  iliac  spiiU'SdifttT  tlio  Ariaiiuc). 

tiou  with  hydramnion  is  distinguished  from  plural  pregnancy  by  the  greater 
inobilitv  of  the  fetus  in  the  former.  There  is  a  larjier  numi)er  of  small 
parts  than  in  single  fetation,  and  they  are  more  widely  distributed.  Two 
<lorsal  planes  and  more  than  two  fetal  ])oles  may  sometimes  be  made  out.  One 
head  in  the  excavation  and  one  in  tiie  upper  utcriiu;  segment  or  in  one  iliac 
fossa  make  the  diagnosis  of  twins.  Two  fetal  poles  njore  than  12  inches 
a[)art  cannot  belong  to  the  same  child.  The  most  conclusive  evidence  of 
double  fetation  is  the  detection  at  the  sanu^  time  of  two  fetal  heart-beats  of 
ditl'erent  rates. 

Palpation  in  nudtiple  pregnancy  is  generally  rendered  diflicult  by  the  per- 
manent tension  (»f  the  ulerine  tumor. 


t^) 


/    ■ 


358 


AMERICAX   TEXT- BOOK   OF   OliSTETPTCS. 


» I 


I 


2.   EXTKKNAI-  MeASUKKMKNTS  OF  THK   Pkia'is. 

In  primipaiw,  and  in  niultipaiw  in  whom  tlio  prcvions  obstetric  liistorv 
gives  rise  to  any  .sn.spicion  of  polvic  contraction,  tin-  external  clianieter.s  of  tlie 
pelvis  should  be  measured.  Tiiree  measurements  are  usually  sufficient — 
namely,  the  external  oonju<iate,  the  inters|)inal,  and  the  intercristal. 

Of  these  measurements  the  most  important  is  the  external  conjugate  (1*1. 
25).  This  diameter  is  measured  from  the  depression  (Fig.  19-1)  just  below 
the  spine  of  the  last  lumbar  vertebra  to  a  point  on  the  pubic  surface  in  front 
of  tiie  upper  part  of  the  symi)hysis.  As  a  rule,  it  may  safely  be  assumed 
that  the  pelvis  is  ample  when  this  diameter  exceeds  7^  inches  (18  centimeters), 


Fid.  I'.i,').— Mmiunl  iiR'tluKl  of  incasuriiiK  tlio  (liiigonnl  rniijuRftte. 

and  that  it  is  contracted  at  the  brim  when  the  diameter  falls  below  that  limit. 
Occasionally  the  saero-pubie  diameter  at  the  brim  will  .a  found  slKjrtened  with 
an  external  conjugate  of  Ih  inches  (IJ)  centimeters),  and  it  may  be  normal 
when  the  diameter  of  Haudelocipie  is  less  than  1\  inches  (18  centimeters). 
Contraction  in  other  diameters   must  be  excluded. 

An  interspinal  equal  to  or  greater  than  the  intercristal  diameter  indicate* 
flattening  of  the  j)elvis  ;  when  both  are  small,  there  is  general  contraction. 

3.    VA(a\AI>    HXAMINATIOX. 

Before  examining  per  viiginam  the  obstetrician's  hands  and  the  external 
genitals  of  the  patient  are  to  be  cleansed  with  the  same  care  that  is  observed 
during  labor. 


Lt  limit. 

led  Avitli 

Incn'mnl 

liiotors). 

fdicatc- 
Ion. 


eternal 
Iservcil 


(ONDITT  Ol'    NOIJMAL    1,AI!()K. 


I'l.ATi:  -J'). 


Mt'iisuriiif;  tlie  oxtiTiiiil  Kinjugato :  llio  Murk  ilots  show  tlio  points  from  wliich  tlio  moiisuroinciits 

arc  iukeu  (from  a  photograph). 


ku, 

Bft' 

JM 

|w:Hi; 

Ifl 

it 


I    ' 


v\ 


w 


r 


t  HI  jHli 


ri; 


li 


i  ! 


r 


I 


I 


<L 


(ONDrcr  ol"   NuKMAI.    I.AIiui:. 


I'l.ATi;  'Jti 


.Miiimal  mi'thoil  of  muasuring  tlie  diiit;oiial  conjiiiiiitc :   p,  promontory;   r,  n,  periiu'iil  bmly  dis- 

pliicril  luickwani. 


It 

1                                *■■ 

i.                   ' 

j                    '        i 

;i^^    »"Li;;- 


|ii,,i   If'l 

1 

m 

1 

m-:. 

V    ;■ 


/ 


I 


in 

tli| 
gi'( 
iiK 

IIKJ 

In 


tioi 

nial 

( 

rece 

M'Oll 

exec 

arat( 

bed 

1 

nient 

apj)!! 

be  cc 

with 

sei.sso 


rm:  i'oxnrcr  or  xonmal  lahoil 


.•{■)!) 


In  parous  woiiicii  tlic  pelvic  Hour  aiul  tlic  cervix  are  <>.\atniiu><1  for  injuries 
iiillietod  (liiriiij;  previous  lalxirs.  In  all  <'ases  the  (lia;i;oiial  eoiijiitiate  and  the 
aiitero-posterior  and  hisisehial  diameters  at  the  ontlet  should  earel'nlly  ho 
nieasin-ed  and  the  width  and  curvature  of  the  saernin  be  noted.  The  method  of 
measuring:;  the  diagonal  conjugate  is  shown  in  Fij;ure  lJ»r)  and  Plate  2<).  With 
the  patient  in  the  lithotomy  position,  two  Hnjiers  of  the  exainininjjf  hand  are 
passed  into  the  vaj^ina,  and  the  tip  of  tlie  second  fniffcr  is  made  to  rest  by  its 
outer  mari^in  against  the  most  prominent  part  <tf  the  sacro-vertebral  angle. 
The  point  at  which  the  edge  of  the  subpubic  ligament  cuts  the  radial  border 
of  the  examining  han*l  is  marked  by  a  finger-nail  with  the  other  hand.  The 
distance  between  the  points  of  contact  is  the  value  of  the  diagonal  ctinjugate. 
To  Hud  the  true  conjugate  the  amount  to  be  subtracted  from  the  diag<(nal  is 
usually  'S  to  J  inch,  according  to  the  depth  and  inclination  of  the  symphysis. 
The  diameters  of  the  cavity  and  the  transverse  diameter  at  the  brim  are  esti- 
mated by  ])al|)ating  the  walls  of  the  pelvis. 

The  examining  hand  is  to  be  used  wet  with  the  antiseptic  solution.  If  any 
other  lubricant  is  required,  glycerin  or  vaselin  sterilized  by  heat,  or  glycerin 
biniodized  or  sublimated  (1  :  600),  may  1-  >  employed. 

The  Lying-in  Room. 

In  pi'ivate  practice  the  patient  is  generally  confine<l  in  the  room  which  she 
is  to  occupy  during  convalescence.  The  choice  of  room  is  not  a  matter  of 
indifference.  One  of  the  first  requisites  of  health  at  all  times  is  pure  air,  aiul 
this  should  not  be  deniinl  the  patient  at  a  time  when  the  need  of  oxygen  is 
greater  than  usual,  owing  to  the  severe  muscular  activity  of  labor  and  to  the 
increased  tissue-waste  of  the  puerperium.  If  possible,  therefor(\  a  com- 
modious room,  one  which  permits  of  constant  ventilation,  slu)uld  be  selected. 
In  cold  weather  an  o])en  fire  is  an  efficient  aid  to  ventilation,  and  it  adils 
greatly  to  the  cheerfulness  of  the  lying-in  chamber. 

A  sunny  exposure  is  desirable.  Dust-laden  hangings  are  especially  objec- 
tionable, vet  it  is  neither  necessarv  nor  best  to  so  far  disnuintle  the  room  as  to 
make  it  cheerless.     Ordinary  claanliness  is  usually  suflKcicnt. 

On  no  condition  should  the  confinement  be  conducted  in  an  apartment 
recently  occu])ied  by  a  patient  with  erysipelas,  childbed  fever,  siij)pu"'ating 
w(junds,  or  cMier  diseases  which  are  recognized  sources  of  possible  sepsis, 
except  after  systematic  cleansing  and  disinfection. 

The  management  of  the  patient  at  the  close  of  labor  is  simplified  if  a  sep- 
arate cot  be  providetl  for  the  confinement,  the  patient  being  transferred  to  the 
bed  at  the  close  of  the  labor. 

The,  Nurse^s  Prcpdmiions. — An  orderly  nurse  will  have  ready,  conve- 
niently near  the  bed,  a  small  table  (Fig.  196)  properly  eijuipped  Viith  such 
appliances  as  the  doctor  will  need  for  use  during  the  labor.  The  table  should 
be  covered  neatly  with  one  or  two  frcsh-lannderwl  towels,  and  be  supplied 
with  a  wash-basin,  a  hand-brush,  soap  and  hot  water,  an  antiseptic  solution, 
scissors,  a  ligature  for  the  navel,  and  a  suitable  aseptic  lubricant  for  the  hands. 


iliilil 


I-    vv 


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AM/:iU(Ay  Ti:xT-nooh'  of  obstetrics. 


■f    ,   !    :  V^ 


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The  iiiirso  shoiiKI  also  provitlc  j)l('iity  of  clean  sheets  and  towels,  one  or  two 
pieces  of  niihleachcd  nnislin  for  alxlorninal  hhulers  a  half  yard  in  width  by  one 
and  a  (jnarter  yards  in  length,  one  or  two  snrgically  clean  rnbber  sheets  large 
enough  to  cover  the  ent're  width  of  the  bed,  plenty  of  nuislin  sheets,  a  nig  or 
oil-cloth  lu  protect  the  carpet  beside  the  bed,  safety-pins  of  convenient  size  for 
pinning  the  binder,  a  fountain  syringe,  a  suitable  be<l-pan,  a  supply  of  hot  and 
of  cold  water,  a  package  of  salicylated  or  borated  cotton  for  the  navel  dressing, 
a  blanket  for  wrapping  the  child,  and  the  child's  clothing. 

PvcparatUm  of  flic  Bed. — The  patient  should  lie  upon  a  firm  mattress.  It 
is  customary  to  protect  the  bed  by  means  of  a  rubber  sheet,  which  ought  to  be 
large  enough  to  cover  the  entire  width  of  the  bed  and  the  greater  part  of  its 


I:   lA   M 


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V,      ;    Ml 


t    * 


Ki(i.  I'.Kl.— TiilMc  ('(iiii|>pe(i  with  basins,  briislies,  milisoptics,  etc.,  for  the  pliysiciaii's  use. 


! 


li 


hi 


length.  Over  this  rubber  covering  is  .spread  a  nni.slin  sheet,  the  two  cover- 
ings being  pinne<l  fast  to  the  mattress.  These  spreads  are  covered  with  a 
second  rubber  overlaid  with  a  bed-sheet.  The  latter  coverings  are  withdrawn 
after  labor,  leaving  th(>  \)ed  clean  and  protected  l)y  the  first  rubber  and  its 
mti.>^lin  covering.  Two  or  three  fre.sh-Iaundered  sheet.s,  each  folded  to  four 
thicknes.ses,  may  be  placed  upon  the  bed  in  jnisition  to  receive  the  tli.scharges. 

In  phux*  of  the  sheets  a  good  absorbent  dressing  is  a  pad  specially  made  for 
the  purpose.  It  consists  of  a  cheese-cloth  sack  or  bag,  which  i,^  filled  with 
jute,  absorbent  cotton,  cotton  waste,  or  other  absorbent  material  that  has  j)revi- 
ously  been  prepared  and  sterilized.     The  stick  rctiuires  (o  be  from  2^  to  3  feet 


«<l"-e  aud  .3  or  4  i.u,.„o«  thick      Tl  ,  ''' 

«"  ''o.n.  sI.o.,lv  before  use     1  '  ^'''  ''  ^''  ''^^'^^^'-^1  by  sfon     •       . 

An  oiiji.t  ;:ut  "JT"";  "'"^'^'  ^'--f^-'.        "  """"^'"^^''*'  ^-^ 

«>nuiioiiIv  eninlMxv.  i   •  ^  ^'  absorbent  pad  i*  ihn  t-  n 

»l"tio„    ir,;    **  "■'"''(«•     A  ..apfet  „.  1  "    "'•  ''"""8  "«'  firs'  «ta J 

i    ^^'J;  a  Jialf-dozeii  iicedJes, 


''"'•"•'-^<">"t«'spo.vi.„etor 

••'hout  2  i„eI,o.s  i„   K,„,,..     .    , 

C:';::;  ::::£-•- -k™  2t,:r' '^v•■'"--- 
•' ''N>"".-i...i.  ,,^  ,?;;t  ;';'''''f  ''-!•'■  ■■'-:.,  ::'?,"" -'■■■  ■■'  ■^""■' 


U       i 


(.; 


•/ 


i.li\ 


362 


AMERICAN   TEXT- Ji 00 A'   OF   OBSTETRICS. 


The  bag  should  also  be  supplied  with  two  or  three  ouuces  of  chloroform, 
twice  as  much  ether,  a  few  ounces  of  carbolic  acid,  and  a  drachm  or  two  of 
chloral.  Mercurial  antiseptics  and  also  obstetric  cmergeuts,  such  as  niorphin, 
elaterin,  digitalis,  ergot,  and  veratrum  viride,  are  most  conveniently  carried  in 
tablet  form. 

3.  Anesthesia. 

Of  anesthesia  in  obstetrics  for  the  usual  surgical  indications  little  need  be 
said.  The  eniplovnient  of  anesthetics  in  obstetric  operations  is  governed  by 
the  well-established  usages  of  surgical  practice. 

]iy  obstetric  anesthesia  is  understood  something  entirely  distinct  and  apart 
from  the  surgical  use  of  anesthetics.  It  is  intended  to  diminish,  not  to  abol- 
ish, pain.  Its  object  is  merely  to  mitigate  the  severer  sufferings  of  ordinary 
labor,  not  to  cause  complete  insensibility. 

To  what  extent  anesthetic  agents  may  be  used  to  advantage  in  a  simple 
labor  is  a  question  that  calls  for  the  exercise  of  tact  and  judgment.  That,  on 
the  one  hand,  obstetric  analgesia  accomplishes  a  distinct  gain,  in  so  far  as  it 
spares  the  {)atient  the  exhausting  effects  of  severe  pain  and  prolonged  nervous 
tension,  cainiot  be  doubted  ;  nor  has  the  obstetrician  any  more  pleasing  duty 
than  to  save  the  needless  sufferings  of  childbed.  On  the  other  hand,  except  in 
moderate  doses  and  during  the  most  active  period  of  labor,  anesthetics  are  lia- 
ble to  impede  the  progress  of  the  birth.  The  careless  and  long-contimied  use 
of  these  agents,  especially  in  excessive  quantities,  is  fraught  with  serious  dan- 
ger to  the  j)atient.  Their  abuse  is  doubtless  at  times  an  unrecognized  factor 
in  grave  and  even  fatal  accidents  of  childbed.  These  objections  obtain  more 
csj^cially  against  chloroform. 

With  reference  to  the  influence  of  anesthetics  upon  the  strength  and  the 
frequency  of  the  uterine  contractions  we  have  some  recent  observations  from 
Ponlioff.'  lie  administered  chloroform,  in  various  degrees,  to  five  parturients, 
studying  the  effect  upon  the  pains  with  the  aid  of  a  tokodynamometer.  Even 
under  small  doses  the  labor  was  retarded.  In  eight  observations  the  muscu- 
lar pressure  sank  nearly  to  one-half  that  present  before  the  administration, 
and  the  strength  of  the  uterine  contractions  was  not  fully  restored  for  several 
minutes  after  the  inhalations  were  stopped. 

That  the  use  of  anesthetics  during  labor  ])redisposes,  in  some  degree,  to 
relaxation  of  the  uterus  in  the  third  stage,  as  claimed  by  Ijusk  and  others,  is 
abundantly  exemplified  in  the  writer's  experience. 

The  foregoing  facts,  while  they  do  not  forbid  the  employment  of  obstetric 
anesthesia,  call  for  the  exercise  of  caution  in  its  use.  When  rctpiircd  for  no 
other  purpose  then  to  mitigate  the  sufferings  of  the  patient,  anesthetics  should 
be  reserved  until  the  latter  part  of  the  second  stage,  and  even  then  they  may 
be  withheld  so  long  as  the  ])ains  are  well  borne.  Tlieir  employment  is  per- 
missible at  an  earlier  period   in  the   labor  when,  recpiired  to   subdue   great 

'  Archil'  fur  Gi/n.,  Hai.d  xlli,  12. 


(1  the 

from 
jionts, 

^vcn 
luscu- 

lition, 

Ivcral 

["C,  to 

Irs,  is 

totric 
Lr  no 
konUl 

1  may 

per- 

brcat 


THE   COXDUVr   OF  NORMAL    LABOR. 


363 


nervousness  and  excitement  or  to  relieve  pains  of  extreme  and  unusual 
severity.  In  cxeoptional  oases  these  agents  may  act  to  accelerate  the  labor  by 
counteracting  the  inhibitory  effect  of  pain  upon  the  uterine  contractions. 

In  the  third  stage  of  labor  the  uses  of  anesthetics  are  chiefly  surgical. 
When  anesthesia  is  recjuired  to  the  surgical  degree,  it  nnist  not  be  assumed 
that  the  obstetric  jiatient  enjoys  any  special  innniuiity  from  the  usual  dangers 
of  anesthetics.  The  relative  safety  of  obstetric  anesthesia  lies  not  in  any 
peculiarity  of  the  subject,  but  in  the  mode  of  administration,  the  limited 
dosage,  the  slow  and  gradual  inhalation,  and  the  intermittent  use  of  the 
drug,  during  the  pains  only.  Under  complete  anesthesia  the  parturient 
woman  is  exposed  to  the  same  dangers  as  are  other  patients. 

In  eases  in  which  an  operation  must  be  performed  requiring  anesthetics, 
neither  disease  of  the  heart,  of  the  lungs,  nor  of  the  kidneys,  nor  the  exhaus- 
tion of  the  third  stage,  forbids  their  use.  These  conditions,  however,  neces- 
sitate increased  caution  in  their  administration.  In  cardiac  disease,  even  in 
lesjons  of  the  myocardium,  anesthetics  lessen  the  danger  by  subduing  the 
rt  i'  Kos. 

Choice  of  Anesthetics, — For  mere  obstetric  analgesia  chloroform  is  gen- 
erally preferred.  It  has  the  advantage  of  being  pleasanter  than  ether  and  is 
less  bulky  to  carry.  The  latter  agent  seems  to  be  growing  in  favor,  however, 
for  obstetrical  use,  and  it  is  claimed  to  be  no  less  manageable  than  its  rival, 
chloroform,  for  partial  anesthesia.  Hirst  thinks  analgesia  is  even  more 
promptly  produced  by  ether  than  by  chloroform.  The  satisfactory  use  of 
ether  for  this  purpose,  however,  depends  ujion  its  jn'oper  administration.  It 
must  be  given  very  gradually  in  quantities  of  a  few  drops  with  each  inspira- 
tion. The  difference  in  the  safety  of  the  two  agents  is  insignificant  when  .^ed 
in  the  obsteirio  method. 

When  couiplcle  insensibility  is  required  for  surgical  interference,  chloro- 
form should,  as  ti  rule,  give  place  to  ether.  The  general  mortality  of  chloro- 
form when  push(j.l  to  the  surgical  degree  is  four  or  five  times  greater  than 
that  of  .  thiM*.  0\  the  two  agents,  chloroform  is  the  more  potent  and  its 
effects  persist  i -ngor  r,%>r  inhalation  stops.  Ether,  since  it  is  used  in  larger 
(piantities,  is  nv  \^  irritant  to  the  air-passages  than  is  chloroform ;  hence  the 
former  pgent  should  be  replaced  by  chloroform  in  inflammation  of  the  air- 
passage,',  especially  if  it  be  acute.  Ether  is  generally  believed  to  be  more 
dangerous  in  nephritis  than  is  chloroform,  but  this  question  is  not  fidly  set- 
tled. Owing  to  the  tendency  of  the  former  agent  to  produce  high  arterial 
tension,  it  is  dangerous  in  marked  atheroma. 

Methi '  of  AdminiKtrnfioH. — The  patient  is  prepared  for  anesthesia  by 
looseniii  :•  .i'^  clothing,  by  lowering  the  head,  and  by  attention  to  such  other 
l)recaution>.  arc  commonly  observed  in  surgical  practice.  To  protect  the 
skin  from  the  irritating  effects  of  the  chloroform  vapor  the  lips,  nose,  and 
chin  may  be  smeared  with  vaselin  or  with  glycerin.  A  towel  spicad  in  one 
thickness  over  the  head,  and  lifted  by  the  middle  so  as  to  form  a  large  air- 
chamber  about  the  face  (Fig.  198),  makes  a  suitable  inhaler.     An  Esmarch 


w  r'' 


I.,     !i 


;};t 


;■  '    .  i 


304 


AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 


mask  is  also  a  convenient  apparatus  for  administering  the  anesthetic  in  the 
lying-in  room. 

On  the  first  premonition  of  a  coming  pain  the  inhaler  is  placed  over  the 
face  of  the  patient,  and  the  anesthetic  is  dropped  upon  it  opposite  the 
mouth.  With  chloroform,  one  drop  or,  at  the  most,  2  drops  should  be  let 
fall  at  each  breath.  In  case  ether  is  used,  .3  or  4  droj)s  with  each  inspiration 
will  suffice.  When  sufficient  effect  is  not  obtained  in  this  manner,  the  patient 
may  be  requested  to  breathe  rapidly  as  the  pain  is  coming  on. 

For  convenience  in  graduating  the  administration  a  bottle  specially  con- 
structed for  the  purpose  may  be  used,  or  a  dropping-bottle  may  be  improvised 
by  cutting  a  longitudinal  slot  in  the  side  of  the  stopper  (Fig.  198). 

The  foregcing  methods  of  administration  ensure  abundant  dilution  of  the 
anesthetic  vapors  with  air  and  a  safe  and  gradual  development  of  anesthesia 


Kio.  li»8.— Mi'lliod  <if  Hiving  cliliinifunii  witli  Uw  tnwcl  inlmlor:  tliL'  illustnition  repivsoiUs  the  towel  as 

trimsiinrciit  {from  a  phologrupli). 

with  the  least  possible  quantity  of  the  drug.  The  inhaler  should  be  removed 
on  the  ap})roaeh  of  unconsciousness,  and  should  always  be  withheld  in  the 
intervals  between  the  pains.  During  the  severer  ])ains  at  the  acme  of  ex- 
pulsion the  inhalation  may  usually  be  pushed  nearly  or  quite  to  the  surgical 
degree. 

Other  Anesthetic  Af/cnts. — An  agent  of  great  value  as  a  partial  substitute 
for  the  anesthetic  vapors  is  chloral.  It  is  particularly  useful  for  alleviating 
the  pains  of  the  first  stage  when  they  arc  not  well  borne.  From  4o  to  GO 
grains  may  be  given  in  doses  of  15  grains  repeated  every  twenty  minutes. 
The  total  quantity  should  not  exceed  a  drachm.      Under  the  full  dose  the 


L'l  as 

zed 
I  the 
lox- 

licnl 

[utc 
|ini>; 
GO 
tp?. 

itlu! 


THE   CONDUCT  OF  NORMAL    LABOR. 


365 


patient  usually  bears  the  pains  with  little  complaint,  and  sleeps  quietly  in  the 
intervals.  Chloral  in  the  (piantity  mentioned  has  no  inhibitory  effect  upon 
the  uterine  contractions.  In  disease  of  the  heart,  either  organic  or  functional, 
the  wisdom  of  its  emj)loynient  is  questionable,  owing  to  its  depressant  effect. 
It  is  said  by  some  authorities  to  be  unsafe  to  give  chloroform  to  a  patient  who 
is  already  under  the  influence  of  chloral. 

The  coal-tar  analgesics  relieve  the  i)ains  of  lab(»r,  but  they  also  tend 
to  cause  uterine  inertia. 

The  hydrochlorate  of  cocain  applied  to  the  cervix  and  vagina  has  proved 
of  little  service,  its  action  being  merely  superficial.  It  is  especially  objection- 
able on  the  ground  that  it  necessitates  interference  within  the  passages. 

From  an  eighth  to  a  quarter  grain  of  the  sulphate  of  mor{)hin,  admin- 
istered hypodermatically,  as  a  rule  acts  kindly  in  unusually  painful  labors,  but 
it  is  rarely  to  be  recommendeil  in  strictly  normal  conditions. 

Examination  during  the  Labor. 

The  first  duty  of  the  obstetrician  on  reaching  his  patient  in  resjionse  to  her 
sunnnons  is  to  satisfy  himself  that  she  is,  as  she  assumes,  actually  in  labor. 
The  beginning  pains,  however,  are  not  necessarily  to  be  taken  as  ovidence  that 
active  labor  is  near  at  hand.  Painful  uterine  contractions  are  sometimes  ex])c- 
rienced  at  intervals  for  days  before  the  birth.  Rarely,  after  they  are  fully 
established,  they  may  wholly  cease  for  hours. 

Inquiry  is  made  for  the  usual  i)henomena  of  beginning  labor,  the  time  when 
tiie  pains  began,  and  their  character,  strength,  and  fre(juency.  Most  distinctive 
of  labor  is  the  rhythmical  character  of  the  j)ains  and  the  contraction  of  the 
uterus  during  the  ])ains  as  felt  by  the  hand  laid  upon  the  abdomen.  The  first 
uterine  contractions  of  childbirth  frequently  give  rise  to  little  more  than  a 
sense  of  i)ressurc  in  the  sacral  and  the  lumbar  region.  As  the  labor  progresses 
they  are  felt  in  front  over  the  lower  abdomen,  and  finally  radiate  down  tiie 
thighs.  If  the  labor  is  in  actual  progress,  a  systematic  external  and  internal 
examination  is  to  be  made.  The  general  object  and  method  arc  substantially 
the  same  as  in  the  preliminar '  examination,  with  the  addition  of  certain 
details  which  pertain  more  especially  to  the  labor. 

The  abdominal  examination  aims  to  determine  whether  the  (ihild  is  living, 
what  is  the  presentation  and  position,  the  quality  and  frequency  of  tlie  fetal 
pulse,  how  far  the  lir  d  has  descended  in  the  pelvis,  the  presence  of  anomalies 
that  may  com})licate  the  birth.  The  relative  si/e  of  the  head  and  pelvis  can 
be  eslimated  by  observing  how  far  the  head  has  suidv  or  can  be  made  to  sink 
into  the  excavation.  In  doubtful  cases  measurements  of  the  head  may  be 
taken  with  calipers  through  the  abdominal  wall.  Distention  of  the  bladder 
is  recognized  by  palpation  over  the  supra])ul)ic  region. 

The  diagnosis  of  presentation  and  position  by  abdominal  pal|)ation  is  not 
usually  so  readily  made  at  this  time  as  l)efore  labor,  but  in  most  cases  it  offers 
no  special  difficulty.  The  character  of  the  fetal  heart-sounds  affords  im- 
portant information  as  to  the  prognosis  for  the  child,  and  they  should  fre- 


!.i  1 


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366 


AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 


\:\ 


II 


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quently  be  Ustcned  to  throughout  labor.  A  fetal  pulse-rate  much  above  or 
bel'^'w  ^'.'.0  liornial  range,  or  a  pulse  which  grows  progressively  weaker,  indi- 
cates danger  to  the  child. 

When  a  systematic  preliminary  examination  has  been  made,  little  additional 
information  remains  to  be  gained  by  examining  internally  after  labor  begins. 

For  the  detection  of  possible  complications  that  may  have  developed  at 
the  onset  of  labor,  such  as  prolapse  of  the  cord  or  of  a  fetal  member,  as  well 
as  for  more  precise  information  of  the  stage  of  progress,  a  vaginal  examination 
is  usually  desirable,  even  though  the  obstetrician  be  expert  in  abdominal 
palpation. 

Before  examining  internally  the  nurse  is  directed  to  cleanse  the  abdomen, 
the  vulva,  and  the  inner  surfaces  of  the  thighs  witii  soap  and  water,  and 
finally  Avith  an  antiseptic  solution ;  meantime  the  obstetrician  sterilizes  his 
hands  and  forearms. 

The  object  of  this  examination  is  to  learn — (1),  the  condition  of  the  vulva 
and  the  degree  of  resistance  it  will  be  likely  to  ofter  as  the  liead  descends;  (2), 
whether  the  vagina  is  well  lubricated  by  the  secretions,  and  the  presence  or  ab- 
sence of  obstruction  ;  (.3),  the  condition  of  the  cervix,  how  far  dilated,  whether 
dilatable  as  judged  by  the  extent  of  softening  and  thinning;  (4),  the  size  and 
protrusion  of  the  bag  of  waters;  iv  J  {'i),  the  presentation  and  ptsition  of  the 
child  in  confirmation  of  tlie  abdominal  examination. 

Vertex  presentations  iire  recognized  by  the  hardness  and  the  globular 
shape  of  the  cranial  portion  of'  the  head  and  by  tracing  the  sutures  anil 
fontanelles.  As  the  anatomical  characters  of  the  presenting  j)art  are  often 
somewhat  obscured  by  the  caput  succedaneum,  the  examination  nuist  be  made 
with  care,  using  firm  pressure  and  searching  as  far  as  the  fingers  can  reach. 
In  other  than  vertex  presentations  still  greater  pains  will  generally  be  needed 
to  identify  the  presenting  part.  During  the  vaginal  examination  the  hardness 
of  the  child's  head  should  be  taken  into  account  as  an  important  element  in 
the  prognosis.  The  position  is  determined  by  finding  in  which  quadrant  of 
the  pelvis  the  small  fontanelle  lies.  This  is  best  locatwl  by  first  tracing  the 
sagittal  suture.  (For  diagnostic  signs  of  other  than  vertex  presentation  the 
reader  is  referred  to  the  (;lui])ter  treating  of  those  presentations.) 

The  examiner  will  learn  whether  the  membranes  are  still  intact,  and  liow 
far  they  protrude  during  a  pain,  and  will  make  sure  that  a  loop  of  the  cord 
has  not  ])r()lapscd  into  the  bag  of  waters.  It  is  perhaps  unnecessary  to  say 
that  in  this  part  of  the  examination  care  will  be  needed  lest  the  membranes  be 
prematurely  ruptured. 

To  the  question  which  is  invariably  asked,  "  How  long  will  the  labor  last?'' 
a  guarded  answer  must  be  given.  Definite  predictions  are  seldom  possible  at 
the  beginning  of  labor.  The  prognosis,  so  far  as  it  can  be  estimated,  must  be 
based  on  the  strength  and  the  frecpiency  of  the  pains,  the  extent  of  dilatation 
and  the  dilatability  of  the  cervix,  the  position,  size,  and  hardness  of  the  head, 
and  the  degree  of  descent.  When  nothing  abnormal  has  been  discovered 
assurance  should  be  given  accordingly. 


--  -—  o.  .on.u,  ,,,„,. 


_  Management  op  thp  Pr«      « 

Duni,g  the  first  ,st«ire  nf  .  i         .  "'®'"  '^^^OE. 

«"^^'  to  tl.e  bed  u„ti     til    •       "'  "'^  ^'•''*'*^"t  o,„.J,t  not  .  , 

"H'ted.    Much  „.  1.             '''^-^'^^^''^^  room  and  fl            "'^"""r '"ore  eon,- 
"■<"'-  being  re,  iJ?',™'""""  "f  «>.-.«,i„     bt^  "  " '; «»• 

';»g  break,  before  ,, eta  'f''"  °'  "«=  "'^'bra,,        1,       I  '"«'   "*   be 

"•P"l»ive  elibrt.     "     *  ""'•'■  '»  n«ma,T,  ,„  b7  j        ,'  "'  '"  b"  all„„.„l 

ova™a,«l,  ''--"   «b.,„l.,  bo  el™,.  ".,„  '^'  ■";"/'-  J--".,  ..Z 

„    »'"■'«  «"■«  sfage  i,  ;,  ,  „,        ,  "  """'""■   «-l'.on,l, 

'bepaliejitiiiifilir         ,        *'™™' ™le  for  tl,e  .  1      ■. 

; '!""o..  :.:!„t,r,H  "■"'"'"• "-  ^•-  - :  ^ict?,  ■""  '<>  ■«--,  „,,b 

'""'H.|f  f,,,,;,  „,e  r„.'      '  '""""■'"  ■•-1"b«l,  be  ,,■,■'''■'■"•'■■     ''=™"  after  ),i, 
"""b  'be  ,„a,er„a|  „„,  ,,     ,.     ,  "  """"'''  *"  be  left  t„ 


1  :  I. 


1 


1 1 


3G8 


AMERICAN   TEXT-BOOK   OF   OBSTETlilCS. 


Management  of  the  Second  Stage. 

In  the  second  stage  of  labor,  as  in  the  first,  so  long  as  all  is  nornuil 
the  duties  of  the  obstetrician  are  few  and  simple.  From  the  time  dila- 
tation is  nearly  complete  the  patient  must  not,  as  a  rule,  be  allowed  to 
leave  her  bed,  not  even  for  evacuations  of  the  bladder  or  the  bowels.  She 
is  to  be  dressed  in  the  usual  night-clothing,  which  the  imrse  will  keep  well 
tucked  under  the  arms,  beyond  the  reach  of  soiling.  A  folded  sheet  hung 
like  a  skirt  from  the  hips  still  further  conduces  to  cleanliness.  AVhen  the 
pains  are  feeble,  their  intensity  may  be  increased  by  retjuiring  the  patient 
to  move  about  in  bed  or  even  to  assume  for  a  time  a  sitting  or  a  half-sitting 
jiosture.  The  uterine  expulsive  efforts  should  be  reinforced  by  the  voluntary 
muscles.    Direct  the  patient  to  "  hold  the  breath  and  bear  down  with  the  j)aiiis," 

Most  women  during  the  expulsive  pains  instinctively  brace  their  feet  and 
catch  the  hands  of  the  nearest  bystander  to  assist  the  straining  etfort  by  pull- 
ing. Except  in  precipitate  labor  this  pra(!tice  is  to  be  encouraged.  A  sheet 
rolletl  into  a  loose  rope  and  fastened  by  one  end  to  the  foot  of  the  l)ed  makes 
a  convenient  and  efficient  sling  for  the  purpose. 

An  abdominal  binder  is  frecjuently  useful  in  helping  the  progress  of  labor 
during  the  second  stage,  particularly  in  multipara)  having  lax  abdominal  walls. 

The  distressing  sacral  pains  so  common  in  the  expulsive  stage  of  labor  may 
be  relieved  in  some  degree  by  pressure  over  the  painfid  region.  For  this  pur- 
j)ose  the  nurse,  taking  jmsition  on  the  bed  behind  the  patient  as  she  lies  upon 
the  side,  supports  the  back  by  pressing  firmly  against  the  sacrum  with  the 
palms  of  the  hands  during  the  pains. 

Cramps  in  the  lower  limbs  are  best  overcome  by  powerfully  contracting  the 
antagonistic  muscles.  In  case  of  crami)s  in  the  calf  of  the  leg,  for  exani))lc, 
the  patient  should  forcibly  flex  the  foot  and  hold  it  so  until  the  muscular  spasm 
subsides. 

Rupture  of  the  Membranes. — When  the  bag  of  membranes  does  not  burst 
spontaneously  by  the  time  it  reaches  the  pelvic  floor,  it  should  be  ruptured  by 
the  obstetrician.  Care  nnist  first  be  taken  to  see  that  a  loop  of  the  cord  has  not 
slipped  down  beside  the  head,  as  that  condition  of  things  would  seriously  be 
complicated  by  the  escai>e  of  the  waters.  It  is  not  usually  difficult  to  tear 
the  sac  with  the  finger-nail  during  a  pain.  Failing  by  this  method,  a  sharji- 
pointed  scissors,  previously  sterilized,  may  be  used.  A  convenient  instrument 
for  tl  "  purpose,  generally  to  be  found  in  the  lyiiig-iu  room,  is  a  coarse  hairpin. 
It  is  li.  t  straightene<l  and  then  well  flamed.  This  perforator  is  passed  on  the 
finger-tip  as  a  guard  and  a  guide,  and  the  bag  of  membrane  is  punctured  while 
tense  during  a  jiain. 

Obstetric  Position. — As  a  rule,  the  posture  of  the  patient  should  be  left 
largely  to  her  own  choice.  Occasional  changes  relieve  fatigue.  In  simple 
slow  labor  the  pains  are  promoted  by  permitting  her  to  move  about  in 
bed  and  now  and  then  to  take  a  sitting  position.  Until  the  head  reaches 
the   pelvic   floor   a   half-sitting    posture   is    the    most    favorable,   since   the 


'"'"  ""■'-''"■■'■  -•  -o,n,u.  ,,,,,, 


a(;9 


perineal  stm^,  ^j,^.  ,  '"' ^^  oflcofivdy  i„  tJ.e  Ji„.  „.■    , 

•'" "« ti,o xz.-  '"''"'""'"'><' "f'^v'^iZt  ""r''.""-<»'si.  .1.0 

"■"'«  •■vposo  2  ^    '"*""'  "'"'  ••"«„ib„i,„        ,"  "'  "'*■■'  «'"  "-"ally  1,0 

<-«<'".l     into        '      •     '  •"■'"^"la.-l.v  i,,  ,1,;,,  ,1,0      1  ,;'"'■  "■T"'  "'««a,tor 

i...  to  ,„„  .,„.      '""  "■"*  a,,.,  rnsei.,  „„;,  noZ,,:':''  ^^ilt'  '"''  '- 
"""  ''avo  boc°,  „„l!f,    ^'""''«'"«i„„  i„  t|,i,  ,,.   '"    !'""'"'""  of  ,,o,-i,„,,l 
.^'•''•■"  wo  ,,,fl«   „,,,  ,,  "■'""■  "  '""  "on  „„■._ 


►  i;  ' 


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370 


^^rI•:^iI('Ax  text- hook  of  oustktrics. 


and  (listc'iisibility  of  tlic  pelvic  fl(n)r,  or  to  lessen  the  teiision  to  which  it  is 
Hubjected  (hiring  the  birth,  or  both.  The  former  object  is  best  accomplished 
by  the  slow  and  gradual  delivery  of  the  head,  permitting  time  for  the  tissues 
to  stretch ;  the  latter,  by  so  regulating  the  expulsion  of  the  head  as  to  keep 
its  sujallest  circumference  in  the  grasp  of  the  resisting  girdle  and  the  propel- 
ling power  directed  in  the  axis  of  the  outlet. 

The  rate  of  descent    is  perfectly  at  conunand   of  the  obstetrician.     The 


Kiii.  I'.i'.K— lU'Kuliuiiifj;  the  liirlli  (j1'  tlio  liciiil  (I'nmi  a  iilmtoKnipli)- 

expulsive  force  of  the  abdominal  nuisclcs  may  sometimes  be  suspended  by 
rc([uiring  the  i)atient  to  breathe  rapidly  during  the  pains.  This,  however,  is 
not  always  possible.  The  action  of  th(>  abdominal  nuiscles  is  at  this  stage 
frequently  involuntary  and  wholly  beyt)nd  the  jjatient's  control.     ]\Iost  effect- 


i,l  by 
lor,  is 

llVect- 


TlIK    VONDL'CT   OF  yoiiMAL    LMiOIi. 


371 


ual  for  the  regulation  of  tlio  pxpclling  ])()W('r.s  is  tlie  use  of  anesthetics. 
Cliloroform  or  ether  shouhl  he  given  at  this  jx'riod  on  the  a|)i»earance  of  tlio 
slightest  danger  of  laceration.  \\y  the  jntlieions  use  of  the  anesthotie  the 
strength  and  fretjuency  of  the  pains  and  the  rapidity  of  expulsion  may  bo 
reutdated  at  will. 

The  advance  of  the  head,  however,  can  still  further  be  controlled  by  pres- 
sure with  the  thumb  and  Hnger  held  constantly  upon  the  occiput.  With  the 
thund)  a])plied  to  the  head  inunediately  in  front  of  the  tense  border  of  the 
perineum,  and  with  two  lingers  resting  upon  the  occiput,  the  rate  of  descent  is 
easily  watched  and  regulated. 

To  keep  the  tension  of  the  vulva  at  a  niininiuni,  the  hmg  axis  of  the 
cephalic  cylinder  must  be  kept  at  a  right  angle  with  the  jilane  of  the  outlet 
of  the  soft  parts  Too  rapid  extension  of  the  head  must  be  prevented.  1'he 
forehead  should  not  be  permitted  to  pass  the  j)erineum  until  the  occiput  is 
fully  expelled  and  the  nape  of  the  neck  rests  in  the  subpubic  arch. 

Moreover,  to  guard  against  too  great  strain  upon  the  i)elvic  Hoor,  the 
direction  of  expulsion  must  be  regulated  by  crowding  the  head  well  up  in  the 
pubic  arch,  especially  at  the  time  when  the  e(juator  of  tiie  head  passes  the 
vulvar  ring.  The  expelling  force  is  thus  directed  in  the  axis  of  the  outlet, 
and  the  least  possible  downward  thrust  is  exerted  upon  the  jK'lvic  floor. 

The  foregoing  manipulations  arc  best  conducted  with  the  patient  in  the 
left  lateral  position.  In  first  labors,  therefore,  and  in  others  in  which  the 
])erinouni  is  liable  to  be  torn,  the  jnitient  should,  as  a  rule,  be  placed  upon  the 
left  side,  with  the  buttocks  close  to  the  edge  of  the  bed,  as  soon  as  the  head 
has  reached  the  floor  of  the  pelvis.  There  is  rarely  danger  of  laceration  until 
after  the  occipital  pole  appears  in  the  vulvar  fissure.  Up  to  this  point  usually 
the  ])rogress  of  the  perineal  stage,  when  not  over-rai)id,  may  be  noted  by  the 
touch  alone.  With  the  finger  upon  the  perineiun  just  behind  the  posterior 
vulvar  comnussure  the  occiput  can  be  felt  through  the  soft  parts  some  time 
before  it  licgins  to  distend  the  perineum,  and  the  rate  of  descent  can  be 
observed  as  accurately  as  by  passing  the  finger  within  the  ])assages. 

From  the  moment  the  occiput  ap])ears  in  the  vulvar  orifice  the  parts  ought 
to  be  under  ocular  inspecttion.  The  vaginal  discharges  are  occasionally  washed 
away  with  a  cloth  which  is  kept  lying  in  a  warm  antiseptic  solution.  'S !  c 
tension  of  tiie  resisting  rinj";  may  be  tested  by  now  and  then  passing  the 
finger  within  the  vaginal  orifice  dm-ing  a  pain.  The 
head  is  allowed  !:o  a(',ance  during  a  pain  until  the 
perineal  edge  becomes  as  tense  as  is  deemed  safe.  Its 
further  progress  is  then  arrested  by  direct  pressure  with 
the  fingers  in  the  line  of  descent  (Fig.  iOO).   Until  about        Fi„.jon    K,..„i.ui„j,M.x. 

°  _  ...  IMllsKill    lit     IIk'    llOlKl    With 

to  be  expelled,  driven  down  with  the  pains,  it  recedes    tho  lini-t  is  of  .mo  iiami 
in  the  intervals,  and  by  this  to-and-fro  movement  the    '"'"''"^'  •"^'  '"■'"^"'■ 
jiolvic  floor  is  moulded  as  it  were  to  the  re(|uired  degree  of  distention. 

AVhen  the  bregma  apjM-ars  at  the  edge  of  the  perineum,  the  head  no  longer 
recedes  between  the  pains  and  is  on  the  verge  of  expulsion.     During  the 


Am 


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4' 


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.']72 


.  I  Mi:ni<  \  1 S    TEXT- HOOK    ()  /•'    OliSTKTliK  'S. 


passaj^o  of  tlic  ei|iiaf<ir  of  the  licail  cxtoii.sion  unist  be  prcvt'iitnl  by  upward 
])rcssure  in  tlie  axis  uf  expulsion  with  tiic  tluiiuli  placed  upon  the  sinciput 
dose  to  the  perineum,  the  finu;ers  restinj;'  upon  the  occiput.  The  sinciput 
must  not  be  jwrmitted  to  advance  faster  than  thi'  occiput.  K  reipiired  for 
tlic  bottler  control,  both  hands  may  i)e  used   [V\\i.  201). 

A  favorite  method  for  mana<rint>:  the  expulsion  of  the  heatl  is  the  fol- 
lowing :  The  |)atient  lyintr  upon  the  left  side  close  to  the  etlgo  of  the  bed, 
the  operator,  >ittin<f  lu-hind  her,  grasps  the  head  with  the  fingers  of  the 
right  hand  placed  Just  in  front  of  the  fourehette,  while  the  left  hand,  passed 
over  the  abdomen  and  between  the  thighs  of  the  mother,  seizes  the  occiput 


\\ 


Fl(i.  Jill.— Prtfurri-d  iiiotlind  fur  RKiiliitiiiK  I'XpDl.sidii  of  tlie  lu'iid. 

(Fig.  199).  This  ])rocedure  gives  easy  command  of  the  birth  of  the  head, 
yet  offers  no  importan*^  advantage  over  simj)ler  methods.  The  writer  prefers 
to  this  the  manipulation  shown  in  Figure  201. 

As  a  rule,  in  first  labors  a  half  iiour  or  more  from  the  time  the  pelvic 
floor  begins  to  l)e  distended  will  be  recpiired  before  the  head  can  safely  be 
allowed  to  pass.     In  subse(|Uent  births  a  shorter  time  will  usually  suffice. 

While  the  jirocedtires  just  described  are  to  be  recommended  to  the  general 
exclusion  of  other  methods,  there  is  no  objection  to  the  use  of  gentle  pressiu'c 


'10 


I'll!  and  tlio  B,,,  ,,„„  %       '■  ""  '■•Miii'»n,i,  bv  i|,e  ,i,„„.i.     '  '      "'"  '«'  '"""') 

"■«.  bettor  tl,„      ft'  ''"'"•'  "■""•  "ft^'r  «|.isi..to„v   '■,""'-■"'"'■     T'"= 

I  lie  .success  of  tl      '     •  '    '      ^'"^'^  "'^ '"  t''o 

•"«y  fiiKl  r»„m  ft,,  r         '      "'"'  '"  "I'i'^l'  ovc,  t|,o  ;  '        ,.!'"'  -'I'l'^iwitlv 

■"-•.ai.ie„  J;    ,;"'-"•;"""'  '™o,.„n.',  if:''"',;:,™" «'  i"  .1.0  ,.„„, 

»^"""o:;,t„,  I  ,^  ;:«!'■  -;  "■<■  ".*i„„  ;,„iu :;:;;;'' r  "'T'-  °"  "■« 


1/   ' 


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AMl'UilCAN  TEXT-BOOK  OF  OBSTETJilVS. 


Most  essential  is  it  that  the  cuts  be  made  parallel  with  the  long-  axis  of  the 
mother's  hody,  not  with  the  vaginal  axis.  The  cuts  will  then  he  found  on 
exaujination  after  labor  to  run  parallel  with  the  outlet  of  the  birth-eanal.     If 

the  knife  be  held  in  line  with  the  axis 
of  the  vulvo-vaginal  outlet  as  the  latter 
appears  at  the  time  of  incision,  its  point 
will  be  liable  to  invade  the  very  struc- 
tures the  operation  aims  to  save;  the  ])os- 
terior  ends  of  the  incisions  will  be  ibund 
after  delivery  nnich  nearer  the  median 
lijie  than  was  intended,  and  the  trans- 
versus  perinei  and  other  iiuportant  struc- 
tures will  possibly  be  divided.  This 
result  is  well  shown  in  the  accompany- 
ing illustrations  by  Dr.  R.  L.  Dickin- 
son'  (Figs.  •202,  20;3). 

If  j)referred,  the  resisting  ring  may 
be  divided  with  scissors.  Alter  labor 
the  cuts  should  immediately  be  reunited 
with  stitches.  A  running  or  an  inter- 
rupted sutiu'c  with  fine  catgut  best  an- 
swers the  purpose.  The  wounds  may 
generally  be  closed  without  waiting  for 
the  delivery  of  the  placenta,  thus 
saving  the  necessity  for  renewing  the 
anesthesia.  During  the  suturing  the 
patient  may  lie  on  the  buck  or  on  the 
side    opjiositc    the    one    being    repaired. 

jraiKif/ciiicnt  of  the  Cord. — Tlie  moment  the  head  is  born  a  finger  is  slipped 
within  the  passages  to  ascertain  if  the  cord  is  coiled  about  the  child's  neck. 
When  so  fotmd,  the  loop  or  loops  should  be  drawn  down  one  by  one  over  the 
licad.  Should  the  coil  be  so  taut  that  it  cannot  be  brought  down — an  accident 
that  nuist  be  extremely  rare — the  cord  may  be  tied  at  two  points,  and  be  cut 
between  the  two  ligatures  and  the  trunk  promptly  delivered. 

Jk/ivcri/  of  t/i:'  Trunk. — The  head  should  now  be  held  in  the  hand  to  keep 
it  in  the  axis  of  expulsion.  Contrary  to  the  usual  teaching,  the  writer  prefers 
to  deliver  the  posterior  shoulder  first.  While  the  anterior  shoulder  lies  behind 
the  symphysis  the  finger  is  passed  over  the  dorsal  aspect  of  the  posterior  shoul- 
dc!"  and  is  slipped  into  the  axilla.  The  j)osterior  shoulder  is  then  folded  for- 
ward and  is  cautinMsly  liftetl  over  the  ))erinenin. 

Kxcept   in   emergency  calling  for  immediate    delivery  in  the  interest  of 

mother  or  child,  the  expulsion  of  the  truidv  is  left  to  nature.     It  is  not  good 

jtractice  to  drag  the  child  out  of  the  uterus.     The  uterus  should  be  compelled 

to  expel  it.     The  presence  of  the  trunk  and  the  extremities  stimulates  contrac- 

''Tlif  l)iiV('tion  of  tliL'  Incision  in  lOpisintDinv,"  Tniiin.  Am.  (lyn.  Sor.,  1S92. 


Kli,.  JiiJ.-  Double  i|ii>iiitiiniy(skctc'li,  just  aftor 
delivery,  liuMi  iiiilure.  K  1..  Diekiiisoui :  A.diree- 
tiiMi  (if  iiieisiiiii  laulty.  iinintinj,'  tnwiinl  the  )mis- 
teriiir  viiL'iniil  will  I  ;  li,  enrreet  line  of  iiieisiuu. 
nimihii.'  ii:n-iille!  willi  llie  iixis  nl'  the  vulviir 
(ipeiiiMi,'. 


^^^/^    mv/>6YT   OF  Js^oPU^r 


if  ■ 

•   *    •        i!  , 


-^ 


ill*  , 


376 


AMKRIVAX    TEXT-BOOK    OF    OnSTKTJilCS. 


of  the  weight  of"  the  cliild  in  the  tir.<t  moinent.s  after  birth  i'vom  rehixatioii 
of  the  uterus,  too  early  ligation  of  the  eord  exposes  the  new-born  infant  to 
the  loss  not  only  t)f  reserve  blood,  but  also  to  a  ])art  of  its  own. 

8iuee  the  ehild's  heart  may  be  endangered  by  forcing  too  much  blood  into 
the  eircnlation,  compression  of  the  uterus  should  not  be  practised  before  the 
cord  is  tied. 

In  certain  emergencies  immediate  ligation  nuiy  be  necessary,  owing  to  con- 
ditions of  the  mother  requiring  the  obstetrician's  entire  attention.  In  case  of 
well-developed,  vigorous  infants  the  rule  of  late  ligation  loses  nuich  of  its 
importance. 

The  practice  now  usually  observed  is  to  tie  the  cord  after  notable  pulsation 
has  ceased   and  the  respiration    is  fully  established.     If,  as  seems  pmbable 
from  the  researches  of  Caviglia,  the  principal  cause  of  the  afflux  of  blood  is 
uterine  pressure,  neither  the  child's  respiration  nor  the  funic  pulse  is  the  ti. 
guide  to  the  time  for  tying  the  cord,  but  rather  the  iirst  firm  contraction  of 
the  uterus. 

In  case  of  twins  the  cord  should  always  be  ligated  on  the  maternal  as  well 
as  on  the  fetal  side,  owing  to  the  possible  existence  of  a  vascular  connection 
between  the  two  placentas. 

A  suitable  material  for  the  ligature  is  narrow  linen  bobbin.  For  greater 
security  against  hemorrhage  a  rubber  elastic  baud  may  be  used.  It  is  perhai)s 
needless  to  say  that  the  material  should  be  surgically  clean.  It  may  be  left  in 
the  antiseptic  solution  until  wanted. 

The  common  practice  is  to  tie  from  one  and  a  half  to  three  inches  away 
from  the  umbilicus.  For  this  rule,  in  the  absence  of  a  navel-cord  hernia, 
there  is  apparently  no  better  reason  than  custom.  It  is  in  the  interest  of  an 
aseptic  healing  of  the  navel  wound  to  reduce  to  a  mininunu  the  amount  of 
necrotic  nuiterial  in  the  stump.  The  ligature  should  therefore  generally  be 
placed  not  more  than  half  an  inch  from  the  cutaneous  line.  It  is  to  be  tied 
as  tightly  as  it  can  be  drawn,  with  care  to  put  no  strain  on  the  umbilical 
insertion.  JJefore  tying,  the  cord,  except  it  be  already  thin,  should  be  pinched 
firndy  between  the  thumb  and  finger  at  the  point  to  be  ligated.  This  procedure 
is  better  than  stripping,  which  is  liable  to  do  violence  to  the  navel. 

The  cord  is  divided  within  a  f|uarter-incli  of  the  ligature.  It  is  cut  with 
clean  scissors  while  held  in  the  hollow  of  the  hand  to  guard  against  injuring 
the  child.  A  bit  of  cheese-cloth  ju'cssed  a  ^^'W  times  against  the  cut  end  of 
the  stiunp  will  show  whether  the  vessels  are  securely  tied.  It  is  a  common 
practice  to  ))la('e  a  second  ligature  a  short  distance  from  the  first  to  control 
the  matermil  end  of  the  cord.  This  jiromotes  cleaidiness  and,  it  is  gener- 
ally believed,  favors  the  placental  expulsion.  The  latter  claim,  however,  is 
doubtful. 

Management  of  the  Third  Stage. 

Xot  the  least  ini])ortant  duties  of  tlu'  obstetrician  in  the  condiu't  of  natural 
labor  fall  in  the  third  stage.     Upon  the  skill  and  attention  given  to  this  period 


Vlu 


%1^ 


tiie  iiuraecJfate  safbtv  of  fl,  ^    '      '  ''  ''"" 

"•";•>"■•"«.(  of  ,1,0  „„•,,,  «,,:,;'';■'''*'' •*'''-''^  "'"I  -"'''im-oiuCr' 


-"'-<  iv<it.'.s  „i,..tiuHi  ,,,-  i  TUT  iTTT  ^«i^..,-'r«y  .« 

,.         .  ""»" -,      -•"■"•■"■M ,.„* „„„„„„„„ 

T'""  '■"""■"I'i"' "ill.  oll,c.,.  ,l„,i,.       Tl      ,        , 

'"'"'■  ""■'-•'  '.f  el  .         "  ',';•■  '■■'■"■ '"'""'^'I  -vail,  „C      .  „  '""  -'."'"I"'-" 

"' ^"•'^"""•^  applied  t„ 


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i 


I 


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:(:i: 


i 


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378 


AME/ilCAN  TEXT-IiOOk'  OF  OBSTF/FIiTCS. 


the  uterus  until  a  vigorous  contraetiou  is  induced.  The  hand  is  then  plaeed  in 
such  position  upon  the  al)douieu  that  the  fundus  rests  in  the  lioUow  of  the 
hand  with  tlie  thiinih  in  front  and  the  four  fingers  behind  (Fig.  2(J4).  At  tiie 
height  of  the  contraction  the  uterus  is  conij)ressed  and  thrust  downward  in  tiie 
direction  of  the  pelvic  axis.  If  not  at  once  successful,  the  process  is  repeated 
at  short  intervals  until  the  object  is  gained.  Until  recently  C'red6  advocated 
much  earlier  interference.  Shortlv  before  his  death  he  reeoninieuded  waitin<r 
thirty  minutes.  His  procedure  is  now  generally  adopted.  The  expectant  [)lau 
still  advocated  by  certain  authorities  is  open  to  the  objection  that  the  |)lacenta 
may  be  retained  for  hours,  din'iug  which  the  patient  is  exposed  to  the  danger 
of  hemorrhage  and  is  deprived  of  nuich-needed  repose. 

Traction  upon  the  cord  while  the  after-birth  lies  in  the  upper  uterine  seg- 
ment is  inconsistent  with  the  normal  mechanisn!  of  placental  expulsion.  When 
the  placenta  has  passed  into  the  h)wer  segment  of  the  uterus  or  the  vagina,  no 
harm  will  be  done  by  gently  pulling  the  cord  to  assist  the  delivery. 

As  the  jilacenta  is  extruded  the  membranes  are  gradually  detached  from 
the  uterus,  care  bcMug  taken  that  no  fragments  are  torn  off  and  left  behind. 
To  i)revent  this  the  placenta  is  caught  in  the  hand  as  soon  as  it  ])asses  the 
vulva,  and  if  the  membranes  are  not  already  free  they  should  be  twisted  into 
a  rope  by  turning  the  placenta  over,  and  the  twisting  contimied  until  tiie 
separation  is  complete.  Should  a  strip  of  membrane  accidentally  be  left  in  the 
passages,  it  may  be  removed,  if  in  the  vagina  or  hanging  from  the  cervix,  by 
grasping  it  with  the  fingers  and  gently  drawing  it  away,  or  by  seizing  it  witli 
sterilized  catch-fbrceps  and  twisting  it  oH".  Fragments  of  membranes  remain- 
ing wholly  in  the  uterine  cavity  above  the  cervix  are,  as  a  ride,  better  left  to 
be  expelled  with  the  lochial  discharge  unless  they  give  rise  to  hemorrhage. 
Placenta  and  nieud)ranes  must  be  examined  carefully  to  see  if  they  are  coni- 
])lete.  Possible  anomalies  of  the  after-birth  or  the  cord  may  also  be  looked 
for.  To  make  sure  that  both  amnion  and  chorion  are  entire  the  membranes 
are  best  examined  by  transmitted  light. 

The  duties  of  the  obstetrician,  even  in  strictly  normal  labor,  are  by  no 
means  ended  with  the  delivery  of  the  after-birth.  The  third  stage  is  not  com- 
plete mitil  uterine  retraction  is  fully  established.  For  at  least  a  half-hour 
after  the  placenta  comes  away  the  uterus  is  to  be  watched  with  the  hand  upon 
the  abdomen,  using  friction  if  necessary  to  provoke  contraction.  It  is  a  useful 
precaution  to  give  a  half-drachm  of  the  Huid  extract  of  ergot  at  the  close  of 
labor  if  the  uterus  is  not  firmly  contracted.  Its  use  is  proper  only  after 
evacuation  of  ])laecnta,  membranes,  and  clots.  Its  action  is  most  prompt 
and  certain  when  injected  subcutaueously.  One  or  two  doses  may  be  left 
with  the  patient  with  instructions  that  they  be  taken  in  the  event  of  flow- 
ing too  freely.  The  use  of  a  moderate  dose  of  ergot  at  the  close  of  laboi' 
is  not  only  harmless,  but  it  is  also  entirely  in  keeping  with  the  t)bjects  ol 
treatment  at  this  period.  It  limits  the  danger  of  hemorrhage,  and  by  dimin- 
ishing the  blood-supply  it  promotes  involution.  It  closes  the  gates  against 
infection,  guards  against  the  retention  of  blood-clots  in  the  uterine  cavity,  and 


Tin-:  coxnucT  of  normal  labor. 


•.M\) 


1» 


tlRTofore  los.-!oiis  the  toiuloncy  to  af'tor-paiiiri  ami  to  putrid  accuniulatioiis  in  tlie 

UtlTllS. 

IvKi'Aiu  OK  liAcr.KATioxs. —  ( 'crclcdl  facerofions  .should  ho  sutured  at  the 
elose  of  lahor  in  case  they  give  rise  to  much  hemorrhage.  In  the  absence  of 
troublesome  bhteding  the  advantage  of  the  primary  suture  is  doubtful. 

The  method  of  operating  is  as  follows.  No  anesthetic  is  rc(|uired.  The 
cervix  is  most  readily  brought  down  within  easy  reach  when  the  patient  is  on 
the  back.  She  may  lie  across  the  bed  with  the  hips  close  to  its  edge,  or  still 
better  on  a  Krm  table,  [f  necessary,  the  ])erineinn  may  be  retracted  witii  a 
large  Sims  speculum.  The  anterior  vaginal  wall  may  be  held  up  out  of  the 
wav  with  a  retractor,  if  recpiired.  The  cervix  is  drawn  well  down  with  a 
volsella.  The  lips  of  the  wound  are  most  conveniently  held  in  contact  with  a 
single  volsella,  one  hook  being  caught  in  each  lip  near  the  lower  end  ol"  the 
tear.  The  lirst  suture  should  be  passed  just  above  the  upper  angle  of  the 
laceration  and  tied.  This  suture,  if  properly  placed,  controls  tlu;  bleeding. 
The  otiier  sutures  are  then  applied  as  in  the  secoixhuy  o|)eration.  The  mate- 
rial may  be  waxed  silk  or  silver  wire.  The  former  is  recommended  as  being 
more  mauagealtle,  and  it  has,  in  the  writer's  experience,  proved  entirely  satis- 
factory when  well  saturated  with  paraffin  wax. 

Laccrdtions  of  flic  jnlri''  floor  in  general  practice  ])rol)ably  occur  in  not  less 
tlian  ;}o  ])er  cent,  of  first  and  in  about  10  per  cent,  of  .subsequent  labors. 
This  percentage  of  injuries,  however, 
is  capable  of  considerable  reduction 
under  proper  management  of  the  i)er- 
ineal  stage  of  the  birtli.  In  skilfidly 
conducted  labors  the  ])roportion  of  lac- 
erations should  .scarcely  exceed  1 ")  per 
cent.  In  cas(>  of  relatively  small  vulvo- 
vaginal oritice,  narrow  ])ubic  arch,  un- 
usual rigidity  of  the  pelvic  floor,  in 
breech  extraction,  and  in  other  rapid 
(icliveries  notable  injuries  are  inevi- 
table in  a  large  proportion  of  cases. 

The  type  of  laceration  most  fre- 
i|uently  encountered  is  one  that  riuis 
nearly  in  tiie  median  line  of  the  super- 
litial  structures  and  to  one  side  of  it  in 
tlie  vagina  (Fig.  205).  Sometimes 
the  wound  presents  the  shape  of  a  Y 
with  one  arm  to  citiier  side  of  the 
inctlian  line. 

Time  for  Ixcjiair. — I  'nlcss  the  con- 
dition of  the  patient  at  tiie  close  of 

I;>l)or  is  such  as  to  forbid — and  this  is  vciy  rarely  tiic  ease — lacerations  of  the 
pelvic  floor  shoidd  innnediatoly  be  sutured.     Vet  perfect  union  may  be  obtained 


¥%"'" '' 

^'    '                   '^iMV'"        "^^     -jmmmg^ 

B  ^'       ..      i 

^^   ^S 

-%  WF'  VJ 

Wk  wi 

ik^ 

Mm 

:^^^^m*'  ^i^-'^' 

imM 

w^^^^e^tm 

9^K 

l-'|i;.  JO."..— l.iici'ratinii  cif  tlii'  [n'lvic  llimp.  cxIciiiHiiK 
liiilf  wiiy  tci  till'  rL'clnm  nml  runiiiiit;  tDWiinl  llir  ritjlit 
v.'iL'innl  siilcii-;  (t'ruiii  n  ski'Ich  ill  tliu  I'losu  (if  liilicir  liy 
Uiilurt  I..  Ilickiiisnii,  M,  I),). 


380 


AMJ:iiIC\N    TEXT-BOOK    OF   OBSTETRICS. 


t  1  / 


11     .!      I 


ii 


•/ 


i»i 


l)y  nporatinj.  at  any  tiino  within  twcnty-f'our  honrs.  Tho  j^nturing  may  generally 
be  clone  with  ('oinplete  sncceiss  even  after  so  long  a  period  as  a  week  if  for  any 
reason  it  has  previonsly  bi'en  negleeteil.  AVhen  perfornieil  thus  late  the 
wound-siirfaees  are  first  to  be  vivitied  by  rubbing  theiu  with  a  told  of  cheese- 
eloth,  and  then  made  smooth  by  trimming  with  seissors. 

The  writer  has  frequently  repaired  laeerations  while  waiting  for  the  delivery 
of  the  jilaecnta.  This  praetiee  saves  time,  and  generally,  too,  the  renewal  of 
the  anesthesia.     It  is  not  to  be  advised  in  extensive  and  complicated  injuries. 

Siifwe  Material. — For  ordinary  use  prepared  silk  is  recommended.  Silk- 
worm gut  or  silver  wire  is  less  likely  to  cause  suppuration  along  the  needle- 
track,  but  neither  is  so  easy  of  ai)])licatit»n  nor  so  comfortable  for  the  pa- 
tient. Catgut  is  best  reserved  for  buried  sutures,  owing  to  its  tendency 
when  j)artially  exjjosed  to  decompose  and  to  lead  septic  niaterial  into  the 
needle-track. 

The  writer's  method  of  sterilizing  silk  by  immersion  for  two  hours  in 
melted  paraffin  at  a  temperature  between  240°  and  260°  F.  has  iri  his 
hands  ])roved  sa«^isfactory.  A  thermometer  specially  made  for  the  pur])ose, 
which  can  be  kept  immersed  in  the  melted  wax,  must  be  used  for  regulating 
the  temperature,  otherwise  the  silk  is  liable  to  be  overheated  and  charred. 
The  wax  employed  should  be  soft,  as  the  harder  varieties  crumble  in  hand- 
ling the  thread.  A  No.  7  silk  is  a  gooel  size  for  the  larger  wounds ;  somewhat 
smaller  sizes  mav  be  used  for  slight  lacerations. 

Needles. — For  use  in  the  external  and  more  accessible  portion  of  the  wound 
the  needle  should  be  straight  or  be  slightly  curved  and  about  2  inches  in 
length.  For  suturing  tears  high  up  in  the  vagina  a  needle  as  much  shorter  as 
the  depth  of  the  wound  will  permit,  and  having  a  more  pronounced  curve,  may 
more  conveniently  be  used.  Xeedlo.-?  of  ihe  Hagedorn  pattern  will  be  found 
most  satisfactory. 

Jfethod. — An  anesthetic  is  usually  necessary.  Ether  is  to  be  preferred 
here,  as  usual  for  surgical  anesthesia.  Small  tears  may  be  repairal  under 
coeain  anesthesia  if  for  any  reason  it  is  desirable  to  avoid  the  use  of  the 
general  anesthetic.  Coeain  is  most  effective  when  injected  at  several  points  in 
the  lips  of  the  wound.  Not  more  than  a  grain  at  most  can  safely  be  used  in 
this  manner,  and  the  solution  should  be  rendered  sterile  by  boiling.  Many 
women,  however,  suffer  very  little  pain  from  the  introduction  of  sutures,  since 
the  tissues  have  largely  lost  their  sensitiveness  by  the  j)ressure  and  contusion 
received  during  labor.  If  care  is  taken  to  plunge  the  needle  quickly  through 
the  skin-margin  at  the  mf)ment  the  greatest  amount  of  pain  is  produced, 
lacerations  not  very  extensive  n>ay  be  sutured  without  anesthesia.  The 
])atient  lies  in  the  lithotomy  position,  crosswise  of  the  bed,  with  the  hips  close 
to  the  edge  of  the  latter,  or  upon  a  table.  The  knees  are  held  by  assistants  or 
by  some  of  the  numerous  appliances  eonuuonly  em])]oved  for  the  purpose  in 
gynecological  practice.  The  sheet  sling  of  Dr.  Dickinson  has  the  advantage 
of  being  always  available. 

One  of  the  chief  difficulties  in  determining  the  extent  and  character  of  the 


^'//A'   coy  DUCT  OF   voru,,     r 


,      ,.  '"'*^  J-Ajion.  no, 

iaceration  arks  f"i-,>i..  fi  .  "°* 

'■""»  "P  one  «,■  lH„|,  ,,M,„  „/-,l'    '"'">■  """  "i'l',  •«  ,„«i,„„|,.  ":'?■ 
-..Uy, o„.,„Vee,, „„ „„,„         ;,«■-';'■«"■.     TU.  aim  t      t'' 

"'  flio  lacerati.,,,.      I,  ,i,„  ,l„     ,'""■'""  '"  «"fart  tlir„ii»|,„Mt  lli, •      , 

'-»""'  to,.,,,,,  „,;,,;*  "'■:  J";',™'.  o"e  b,  o„cr,b  ^:  :';''^'f 


Tir 


1 1 


3H2 


AMI'llilCAX   TEXT-BOOK   OF   onSTKTJtICS. 


5t»    ti  ^1 


(        1 


iniK'otis  nionibi'iiiu",  and  the  rcinainiiit;  wound  is  sntnrod  on  cither  Ine  perineal, 
the  vaginal,  or  both  surfaees  as  may  be  tbnnd  most  expedient.  When  the  rent 
<loes  not  extend  np  the  reotnin  too  far,  in  addition  to  the  last  interrni)ted  sutures 
tied  in  the  rectum,  which  coapt  the  torn  ends  of  the  sphincter,  a  reinforciiiif 
stitch  will  be  useful  passed  in  the  following  maimer:  While  a  tenaculiun  is 
used  to  draw  out  one  retracted  end  of  the  nmscle,  tiie  suture  is  passed  through 
this  end  of  the  nmscle,  and  contiimes  its  course  upward,  buried  along  the  edge 
of  the  rectal  rent,  to  the  apex  of  the  rent;  the  needle  now  emerges,  and  is  again 
buried  along  the  other  margin  of  the  rectal  rent,  and  is  carefully  j)assed 
through  the  other  end  of  the  torn  sphincter,  while  a  tenaculiun  draws  out  this 
retracted  end  of  the  muscjle. 

In  deep  tears  of  any  kind  the  tiered  suture  "s  a  good  one.  Beginning  at 
one  end  of  the  wound,  a  layer  of  the  torn  structures  at  the  bottom  of  the 
laceration  is  closed  with  a  running  catgut  suture ;  this  is  re[)eated  in  a  plane 
next  above  the  first,  and  so  on  until  the  wound  is  entirely  closed.  The  last 
tier  of  stitches,  which  is  partially  exposed  on  the  vaginal  surface,  is  best  made 
with  waxed  silk.  It  is  well  to  dust  the  suture-line  with  some  bhuul  anti- 
sej)tic  powder  like  boric  acid,  iodoforni,  or  a  mixture  of  both  (iodoform  1  part, 
boric  acid  8  parts).  For  a  few  days  this  application  may  be  renewed  with  each 
change  of  the  vulvar  dressing.  The  right  and  tl»e  wrong  methods  of  SHtiu'ing 
are  shown  in  Figures  20(5  to  20H. 

After-care. — There  is  no  necessity,  as  a  rule,  for 
tying  the  patient's  knees  together.  The  sensitive- 
ness of  the  jiarts  will  be  a  sufficient  safeguard 
against  injurious  strain  upon  the  sutures  by  sepa- 
rating the  liml)s,  and  the  patient  will  be  much  more 
comfortable  without  the  leg-binder. 

Retention  of  urine  frecpiently  results,  owing  to 
the  rcfiex  distiu'banee  caused  by  the  perineal  suture, 
es{)ecially  when  the  latter  comes  close  to  the  rectum. 
While  injurious  distention  of  the  bladder  must  not 
be  jK'rmitted,  the  catheter  should  be  withheld  if 
possible.  AVhether  the  bladder  is  emptied  volun- 
tarily or  otherwise,  urine  must  not  be  permitted  to 
trickle  into  the  vagina  or  over  the  suture-line.  The 
bowels  are  to  be  kept  open,  as  in  other  cases,  after 
the  second  day.  The  sutures  are  removed  on  the 
eighth  or  the  ninth  day. 

Toilet  of  the  Patient. — Tiie  child  is  received  in 
two  or  three  thicknesses  of  flannel,  is  well  wrapped, 
I'Kj.  20f..-ucorati(m  iiko  that  ""^1  '■'  1'''<1  '»  =1  wanu  place.     The  nurse  then  U\v\\> 
.shown  in  FiK'uii. 'J05,  with  sutures   jior  attention  to  the  mother:  soiled  portions  of  her 

jiropcrly  placed  I'L'tuly  fur  tyinj;.  '■ 

body  ar(>  to  l)e  cleansed,  best  with  an  antiseptic 
.solution  ;  her  linen,  if  necessary,  is  changed  ;  and  all  blood-stained  articles 
are  removed  from  the  bed.     For  bathing  the  genitals  a  piece  of  fresh-boiled 


10  edge 


"^  uanislied  from  fi,,,  i   •       .        '"•^''^••<'   of   a  snoiKm      u 


'■"•■'^•'•-"•'■t.vinB.-/, 


miiNcli.-,.,,,!^ . 


iTf,  milinjr 


""""""-'■"»'"-- looMai  ;:;;,;';3^ 


I^K;.  20S.— Shows  fllll    .  "'       ^-"-' '^"-^-S'^  "-■  :>St»i»S5<«-- 

'="  -P-ecos  are  attached  to  the  J,,  ,1       H'      '"^''"'^■^  ^^''^'^'  ='"<'  2  i.,e  es  th 
•':•«  b.,rned  after  „sing.     Tl,oso'.        •       "  '"'^'"'"^^  ^"  ^''^^  '^'-Hler     T  '  i " 

<''='tely  before  use      F  .„  ''"'""^^  «'-^"  ^ct  .sterilised  b    T  ^""''''■' 


l\H4 


AMKIilCAX    TKXT-lUtOK    OF    onSTKTIUCS. 


A  (Imw-slu'ot  [tlacod  midcr  tlio  pati-'iit's  Iiips  is  a  ('«mv('iiit'iit  drossinj?  for  pru- 
tc'C'tiiiii;  tlio  1)('(1.  Till'  (Iriiw-slicct  consists  of  a  coinmon  iniisliii  slicet  folded 
to  four  tliic'Iviu'sscs,  It  is  replaced  hy  a  fresh  one  as  often  as  soiled.  Instead 
of  tlio  draw-sheet  an  aseptic  pad  siniihir  to  tiie  hihor-pad,  bnt  thinner  and 
smaller,  in.iy  he  preferred. 

AbdoiiiiiKil  Hinder. — The  ahdoniinal  hinder  is  usefnl  to  steady  the  uterns, 
and  it  [)roniotes  thecond'ort  of  the  patient,  especially  when  the  abdominal  walls 
are  very  lax.  The  nsnal  material  is  a  piece  of  nnhleaehed  nuislin  1|  yards 
in  leniith  and  abont  18  inches  in  width.  'J'liis  y-ives  width  onony-h  to  reach  from 
the  ensiforni  to  a  point  below  the  trochanters  (I'l.  27,  Fig.  1).  Unless  the 
binder  overreaches  these  bony  prominences  it  is  liable  to  slip  up,  and  in  a  few 
hours  is  reduced  to  a  mere  ro])e  around  the  body.  Binders  ready  made  with 
gores  to  fit  the  body  offer  no  advantage.  The  pinning  of  the  binder  shoidd 
begin  at  the  lower  border,  and  at  the  first  application  should  be  fairly  tight. 
If  the  uterus  shows  any  tendency  to  relaxation,  three  folded  towels,  used  as 
compresses,  may  be  placed  on  the  abdomen  under  the  bandage,  one  on  either 
side  of  the  uterus  and  cme  immediately  al)ove  it.  The  binder  may  be  dis- 
pensed with  aft(>r  one  ov  two  weeks. 

IJcfore  leaving  it  is  well  for  tiie  piiysician  to  take  final  note  of  the  pulse  and 
the  general  condition  of  the  mother,  and  the  nurse  should  receive  all  ueeded 
instruction  in  regard  to  the  general  care  of  both  patients. 


III.  THE  MECllANlt?M  OF   LAUOR. 

Labou  is  a  natural  process,  and  it  is  the  province  of  the  accoucheur  to 
restrict  himself  to  watciiing  tiie  processes  of  nature  so  long  as  they  are  normal 
and  ctHcient,  and  to  interfere  with  them  only  when  they  become  disturbed  or 
inefficient.  He  is  at  his  best  when  he  is  able  to  compel  the  faulty  efforts  of 
natural  labor  into  a  normal  course,  and  he  makes  a  comparative  failure  when- 
ever he  is  obliged  to  sul)stitute  for  the  acts  of  nature  the  relatively  crude 
process  of  an  artificial  delivery.  An  ability  to  restore  the  normal  by  making 
trifling  alterations  in  the  mechanical  conditions  presiipposi's,  however,  a  most 
accurate  knowledge!  of  the  details  of  the  mechanism  which  governs  the  usual 
course  of  labor,  and  of  the  alterations  in  them  which  determine  the  advent 
of  any  deviation  from  the  normal.  When,  moreover,  it  is  remembered  that 
obstetric  operations  are  but  efforts  to  direct  an  extraue<iiis  force  into  an  accu- 
rate imitation  of  the  processes  of  nature,  it  becomes  evident  that  the  first 
essential  to  success  in  obstetrics  is  the  ])ossession  of  a  far-reaching  knowledge 
of  the  mechanism  of  labor  in  its  several   varieties. 

Any  intelligent  study  of  obstetrical  mechanism  nnist,  however,  be  preceded 
by  a  comprehension  of  the  technical  terms  used  in  describing  it,  and  of  tiic 
several  classifications  l)y  which  labor  is  commonly  subdivided  into  varictie-. 
It  is  further  necessary  that  the  student  should  possess  an  accurate  knowledge 


(()MtI(T  (»1'    N(»I;M\I,    I.Ar.nl; 


I'l.ATi; 


US- 


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It  the 
'tio-. 


1.  Al  ilniiiiiiiil  liiink'r  ami  liiriist-liiiulcr  in   |i1iiic  din 

(ln>m  II  {>liMtnm'M|>li 


|ilinl(if;rii|ili).     '-■  Uii'ii>t-liiMiUr  ill  jilnt'L' 


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Tin:    MHVJfAXISM    O/'    l.MiOli. 


385 


Iff  tlic  shape  and  dimensions  of  tlie  obstetric  eaiial,  and  (»('  the  i'etiis  whieh  is 
to  pass  tlironffJi  it.  He  is  then  in  a  position  to  a('((i:ire  an  int(  lli<i'ent  iinder- 
standin^f  of  the  principles  whieh  nnderlie  the  ineelianisni  of  all  the  forms  of 
lahor,  nnder  the  head  of  a  description  of  it8  coninionest  variety,  and  so  easily 
(.r^oes  on  to  understand  the  niodilieations  in  the  mechanism  that  follow  upon 
ilie  alterations  in  the  conditions  in  the  other  varieties. 

Attitude  of  the  Fetus. — \\y  the;  attitude  of  the  fetus  is  meant  the  posi- 
tion its  parts  assume  in  iilrro  in  relation  to  one  another,  in  contradLstinctiun 
to  any  relation  they  may  bear  to  the  luiiternal  parts. 

During  the  earlier  months  of  prcffiianey  the  uterine  cavity  is  nearly 
»|)herical  in  shape,  and  it  is  then  so  larj^o  in  proportion  to  the  fetus  that  its 
walls  are  rarely  in  contact  with  the  embryo.  The  fetus  hangs  freely  in  the 
uterine  cavity,  i)eing  suspended  by  the  umbilical  cord,  with  its  head  somewhat 
lower  than  its  pelvis  and  with  its  limbs  in  a  somewhat  extended  position 
(Fig.  209).  As  pregnancy  progresses  the  size  of  the  fetus  increases  more 
rapidly  than  that  of  the  uterus,  until  in  normal  eases  at  term  the  adai)tatioii 


I'Ki.  lin'.i.— licliilidii  lictwi'iTi  tlif  sizi'  (pf  till'  utc-  Kl(i.  ■-'10.— Adiiiitatidii  tjitwct'ti  tlic  iittriis  and 

nis  mid  till' I'l'tus  lit  lil'tli  iMuiilli  (iiiR'-sixtli  imtiinil  tho  f<.'tus  at  ti'i'iii,  in  vitIux  prt'suiitatiuus  (11110- 
^i/^■l.  .sixth  mitural  si/fi. 

I)0tween  the  two  is  siitVieieutly  close  to  make  any  extended  movements  of  the 
f^n.il  lind)s  diflicult  or  impossible.  The  attitude  which  the  ciiild  then  assiunes 
is  that  represented  in  Figure  210,  which  is  readily  seen  to  be  the  most  com- 
pai     attitude  in  which  the  child  can  be  arranged. 

Presentation. — The  word  prcxnitatlon  is  used  to  define  the  relation  which 
the  long  axis  of  the  child  bears  to  the  long  axis  of  the  uterus,  and  the  dif- 
t'cicnt  presentations  are  distinguished  from  one  another  by  the  use  of  adjec- 
tives which  rel^  to  the  part  of  the  child  that  is  to  enter  the  pelvis  first  in  a 
uiven  ease.  The  several  ])resentations  which  may  occur  are  ce)>halic  presen- 
tations— that  is,  presentations  of  the  vertex,  of  the  brow,  and  of  the  face;  pres- 
entations of  the  pelvic  extremity,  whieh  are  sidxlividcd  into  lireeeh  and  foot- 
ling proscntati  w;  and  transverse  iircsentations,  under  which  are  included 
presentations  of  the  hip,  of  the  trunk,  and  of  the  shoidder. 
25 


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AMi:iiICAy    TEXT-BOOK    OF   OBSTETRICS. 


Position. — 111  obstetric  use  the  word  jiosHion  is  restricted  to  a  meaning  in 
wliicli  it  is  used  to  define  the  relation  that  the  dorsum  of  the  child  bears  to 
the  dorsum  of  the  mother  during  its  passage  tlirough  the  ])elvic  canal.  Kach 
]>resentation  is  subdivided  into  i)ositions  according  as  the  dorsum  of  the  child 
is  directed  anteriorly  or  ptisteriorly  and  toward  the  right  or  the  left  side  of  the 
mother.  Thus  we  recognize  under  each  presentation  four  positions,  according 
to  whether  the  part  wiiich  gives  the  name  to  the  jiosition  is  directed  left- 
anteriorly,  right-anteriorly,  right-posteriorly,  or  left-posteriorly  ;  for  example, 
vertex  jtresentatioii,  occipito-left-anterior,  breech  presentation,  sacro-right- 
posterior. 

Classification  of  Labor. 

Presentations. — Tlie  presentations  are  first  of  all  roughly  divided  into 
l())if/iiu(lin(i/  and  ohli<juc  presentations.  The  longitudinal  presentations  arc 
tiuise  in  which  the  long  axis  of  the  fetus  is  in  correspondence  with  the  long 
axis  of  the  uterus ;  the  obliijne  i)resentations  are  thos(i  in  which  there  is  a 
considerable  angle  between  the  two  axes. 

The  lo)i(/itudin(il  pn'ScnUdio)!)^  lU'o,  then,  those  in  which  either  the  cephalic 
or  the  j)elvic  end  of  the  fetus  is  found  at  the  inlet  of  the  pelvis  at  the  begin- 
ning of  labor — that  is,  all  the  variations  of  cephalic  and  pelvic  presentations. 

'f he  ohlifjuc  or  transverse  prcsnitafions  iuchule  all  those  in  which  any  por- 
tion of  the  fetus  other  than  the  head  or  the  breech  is  found  at  the  pelvic 
brim. 

Plead  presentations  are  divided  into  those  of  the  vertex,  of  the  brow,  and 
of  the  face.  Pelvic  presentations  are  divided  into  breech  presentations,  in 
which  both  thighs  are  flexed  upon  the  abdomen  when  the  nates  of  the  fetus 
enter  the  mother's  pelvis,  and  fooUhig  presentations,  in  which  one  or  both 
legs  are  extended  and  enter  in  advance  of  the  infant's  pelvis.  Transverso 
presentations  include  presentations  of  the  hip,  of  the  trunk,  and  of  the 
shoulder;  among  these  presentations  those  of  the  shoulder  are  by  far  the 
commonest  and  most  important. 

It  is  also  convenient  to  classify  the  ]>resentations  of  the  fetus  in  two  other 
ways,  ill  a<'coi'danc(>  with  the  results  which  may  be  expected  to  accrue  from 
their  occurrence — namely,  into  normal  and  abnormal,  natural  and  unnatural, 
presentations. 

Normal  and  Abnormal  Presentations. — A  ])resentatit)ii  of  the  vertex 
occurs  in  about  I'T  ])cr  cent,  of  all  labors,  and,  both  from  its  frecjuency  and 
from  the  favorable  character  of  its  results,  is  considered  to  be  the  only  noriiKil 
presentation,  all  otliers  being  elassifie<l  as  abnormal. 

Natural  and  Unnatural  Presentations. — Natural  ])resentations  are  those 
in  which  the  conditions  are  such  that  they  may  be  exjiected  to  terniinate,  in  ;i 
large  j)roportion  of  cases,  in  delivery  by  natural  or  unaided  labor.  Fnnalural 
pri'scMtiitioiis  are  those  in  which  the  shape  of  the  presenting  part  of  tlie  fetus 
is  so  ill-adapted  to  the  pelvic  canal  that  the  labor  can  ordinarily  be  termiiiati  il 
only  by  tlie  intervention  of  the  obstetric  art.  natural  delivery  being  possible 
only  when  the  pelvis  is  exceptionally  large  and  when  the  fetus  is  at  die  same 


""■'  -'^W-'AV*,.   or  7.,B0«. 


time  i„„„a„„o  or  ,.™.,„i„„„||,  „„,,„  '""""  -^"^ 

—" " ■  -  ™-=~"it':=-- 

Position.—,?  divi^w.n    r  .1 
FfTifo-— V    f  '"^^  '^t  t''("  beginning 

a  z  ";t  .''r"r"  '->'-■■-  .-""i:^:  :  ;;r;v  r™'"-'  -' '>>•"» 

"°Sr£S;S":^';:n::: ""  - '-  -» „„„. 

I »».'•         '""•  ""■"  ""-"■'■■•■" i« »,,  ;:;;;:,;|;:tr'  ';':",""i  ■■" ....... 

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A.VEliJCJX   TEXT-BOOK    OF   OBSTETlilCS. 


Anatomy  op  the  Pelvis. 

The  anatomy  of  tlie  bones  and  the  soft  parts  which  together  make  np  the 
j)elvis  is  (lesc'ril)e(l  in  detail  in  another  portion  ot"  this  work,  bnt  for  tlie  com- 
prehension of  the  medianism  of  hibor  it  is  necessary  to  add  to  the  anatomical 
description  a  discussion  of  the  shape  and  dimensions  of  the  parturient  canal 
as  a  whole,  before  its  mechanical  relation  to  the  fetus  which  is  to  pass  through 
it  can  intelligently  be  discussed. 

The  porfui'icnt  cannl  (Fig.  211)  may  be  divided,  for  purposes  of  descrip- 
tion, intt)  three  i)arts — the  supra pe/vic,  the  pelvic,  and  the  infrapelvic  portions. 


Kl(i.  ■JU— Tlie  imrlurii'iit  ciiiml:  at.  axis  (it  iiliriis;  aI,  axis  iif  inlet;  iti!,  ri'tfiictioii-riiiB  ;  lo,  iiiU'riml  (|^ . 

Ko,  (.■xttTiml  ns  iciiR'-tliird  imtiiriil  sizcl. 

The  xKpraptlvic  or  abdominal  portion  of  the  parturient  canal  is  made  up  of 
the  uterine  ctivity  anil  the  large  or  false  pelvis.  This  portictn  of  the  ju'lvi- 
is  classified  with  the  uterine  cavity  on  account  of  the  similarity  of  their 
finictions;  that  is,  the  obstetric  function  of  the  large  pelvis  is  simply  that  of 
affording  a  resting-place  to  the  lower  [)ortion  of  the  child  during  the  whole  (  r 


THE   MECHANISM    OF  LABOR. 


389 


tlie  greater  portion  of  pregnancy,  and  of  guiding  the  presenting  part  to  the 
inlet  at  the  beginning  of  hibor.  The  pdch-  portion  of  the  ])arturient  canal 
consists  of  the  small  or  true  ])elvis.  The  infra  pel  I'k  portion  is  made  up  of 
tlie  soft  parts  lying  below  the  pelvic  bones,  which  jiarts,  though  small  and 
inconspicuous  in  the  non-parturient  state,  are  stretched  out  during  labor  into  a 
tubular  canal  which  considerably  prolongs  the  parturient  canal,  and  completes 
the  curve  of  its  lower  portion,  known  as  the  chitc,  of  Cams. 

All  adequate  comprehension  of  the  shape  and  the  mechanical  functions  of 
die  parturient  canal  in  its  entirety  will  best  be  attained  by  postponing  the 
description  of  the  canal  as  a  whole  until  its  subdivisions  and  component  parts 
have  been  described  in  detail. 

Suprapelvic  Portions. —  Fterhw  Cavity. — The  uterus  at  term  is  a  hollow, 
ovate-shajwd  viscus,  whose  cavity,  although  anatomically  a  part  of  the  ])ar- 
tiu'ient  canal,  is,  from  a  mechanical  standpoint,  less  a  part  of  the  passage 
than  the  engine  by  which  the  passenger  is  to  be  propelled.  The  function  of 
the  uterus  as  the  source  of  the  propulsive  jiower  by  which  labor  is  accom- 
plished will  be  discussed  later.  Its  function  as  a  portion  of  the  canal 
ictjuires  no  special   description. 

./'W/.sr  Pelvis. — The  false  or  large  pelvis  is  that  portion  of  the  pelvis  lying 
above  the  linea  terminalis.  It  is  composed  of  the  lumbar  vertebrse,  the 
upper  surfaces  of  the  latei-al  processes  of  the  first  sacral  vertcbi-a,  and  the 
Hliiamous  portions  of  the  iliac  bones,  and  functionally  it  is  completed  In-  the 
lower  portions  of  the  anterior  abdominal  nuisclt's  and  their  attachments  to  the 
horizontal  rami  of  tlie  pubic  bones.  The  whole  thus  forms  a  I'umiel  whose 
sloping  walls  terminate  in  the  inlet  of  the  true  pelvis,  and  are  admirably  suited 
to  their  office  of  directing  the  presenting  part  into  the  ])elvis  in  the  initial 
stage  of  labor.  Apart  from  this  point,  the  chief  practical  value  of  the  lidse 
pelvis  is  in  the  light  which  alterations  of  its  sha])e  or  of  its  dimensions  throw 
upon  the  diagnosis  of  ])elvic  deformities.  To  be  in  a  jiosition  to  detect  anv 
departure  from  the  normal  shape  of  the  pelvis,  it  is  especially  important  to  be 
familiar  with  the  normal  shape  of  the  iliac  crests  and  with  the  normal  curve 
of  the  linea  terminalis. 

Although  the  crests  of  the  ilia  are  classically  described  as  presenting  an  S- 
curve,  it  must  be  remembered  that  only  one  portion  of  this  curve — iiamelv, 
tiiat  which  possesses  an  anterior  concavity — enters  into  the  formation  of  the 
basin  of  the  false  pelvis;  the  other  portion  of  the  curve  is  entirely  without 
the  pelvis,  and  is  utilized  solely  for  the  attachment  of  the  saero-iliac  ligaments 
;uid  the  erector  spiuic  muscles.  The  shape  of  the  anterior  portion  of  this 
curve  is  such  that  the  greatest  distaiic(>  between  the  crests  is  normally  '2.5  centi- 
iiieters  (about  an  inch)  more  than  the  distanci>  between  the  anteri(»r  superior  spi- 
nous processes,  the  distance  between  the  crests  being  normally  'J")  centimeters 
(about  10  inches),  and  that  between  the  spines  22.5  centimeters  (about  9  inches).* 

Under  normal  circunistances   the  anterior  ])ortion  of  the  linea  terminalis 

*  TIr'sp  (linu'iisions  aro  found  to  1)0  soiiu'whiit  v;\ii:ilili'  iiiiinni,'  dilli'ioiit  nurs.  Tlic  lifjiiri's 
ijivt'H  are  belifvi'tl  to  lie  !i]ii)ro.\iin;iti'ly  i-orreot  for  Anii-riciui  women. 


tWJ 


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390 


AMKRICAX    TEXT-BOOK    OF   OBSTETRICS. 


presents  ii  uniform  curve  with  an  internal  concavity,  and  there  is  bnt  little,  if 
any,  projection  of  the  crest  of  tlie  piibes  in  or  about  tlie  niecliaii  line. 

Pelvic  Portion. — The  true  or  small  pelvis  comprises  all  that  portion  of 
the  pelvis  lying-  below  the  linea  terminalis,  and  it  is  divided  into  three  portions 
— the  superior  strait  or  inlet,  tlie  inferior  strait  or  (Hitlet,  and  the  excavation. 
It  is  formed  by  the  sacrum,  the  coccyx,  the  lower  portion  of  the  ilia,  the 
ischia,  and  the  pubes.  These  bones  taken  together  form  a  deep  basin-shaped 
cavity,  whose  posterior  wall   is  formed  by  the  sacrum  and  coccyx  and  is 


Yk 


:;12.— I'l'lvis  soun  from  above,  showiiiK  tho  (k'crcaso  in  tlic  trnn^iviTso  ilianu'tiT  from  above  downward 

(ouo-third  natural  size). 


sharply  curved  with  an  anterior  concavity.  The  anterior  wall  is  formed  by 
the  symphysis,  and  is  short  and  nearly  straight.  The  lateral  walls,  which  are 
formed  by  the  lower  portions  of  the  ilia,  the  ischia,  and  parts  of  tlie  descend- 
ing rami  of  the  ])ubes,  are  irregular  in  outline  and  slope  gently  inward,  so  that 
the  transverse  diameter  of  the  pelvis  is  markedly  less  at  their  lower  than  at 
their  upper  extremities  (Fig.  212). 

At  its  upper  and  lower  limits,  which  are  known  as  the  superior  and  inferior 
nfniit.s  (Fig.  213),  the  dimensions  of  the  pelvis  are  much  less  than  in  the  inter- 
vening space,  called  the  "excavation."  An  accurate  knowledge  of  this  por- 
tion of  the  parturient  canal  is  of  the  greatest  importance,  and  on  account  of 
its  complexity  is  most  easily  given  by  sejiaratc  descriptions  of  the  excavation 
and  of  each  of  the  straits,  after  which  description  it  will  be  easy  to  include 
that  of  the  pelvis  as  a  whole  in  the  general  description  of  the  parturient  canal 
that  follows  at  the  end  of  this  section. 

T/ie  .siij)cri(tr  .stniil  is  bounded  by  the  promontory  and  ihe  anterior  surface 
of  the  first  sacral  vertebra,  the  linea  terminalis,  and  the  pubic  crests.  The 
shape  of  the  inlet  or  superior  strait  of  the  pelvis  varies  considerably  in  accord- 
ance with  the  point  of  view  selected,  but  if  the  eye  of  the  observer  is  placcil 
in  (he  probable  position  of  the  axis  of  the  cliiKl  at  term,  it  will  be  seen  that 
the  shape  of  the  inlet  is  approximately  circular  (Fig.  212). 


THE   MECHANISM    OF  LABOR.  391 

It  must  be  remotuberod  that  the  presence  of  the  soft  parts  somewhat  alters 


•*^''-'-5:jir<j^%v 


,/ 


••^'•^ 


it-' 


\ 


\ 


7^»*s:-_->ii«ws'*'L.^_ 


/ 


Fir,.  Ji;!.— Lateriil  viuw  of  the  pelvis,  showing  superior  and  inferior  straits  (one-third  natural  size). 

tlie  shape  of  the  brim.     The  importance  of  this  fact,  however,  is  lessened  by 


V':^>. 


Ittkrcristal 


■     ' "'  Jfansverse 
Intersjfmal 


.V^*      -V, 


F\G.  21 1.— I't'lvis  seen  from  aliove,  sliow  inn  tliiinu'ters  of  lirini  fmu'thinl  natural  size). 

the  fact  that  the  vessels,  ihe  connective  tissues,  and  the  rectum,  as  well  as  the 


1          ( 

r 

V 

^ 

hi 

Cl' 

IM 

teiiit 

si 

ii 


I  i  / 


i  I 


i:    !    f) 


I  "I 


,1 


)    I 


?      1 ' 


4'     -I  I 

!    ^4 


(     I 


392 


AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 


psoas-illaciis  muscles,  which  together  form  the  only  important  soft  parts  in  the 
inlet,  are  concentrated  in  the  sacro-iliac  notches,  where  the  space  is  already 
most  abundant  and  where  its  decrease  is  of  least  importance. 

The  dimensions  of  each  of  the  straits  are  determined  by  measuring  the 
antero-posterior,  the  transverse,  and  the  two  oblique  diameters.  The  antero- 
posterior, or,  as  it  is  more  commonly  termed,  the  conjugate,  diameter  of  the 
superior  strait  (Fig.  214)  extends  from  the  upper  border  of  the  symphysis 
pubis  to  the  promontory  of  the  sacrum;  its  normal  length  is  11  centimeters 
(4}  inches).  A  little  less  than  half  an  inch  from  the  upper  border  of  the  sym- 
physis pubis  is  found  a  point  which,  owing  to  the  thickness  of  the  pubic  bone, 
is  decidedly  nearer  to  the  promontory  than  the  uj)per  border  itself  From  the 
promontory  to  this  point  the  distance  is  10  centimeters  (about  4  inches),  and 
this  is  called  the  "obstetrical"  diameter  or  true  conjugate. 

The  greatest  transverse  diameter  of  the  superior  strait  averages  13  centi- 
meters (5^  inches)  in  length  ;  this  is  the  diameter  referred  to  whenever  the 
transverse  diameter  of  the  superior  strait  is  mentioned.  This  diameter  lies, 
however,  so  far  back  in  the  pelvis — that  is,  so  near  the  promontory  (Fig.  214) 
— that  it  can  never  be  occupied  by  any  of  the  diameters  of  the  fetal  head. 
The  transverse  diameter,  which  could,  in  fact,  be  occuj>ied  by  the  fetal  head, 
lies  some  distance  anterior  to  this,  and  is  so  much  shorter  as  to  be  of  little 
im])ortance,  being,  in  fact,  less  than  are  the  oblique  diameters.  In  point  of 
fact,  the  head  never  enters  a  normal  pelvis  transversely,  and  the  transverse 
diameter  is  therefore  measured  merely  as  a  means  of  comparing  one  pelvis 
with  another. 

The  oI)lique  d'-uneters  extentl  from  the  ilio-pectineal  eminences  to  the  sacro- 
iliac articulations;  their  length  is  12.5  centimeters  (about  5  inches).  Since  the 
terms  rigid  and  left  oblique  diameter  are  differently  used  by  different  author- 
ities, it  seems  best  to  distinguish  these  diameters  as  tlu;  first  and  second 
oI)li(pie  diameters  of  the  inlet,  in  accordance  with  the  frequency  of  their 
importance  in  the  mechanism  of  labor;  the  first  being  that  which  extends  from 
the  left  ilio-pectineal  eminence  to  the  right  sacro-iliac  synchondrosis. 

The  inferior  strait  is  bounded  by  the  subpubic  ligament,  the  descending 
rami  of  the  pubcs,  the  rami,  tuberosities,  and  spines  of  the  iscliia,  the  saero- 
sciatic  ligaments,  and  the  coccyx.  Its  shape,  when  looked  at  in  the  direction 
of  its  axis,  is  that  of  a  lOzenge  whose  anterior  sides  arc  formed  of  the  ])ubic 
and  ischiatic  rami,  while  the  posterior  are  made  up  of  the  saero-sciatic  liga- 
ments.* When  looked  at  from  a  point  somewhat  anterior  to  the  line  of  its 
axis,  it  is  seen  to  present  a  roughly  triangular  shape ;  but  when  we  rememl)er 
that  the  sacro-sciatie  ligaments  become  very  distensible  during  labor,  and  that 
the  softening  of  the  sacro-iliac  and  sacro-coceygeal  articulations  that  occurs 

*  Owing  to  tlie  projection  downward  of  tlie  tuberosities  of  tlie  iscliia,  it  will  be  seen  that 
tlip  surfaet'  of  the  inferior  strait  is  bent  upon  itself  to  form  an  external  I'onvexity  (Fig.  "Jl'ii. 
I'Or  practical  j)nrposes  it  is,  however,  convenient  to  neglect  this  bend,  and  to  deal  with  tlu' 
inferior  strait  as  though  it  did,  in  truth,  lie  in  a  plane  between  the  tip  of  the  coccyx  and  the 
subpubic  ligament. 


Fl(: 


JAjU. 


/ 


lor- 
'ond 
their 
iVoin 


acro- 
otion 

)Ub'H' 

liga- 

)f  its 

iuImt 

tluit 

Iccnrs 

|i  that 
•21'>  • 

111  tli>- 
.1  till' 


T///;   MECHANISM   OF  LABOR. 


393 


during  pregiiaiicv  ])orinits  of  a  considerable  movement  of  these  bones  upon 
each  other,  it  will  be  seen  that  when  the  soft  parts  of  the  inferior  strait  are 


T-  / 


/ 


/ 


/ 


Kiii.  'Jlo.— I.iitiTiil  vk'w  (if  tlu'  pelvis,  slidwiiiK  cxtiTiinl  convoxity  of  tlio  inferior  striiit. 

distended  by  the  heatl,  its  aspect  from  either  position  will  be  that  ut  an  ovate 
or  egg-shaped  orifice  (Fig.  216). 

The  antero-posterior  diameter  of  the  inferior  strait  extends  from  the  lower 
border  of  the  symphysis  to  the  extremity  of  the  coccyx.  Its  length  in  the 
non-parturient  state  is  9.5  centimeters  (about  3J  inches),  but  when  the  move- 


.'■\ 


^  M 


^■-'•* 


'^:^^'\ 


H 


Flii.  2Ui.— View  of  distended  outlet.    Tlie  dotted  lines  sliow  the  possible   position  of  the  sacro-sciutic 
ligament  and  tlie  eonseiiuent  inerease  in  the  transverse  diameter  duriiifj  extreme  distention. 

inents  of  distention  spoken  of  above  are  fully  effected,  the  length  of  this  diam- 
eter is  increased  to  11.5  centimeters  (4^  inches),  or  perhaps  even  to  12.7  cen- 
timeters (5  inches). 

The  transverse  diameter,  which  is  drawn  between  the  inner  borders  of  the 
tuberosities,  measures  10.5  centimeters  (4|  inches),  and  it  is  the  only  nnyield- 


wm 


m\ 


M:,      Cl?/ll,i:f 


i;-! 


V    I 


\\  \ 


'  J 


'U.   n 


V 


c 


,M 


394 


AMERICAN    TEXT- BOOK    OF    OBSTETRICi^. 


'-I 


iug  diameter  of  the  inferior  strait.  The  divergent  direction  of  tlie  tuberosities 
makes  it  possible,  however,  for  the  transverse  diameter  of  the  head  to  corre- 
spond with  a  much  wider  transverse  diameter  of  i\u\  outlet  whenever  the  con- 
ditions of  the  case  permit  the  parietal  protuberances  to  occupy  a  position  pos- 
terior to  the  tuberosities  (Fig.  216). 

The  oblique  diameters  are  manifestly  rendered  unimportant  by  the  uncer- 
tainty as  to  their  length,  the  result  of  the  elasticity  of  the  sacro-sciatie 
ligaments. -f 

The  excavation,  which  is  bounded  by  the  inferior  and  superior  straits,  com- 
prises all  that  portion  of  the  pelvis  lying  between  them.  The  backward  curve 
of  the  bodies  of  the  sacral  vertebrae  and  the  straightness  and  shortness  of  the 
anterior  wall  of  the  pelvis  render  the  excavation  much  more  roomy  in  an 


Fi(i.  217.— Iiiiigram  showiiiKn  (iivision  of  tlir  liitcnil  wall  of  tlie  I'xrnvation  into  sections  In  nccordancu 

witli  tliiir  iiailiuniL'al  functiiins. 


i       -I 


antero-posterior  direction  than  is  either  of  the  straits,  and  this  increase  of 
space  is,  of  coiu'se,  greatest  in  the  middle  j)ortion  of  the  excavation.  The 
oblique  diameters  are  correspondingly  increased  for  the  same  reason,  and, 
indeed,  in  the  middle  of  the  excavation  they  are  often  longer  than  any 
of  the  diann>ters  of  a  small  fetal  head — a  fact  which  is  sometimes  oi'  inii)ort- 
ance  in  the  mechanism  of  posterior  positions  of  the  vertex  and  of  presentations 
of  the  face. 

If  the  transverse  diameters  of  the  excavation  were  similarly  ample,  this 
portion  of  the  pelvis  would  be  devoid  of  obstetrical  interest ;  but  this  is  far 
from  true.  The  transverse  diameter  of  the  excavation  is  at  one  point  the 
smallest  and  also  one  of  the  most  rigid  diameters  of  the  whole  pelvis,  and  the 
importance  of  the  anatomy  of  the  lateral  walls  of  the  excavation  is  so  great 
that  its  comprehension  is  the  key-note  to  the  whole  sid)iect  of  obstetrical  mech- 
anism.    The  anatomy  of  the  lateral  walls  is  so  difficult  of  description  that  it 


(^  ^ 


of 

he 

jiul, 

l)rt- 


Tin-:   MECHANISM    OF    L Alio II. 


395 


IS  possible  to  comprelieiul  it  only  l)v  means  of  a  stilxiivisioii  of  the  lateral 
walls  of  the  excavation  into  three  parts  (Fijj;.  '217) :  An  iipjur  jtortion  {A,  Fijjc. 
217),  which  is  ronj^hly  triangular  in  shape;  a  sccontl  jioiilon  (/>'),  which  lies 
hclow  and  in  front  of  the  first ;  and  a  //(//•(/  portion  (C),  which  lies  below  and 
l)chin<l  the  first. 

Portion  A  is  composed  throuj^hout  of  unyielding  Ixme.  In  .'ts  Vi,  r  part 
its  surface  is  smooth  and  very  uniformly  ciu'ved.  The  transverse  iu.=neter  of 
the  pelvis  at  this  point  is  the  ample  transverse  diameter  of  the  superior  strait. 
The  obliipie  lines  drawn  through  the  anterior  edge  of  this  portion  upon  one 
side  of  the  pelvis  and  through  the  posterior  edge  of  the  corresponding  portion 
jipon  the  other  side  arc  likewise  ample,  and,  indeed,  vary  but  little  from  this 
same  length  (5^  inches).  In  its  lower  part  portion  .1  of  the  lateral  wall 
inclines  inward  to  its  termination  in  the  rigi<l  ischial  sj)ines,  between  the  points 
of  which  the  smallest  diameter  of  the  pelvis  is  found — a  diameter  so  small 
as  to  be  practically  impassable  by  the  biparietal  and  suboccipito-bregraatic 
diameters  of  a  full-sized  head. 

Portion,  li  of  the  lateral  walls  of  the  excavation  has  but  little  rigid  bone 
in  its  compttsition.  Its  upper  part  is  made  up  mainly  of  the  membranous 
coverings  of  the  foramen  ovale,  that  are  covered  by  the  obturator  muscle, 
and  at  the  time  of  term,  like  all  the  other  ligaments  and  fascial  coverings 
of  the  pelvis,  are  mure  elastic  than  in  the  non-parturient  state.  When 
these  muscles  and  fascia)  are  put  upon  the  stretch  by  the  pressure  of  the  pre- 
senting part  during  its  descent,  their  recession  converts  portion  B  of  the 
lateral  wall  into  a  shallow  spiral  groove,  with  bony  edges  and  a  soft  floor, 
which  ileepcns  as  it  descends  and  turns  forward.  The  ischio-pubic  ramus, 
which  forms  the  floor  of  the  lower  part  of  portion  B,  is  here  so  curved 
(laterally   outward)   as   to   lend    itself   readily   to   the   continuation    of  this 


groove. 


Portion  C  has  a  bony  edge  composed  of  the  posterior  bonier  of  the  ischium 
and  the  lateral  edge  of  the  sacrum  and  coccyx,  but  it  is  made  up  maiidy  of 
the  very  elastic  sacro-sciatic  ligaments  and  the  pyramidal  muscle.  When  these 
ligaments  and  muscles  are  put  upon  the  stretch  during  the  descent  of  the  head, 
portion  C'of  the  lateral  wall  is  converted,  like  portion  />,  into  a  spiral  groove 
which  deepens  as  it  descends  and  turns  forward. 

When  the  rigidity  of  portion  ^1  and  the  yielding  nature  of  portions 
B  and  C  are  considered  in  connection  with  the  fact  that  even  in  the  bony 
])i'lvis  the  foramen  ovale  and  the  sacro-seiatic  notches  ar(>  regions  of  recession 
separated  from  each  other  by  the  projecting  ischial  spines,  it  will  be  seen  that 
when  distended  by  pressure  from  within,  the  lateral  walls  of  the  excavation 
may  be  considered  as  consisting,  for  mechanical  purposes,  of  two  deep  grooves 
separated  from  each  other  by  a  prominent  ridgo  of  unyielding  bone  (Fig.  218). 
The  anterior  of  these  grooves  pursues  a  spiral  course  downward  and  forward 
from  the  anterior  end  of  the  oblique  diameter  at  the  brim,  to  end  under  the 
pubic  arch  at  the  anterior  end  of  the  conjugate  diameter  of  the  inferior  strait. 
The  posterior  groove  pursues  a  similar  s[)iral  course  ilownward  and  fui  ward 


; 


'  >  -J' 


h    b'     - 


»  . 


'pHiPiiJII 


\'  n 


V     *' 


f 


.1^' 


39(J 


AMKIilCAX    TEXT-nOOK    OF    OliSTKTIiK'S. 


from  the  posterior  end  of  the  <ither  obIi(|ii((  (lianieter  at  the  brim,  to  end  in 
the  same  point  at  the  anterior  end  of  the  conjugate  at  the  outlet. 


Ki(i.  '.'18.— Suctions  (il'tlio  i)L'lvis,  showing  the  luteral  wronvos  mid  llu'  Imiiy  ridtje  wliicli  separates  them  : 
A,  siifiittiil  soctinn.  Tlio  linos  '',  c,  il.  i ,  inciicutc  the  horizontal  plimi's  Ihrounh  which  tliu  cross-suctions 
h,  t;  (I,  i\  aru  tuljcn.  The  shadud  portions  of  the  liKuru  indicate  tliu  spiral  grooves,  tliu  dui)th  of  the 
fjroovu  licinn  deepest  wliere  tlie  sliadinK  is  darliest.  H,  cross-section,  sliowinn  tliu  nearly-uniform  curve 
of  tlie  uuhroken  tiony  ciniinifercnce  of  the  superior  strait.  C,  cross-section,  showing  the  bony  iseliiuni 
(.\,  V\\i.  -17)  separatiiit;  the  distensible  foramen  ovale  (li,  Kin.  -1")  and  sacro-sciatic  notch  ((',  Fif?.  217).  I>, 
cross-section  through  the  ischial  spines,  which  here  eniphasizu  dellection  inwanl  of  the  bony  rid^e  (.\. 
Ki).'.  217).  K,  cross-section  near  the  inferior  strait.  The  jiosterior  half  is  distensible,  ami  in  the  anterior 
half  the  bony  duscendins;  ramus  of  the  jiubes  <'urves  outwardly  to  contiinie  the  c\irve  formed  by  the 
yielding  tissues  which  cover  in  the  foramen  ovale,  as  seen  in  the  sections  ('  and  1) 

The  oblique  diameters  drawn  toward  the  bottom  of  the  anterior  groove 


I    ! 


THH   MHCIIAXISM    OF  LAJlOIt. 


397 


jve 


upon  on  <i(l('  and  tlir  bottom  of  the  j)o.storior  {jroovo  upon  tlio  other  side  arc 
throiif::Ii()Ut  the  pelvis  aiiipio  lor  the  passaj^e  of  any  of  tlie  diaiiieters  of  the 
t'ctal  ii<'a<i  except  tiie  oceipito-frontal  and  tiie  occipito-nientah  Should  any 
roiintl  body  be  started  at  the  upper  end  ol'  either  of  these  grooves,  and  be 
foreed  downward  by  a  i'ix-u-tvr(i(>  under  the  influence  of  a  (;onstant  intraiielvic 
pressure,  it  must  necessarily  follow  tli-'  \-M\  of  least  resistance — that  is,  the 
course  of  the  i;roov((  in  which  it  started — to  end  its  course  under  the  pidjic 
arch  at  the  outlet.  The  imp(»rtance  of  these  considerations  will  be  apparent 
w  lien  the  section  on  the  Mrc/mniHin  of  (lie  Sccoiuf  S(a(/c  of  Labor  is  reached. 

Infrapelvic  Portion. — When  the  soft  parts  below  the  inferior  strait  are 
distended  by  the  head,  they  inchule  a  hood-shaped  space  of  considerable  si/e, 
bounded  upon  its  upper  border  by  the  edj^e  of  the  pubic  arch,  the  tuberosities 
of  the  iscliia,  and  the  lower  edj^e  of  the  sacro-sciatic  ligaments,  and  upon  its 
other  (»r  inferior  border  by  the  (triticc  of  the  distended  vagina.  Its  anterior 
wall  is  from  a  ((uarter  to  half  an  inch  in  length.  Its  posterior  wall,  when 
fully  disten<led,   is  from  (5  to  10  centimeters  {2\  to  4  inches)  in  length. 

When  the  head  has  wholly  escaped  from  the  inferior  strait  it  occupies  an 
elastic  canal  com[)osed  wholly  of  soft  parts  and  having  but  one  mechanical 
function — an  elasticitv  which  l<cei)S  the  head  constantlv  in  contact  with  the 
edge  of  the  pubic  arch. 

The  Parturient  Canal  as  a  Whole. — The  parturient  canal  (Fig.  211)  con- 
sists functionally  of  two  portions,  an  ovate  reservoir  formed  by  the  uterine 
cavity  and  the  false  pelvis,  and  a  curved  passage  which  extends  downward 
and  forward  from  the  lower  opening  of  the  reservoir.  This  passage  ])ossesses 
an  irregularly  cylindrical  shape  which  has  classically  been  likened  to  the  curve 
of  a  ram's  horn.  The  anterior  wall  is  much  shorter  than  tlic  posterior.  If 
both  the  anterior  and  posterior  walls  are  divided  into  an  equal  number  of 
c(|ual  parts,  and  planes  are  drawn  l>etween  each  pair  of  these  points  (Fig.  219), 
a  curved  line  passing  through  the  centre  of  each  of  these  planes  forms  what  is 
known  as  the  axin  of  the  pclric  canal ;  if  this  curved  line  is  continued  forward, 
it  will  reach  the  abdomen  of  the  mother  at  about  the  situation  of  the  umbilicus 
in  the  non-j)arturient  state.  This  prolongation  of  the  pelvic  axis  is  known 
as  the  curve  of  CarHi<. 

The  centre  of  any  body  j)assing  through  the  pelvic  canal  nuist  travel  through 
a  path  closely  approximate  to  this  curved  axis.  Were  the  jielvic  canal  exactly 
cylindrical  and  the  fetal  head  exactly  spherical,  the  mechanism  of  labor  would 
l)e  limited  to  an  observation  of  the  abovi  -related  fact;  but  in  reality  the  irreg- 
ularities in  the  contour  of  the  pelvic  canal  and  the  corresponding  irregularities 
in  the  shape  of  the  fetal  head  are  matters  of  the  greatest  importance.  It  will 
be  remembered  that  although  the  transverse  diameter  of  the  superior  strait  is 
nominally  the  greatest,  yet  the  ra])id  convergence  of  the  ilio-pectineal  lines  as 
they  stretch  forward  renders  the  length  of  the  practicable  transverse  diameter 
in  fact  less  than  that  of  the  ol)li(pie  diameters,  so  that  any  ovate  body  presented 
to  the  inlet  of  the  pelvis  will  tend  to  enter  the  brim  in  the  oblique  diameter. 

At  the  inferior  strait  the  transverse  diameter  is  the  narrowest  of  the  whole 


) 


Tr- 


ill I IIH 


I  f 


i 


i 
>  ^ 


i 


A 


/ 


31)S 


AMi:itI('AX    TKXT-IiOOK    OF    OliSTr/mil'S. 


pelvis,  iiiid,  since  the  ()l)li(|no  diameters  at  tlie  moment  of  delivery  are  shorter 
than  the  distended  eonjiiLrate,  any  ovate  Ixidy  which  attempts  to  pass  the  ontlel 
will  do  so  most  readily  it'  its  lon^- diameter  corresponds  with  the  antero-posterior 
diameter  of  the  inli'rior  strait.     It   is  therefore  evi«lent  that  the  process  of 


Klii.  21',t.— SuKittnl  Sfctioii  nf  the  iiclvis,  .showing  the  pflvic  axis  "Mil  tlu'  ciirvi'  nf  Ciinis. 

labor  will  most  easily  he  aceomjilished  by  the  occurrence  of  a  rotation  of  the 
longest  diameter  of  the  presenting  parts  from  an  oblique  position  at  the  supe- 
rior strait  to  an  antoro-posterior  position  at  the  outlet ;  in  point  of  fact,  the 
mechanical  relations  which  lead  up  to  this  rotation  lie  at  the  bottom  of  the 
whole  subject  of  the  mechanism  of  labor. 

It  is  to  be  noted  that  when  the  woman  is  in  the  erect  position  the  axis  of  the 
suj)erior  strait  *  forms  an  angle  of  about  30°  with  the  horizon  ;  that  in  the 
same  ])osition  of  the  woman  the  axis  of  the  inferior  strait  is  directed  down- 
ward and  a  little  forward  ;  and  that  the  axis  of  the  vaginal  outlet  of  the  par- 
turient canal  loftks  almost  directly  forwanl  and  but  very  slightly  downward. 

Differences  between  the  Male  and  the  Female  Pelvis. — It  is  important 
that  the  obstetrician  should  clearly  understand  the  normal  characteristics  ol' 
the  female  pelvis  in  contradistinctioti  to  those  of  the  masculine  form,  because 
the  approaches  to  a  masculine  type — which  are  not  uncommon  and  may  occur 
in  any  portion  of  the  pelvis — are  not  unim])ortant  as  a  cause  of  dystocia  and 

*  .\  line  (Innvn  from  tlie  ct'iitre  ol'  tlie  superior  stniit  in  a  diri'ctioii  iierpeiuliciilar  to  ils 
jilane. 


t'J^JL 


the 

.,  the 

\  the 


Ito   11- 


77//;   MIJIIAMSM    <)l    I. Mian. 


3!Ji) 


of  alterations  in  the  nioeluinisiu  ot"  lalutr.  Tlie  (lilH-rences  between  the  male 
and  tlie  female  pelvis  will  be  ren»lere<l  most  easily  familiar  by  the  use  of  a 
series  ol'  figures  showing  respectively  the  shapes  of  the  superior  strait,  of  the 


Fill.  'JJO.— Malo  iK'lvis  viewed  in  tlie  uxis  of  llie  l)rim. 

antero-posterior  curve  of  the  sacrum  ami  the  pubic  arch,  and  of  the  inferior 
strait  in  the  masculine  and  feminine  types. 

Superior  Sfraif. —  In  the  male  the  sacrum  is  narrow,  the  promontory  en- 
croaches deeply  into  the  brim,  the  iliac  crests  are  comparatively  erect,  ami  the 
interior  concavity  of  the  anterior  portion  of  the  ilio-pectineal  line  is  but  little 


Fill.  '2.!1.— l\'mnle  pelvis  viewed  in  the  nxi.s  of  the  brim. 

marked  (Fig.  220).     Tlie  shape  of  the  inlet  is  tlius  angular  and  strongly  eor- 
ilate  as  compared  with  that  of  the  female  pelvis  (Fig.  221). 

Antero-pontcrior  Section  of  the  J'e/cis. — In  the  male  the  sacriun  is  long  and 


i:,  \  I 


¥ !' 


p^--. 


-  l-al 


*    , 


!.:■,  t 


■    ) 


er 


'II 


'■'»/' 


/ 


400 


AMERICAN    TEXT-BOOK'    OF   OBSTETRICS. 


its  upper  ]K)rtic)n  i.s  nearly  straight,  wiiilo  the  K)\ver  part  of  tliis  bone  and  its 
continuation,  tiie  coeeyx,  are  bent  sliarply  forward.  The  symphysis  and  the 
ailjacent  portions  of  tiie  descending  rami  are  long  and  erect  (Fig.  224).    In  the 


I"i    .  II'.'J.— Mule  pelvis  seen  I'niiii  tlir  IVinit. 


female  (Fig.  22"))  the  sacrum  is  sliorter,  its  general  direction  is  more  distinctly 
downward  anil  backward,  its  upper  portion  is  much  more  concave  from  above 
downward,  and  the  antero- posterior  curve  is  throughout  more  uniform  than  in 


Ki(i.  ■Jjn.— Ki'iiiiilo  iu'lvis  si'fii  rrciiii  tlie  front  (oiu'lliinl  iialunil  size)- 

the  male.  Tlie  .-ymphysis  is  short,  and  tiie  wider  jiubic  arch,  shortly  to  l>r 
spoken  of,  decreases  the  importance  of  the  descen«ling  rami  in  the  formation 
of  the  anterior  wall. 

Jtij'erior  >Str<iit. — In  the  male  (Fig.  222)  the  migle  of  the  pubic  arch  mca- 


i'lo. 


i  I 

1  \ 


r 


'■^^  ..«„/.,.v.v.„   oi-  x.„„,. 


"H>.s  in,,,,   7/50  ^^^  g^^„  4QJ 

^^-^ ^,  "  ^"^^'•««'tie.s,  greatly  j 


X> 


/ 


'"'■  --'•-J"'"srMni.n,-i(;  .  „,,,,„ 


"('<'t;il)iila.  and  tU  •        "  *''"''  '^  ■•'  iii'catcr  ,.,.l.,-       .'""  ''■"^  *'''  wnipan 

i"  "■"....■„  ,M„i  i;„.       V     "  '"■' '^  I".-  .1 n,„ ,  ,    '.'"■."""■"""  "f  .1, 

"■'■■■' "'■■-^^^•t:^^':;:i:;;:::';";:--:n;:;/;;:r::^ 


'''"■''^!l!'<l     /111-     I 


•Uollc, 


t. 
10 

noos 
'"■  .^•"■'  ••"I.I  f|,a(  „r 


The  Fetus. 


^.  ■^"   {illicJi 


'.-■s    .      ,  ""■'■'■'■"•'■  '■"  "'■■pa-.-:. ,  T   ',"",' ^'"'I'"   ""'""d 

;;;;;::■■rJ■;^M^,.  H,,,:::!;r::r:,-;v':i^-' -■-    ■ 

, y  .""•''''•«-"<^><.l..rmo-  I,|,„,  ■     ,    •''"    "'   ""•  '••'••-I   lica.l  an.l  „• 


'"  a  (lior'diii^li 
illi  (lie 
iiiiiprc- 


I      h 


■J^ 


f  1,, 


i,        Ik-t' 


1.  T 

(    ■ 

]'. 
•1 

I'ii 

^'ff 

;ff^ 

1             J 

i  i  :\ 

* 

! 

i 

I 


402 


A^f/'JIUCA^'  Ti:xT-ii()OK  of  onsrKTi^rvs. 


sliapo  nnd  <linu'ii>i(»n.s  of  tiu    iv'tiiniiidcr  of  the  fotiis  in  tlio  attitiido  it  onli- 
iiarilv  assiiiiios,  tlnniii'li   loss  often  of  iniportaiieo,   is  iievortlieless  essential. 

The  Fetal  Head. — The  head  is  obstetrieally  divided  into  two  portions,  the 
face  and  the  cnniiiun. 

T/ir  face  is  iniieh  smaller  in  ])roportion  to  the  cranium  than  that  of  the 
adult,  and  is  of  l)ut  little  iiuportanee  in  normal  labors.  It  is,  however,  well 
to  ri'meinber  tiiat  the  i'aee  is  made  up  of  the  most  solid  and  ineom])ressii)lc 
bones  which  enter  into  the  eomjiosition  oi'  the  head,  and  that  its  eoufiguratiou 
i,s  altei'ed  but  little,  if  at  all,  by  the  jiroeesses  of  labor. 

I'/ic  crctniiua  or  brdlii-atnc  is  to  be  divided  for  purposes  of  description  into 
two  ])ortions.  the  fxtnc  and  the  vaitlf  of  the  skull.  The  base  is  formed  by  the 
basilar  portion  of  the  oeeij)it;d  bone,  the  petrous  portions  oi'  the  temporal 
bones,  the  s])heuoid  and  ethmoid,  and  the  orbital  processes  of  the  I'roiUal 
bones.  Tiiese  bones,  even  at  birth,  are  firmly  united,  and  they  foi'ui  a  coiii- 
])aratively  small  but  almost  totally  iueomi>ressible  mass.  Th(>  vault  is  made 
up  of  the  parietal  bones  and  the  scpiamous  ])orti(;ns  of  the  occipital,  tempoi'al, 
and  fi'outal  bones.  These  bones  are  all  wide,  flat,  and  sliLihtly  curved.  The 
scpiamous  portion  of  the  occipital  bone  is  attaciicd  to  the  basilar  |)ortiou  liy  a 
band  of  fibro-cartilaiiiuous  tissue  which  permits  of  (piite  free  motion  between 
the  two  portions.  All  the  bones  of  the  vault  are  united  at  their  (>dtres  l)y 
n>eud)ranous  commissures  formed  of  the  dura  matci'  and  the  uuossificd  exterual 
jK'riosteinn.  Tiie  vault  of  the  cranium,  thouiih  much  lariicr  than  the  base  of 
the  skull,  differs  from  the  i)ase  in  its  ]V)ssession  of  compressibility  and  of  a 
marked  capacity  for  alteration  of  shape  under  the  mouhliuii'  influences  of  the 
constant  pressiu'e  of  labor.  It  nuist  be  remembered,  however,  that  difl'erent 
lieads  present  very  different  detri"«'i''<  <^1  ossification  at  the  tinu'  of  birth,  and, 
indeed,  vary  widely,  from  eases  in  which  the  flat  bones  are  so  slightly  ossified 
as  readily  to  ho  bent  by  the  jnrssure  of  the  finoer,  and  in  whiv'h  the  mem- 
branous intervals  are  extremely  wkh.  and  well  marked,  u])  to  cases  in  wliicli 

the  ossification  luiil  union  of  the  hone- 
are  .><o  far  advanced  as  to  reduce  the 
compressibility  of  the  skull  to  a  min- 
imum of  small   practical  value. 

T/ic  Siifiircs  (tml  tlir  Fimtdiicl/cti. — 
The  uiend)ranous  lines  of  union  between 
the  contii!;uons  bones  of  the  vault  are 
known  as  .^iittirc^,  and  at  the  point- 
where  more  than  two  bones  meet  tlic-e 
sutures  couniionly  widen  out  to  mem- 
branous spaces  known  :\:-  j'i)iil(iii<I/(X  (Fiii'.  2'J(i).  The  suture.-  arc  distinguished 
by  the  fbllowiuir  names:  'I'hat  between  the  frontal  bones  is  the  _/;'f)/(/''/ ;  tlini 
between  the  frontal  and  parietal  bones  is  the  cdroiKi/ ;  that  between  the  parie- 
fals  is  the  s'ti/Htc! ;  and  that  which  separates  the  s(|uamous  portions  of  the 
oceijtital  from  the  two  parietal-  is  the  /mu/xl'iido/  sutiu'c. 

At  the  point  whci'c  the  frontal  and  parietal  Ixmes  come  foocther  the  frontal, 


^ir 


Fi(i. '220— DliiuTunis  (if  tlic  foiitiim  lies :  .\.  iiiitr- 
rii)r:  H,  postiTior;  (',  liilcrnl. 


luilir: 


iinii- 


Iwccn 
It    ;nv 

lint- 
Itlii-'' 


liK'in- 


ll>!ii  tl 


liafi'- 


ir  ti 


l)llt'.ll 


LAIioH. 


I'l.AlK  -28. 


■> 


^-•ti 


.CI 


c^ 


K 


vs 


Ocap/h*  -fFoiital 


* 
^ 


Occipul 


^^s 


Biparletal 


S 


.S 


diparktal       ^  cmspn- 

Ver  Tex 


^'nfane/Ze  ^\ 

(brejwa)  ^ 

Bitemporal         Scmdlm-j 


hstprior 
^ioi**^  Tontande 


>V* 


OcapiTal  Prvtukruncc 


Biparietal 


5' 


inciput 


t 

Bitem  voral 


I 


Kktai.  IIi;aii:  !.  Kcliil  skull  scon  Imni  tlir  siilc ;     j    I-'itnl  skull  sr.n  finm  hIkivi':    ;i.  Kctal  skull  situ  Crniii 
lii'hinil.     I    Kiliil  -kull  sciii  I'nitn  in  Irmit     showing  sulmis,  l.inlHii.llrs.  iinil  cliaiiifli'i-s. 


t       i| 


e 


UT^ 


^*^y- 


; 

' 

'    i 

;:  :ii: 

i,i- 

>',    ; 

1 

I 

I 


THE   MICHANISM    OF  LABOR. 


403 


sagittal,  and  coronal  sutures  moot  in  a  inonibranous  space  or  fontancllc  wliicli 
is  rliouiboidal  in  shape  and  is  ordinarily  of  considerable  extent.  Tliis  space; 
is  known  as  the  (interior  or  large  I'ontanelle,  and  sometimes  as  the  hrcr/tiui  (1*1. 
28,  Fig.  2).  Of  its  four  sides,  the  two  anterior  are  usually  tlie  longer,  and 
when  this  diilerence  is  well  marked  the  resulting  fontanelle  may  more  ])roperly 
be  said  to  assume  the  shape  of  an  Indian  arrow-head  (Fig.  22G,  a). 

The  junction  of  the  sagittal  and  lamixloidal  sutures  at  the  point  where  the 
occipital  and  parietal  bones  meet  forms  a  small  triangular  space,  known  as  tiie 
posfrrior  occipital,  or  small  fontanelle  (PI.  28,  Fig.  .3).  In  well-ossiiied  heads 
ihis  space  is  frequently  small  or  wanting,  and  the  ])osterior  i'.)ntanelle  is  then 
I'cpresented  only  by  the  jiuietion  of  the  three  suturi's.  It  is  to  be  remembered, 
moreover,  that  when  the  bones  are  closely  crowded  together  by  the  jiressure 
oi'  severe  labor,  either  fontarielle,  however  well  marked,  may  ]nu'tially  or 
Avholly  be  ciTaccd  for  the  time  l)y  an  overlapping  of  the  edges  oi'  the  l)oncs 
which  bound  it.  Fxceptionally,  a  locally  defective  ossification  along  tlic  edges 
I  if  tiie  bones  may  result  in  the  ])roduction  of  either  Wormian  bones  or  I'alse 
I'liiitauelles,  hoth  of  which  are  most  connnon  in  the  course  of  the  sagittal 
suture,  and  which  may  result  in  considerable  coul'iision  of  diagnosis  if  the 
])ossil)ili!y  of  tiicir  existence   is  not   borne  in   mind.* 

Dimensions  of  the  Fetal  Head. — Tlie  size  of  the  i'ctal  head  at  term 
varies  greatly  with  the  size  of  the  individual  fetus,  but.  iiowevcr  great  this 
variation  may  be,  the  relative  proportions  between  the  ditferent  parts  of  the 
head  remain  approximatclv  cdustanl,  and  for  the  sake  of  clearness  it  is  usual, 
in  the  discussion  of  general  principles,  to  ignore  this  variation  of  siz(>  and  to 
use  as  the  basis  of  argument  the  dimensions  of  the  average  head,  'llie  diam- 
eters that  have  been  found  most  useful  in  the  description  of  the  head  are  as 
^(lllo^i•s:  The  (iiiftro-itnsfrrlor  >ll(niuii ri^ — the  oecijiito-mentid,  the  oc>'ipito- 
i'lMutal.  the  snl)occipito-l)regmatic  ;  the  traiixrcrxc  lUamdcrs — the  biparietal,  the 
hitemporal,  and  the  bimastoid  ;  the  vcrliral  (liaiiu'fcrN — the  fronto-mental  and 
the  cervico-bregmatic. 

Antrrn-poHtcrior  Diduicfcrs. — The  occipito-niental  diameter  (PI.  28,  Fig.  1) 
is  drawn  from  tluM-hin  to  the  most  distant  jiortion  of  the  occiput.  The  occipito- 
frontal (PI.  28,  Fig.  1)  is  drawn  from  th<'  ]ioint  of  union  of  the  supraori)ital 
ridges  to  that  portion  of  the  occiput  which  is  most  distant  from  them.  The 
suboecipito-bregmatic  (PI.  28.  Fig.  1)  is  drawn  from  tlu'  jinint  of  junction 
hctween  the  occi|)ut  and  the  neck  to  the  centre  of  the  anterior  fontanelle, 
Tnnii^rcrxc  Diaincfrrfi. — The  biparietal  diam<'t(>r  (PI,  28.  l'"'igs.  2,  4)  is  drawn 
li'om  the  a]>ices  of  the  lti|)ari(>tal  protuberances — naiii  ''y,  throuLi'h  that  portion 

It  is  WL'll  to  Iiciir  in  niiiid,  in  luldilioii  to  iln'  iiiitciiiir  :inil  ))osti'riiir  tontniiollcs,  tin  ocia- 
>iniiMl  I'xislctici'  of  ;i  tiiiiil.  tlu>  hiliriil  fontiuirlli'.  Tills  lontjiiu'lle  is  iinxMii  nnly  in  ]ioorlv-ossi- 
liid  Imids,  nnd  wlu'ii  ]irt'scnt  is  found  at  tlir  jmu'tion  of  iho  c>tTi])it!ii.  piirit'ial,  and  ltin]ionil 
I'oiu's,  ni'ar  tiio  l)as('  of  the  mastoid  j'roct'-s  ;in<l  luliiiul  tiic  lar.  Tiio  iatcrrd  fonlaneilc  may 
-oiiu'tiiiiis  1)1'  niistaivi'ii  for  llic  lircirnia  iiidi"-s  carcfiiily  oIim  rvid.  It  i-^  foMi-siiiid,  Imt  is  iii(  iru- 
!:ir  in  siiapc  il'l.  SS.  Fijr.  l!i.  It  may  \»'  >aid  tlial  llic  mastoid  iitorcs'.  iWU  lil<r  tlir  side  of  a 
l:iri;r  canine  toolii  imiieilded  in  tlie  tem|"in\l  lione.  It  is  nsually  iceouni/.aMe,  i  it  is  some- 
linns  a  valuablo  [loinl  in  the  (iia>;nosis  <>(  lids  region  of  tl     skull. 


'  m 


■  m 


e' 


ff 


I    I 


fl 


ni'ui 


Hi 


■ 


404  AMEIUVAN    TEXT-BOOK    OF    OBSTETRICS. 

of"  the  skull  at  wliicli  tlic  lateral  .siirlht'cs  arc  most  widely  distant  from  eaeli 
other;  the  bitemporal  (PI.  28,  Fij-s.  2,4)  extends  transversely  between  the 
most  distant  ])()rtions  of  the  coronal  sutures  ;  the  bimastoid  extends  between 
the  mastoid  processes  at  the  base  ot"  the  skull.  To  these  diameters  is  some- 
times added  a  less  important  diameter,  which  is  that  lying  between  the  base 
of  the  zyj^omatic  ])rocesses,  the  bi/,yi>'omatie. 

Vcii'mil  J)i<niictcrx. — The  fronto-niental  diameter  (IM.  2(S,  Fijjs.  1,4)  extends 
from  the  chin  to  the  upper  part  of  the  forehead  ;  in  the  absence  of  anv  dis- 
tinctive point  of  ori<;in  at  its  upper  extremity,  as  well  as  from  its  small  size,  it 
is  of  but  little  importance.  The  cervieo-l)rc<imatic  (I'l.  28,  Fij>\  1)  is  drawn 
between  the  junction  of  the  neck  and  the  chin  and  the  centre  of  the  anterior 
fontanelle. 

The  lengths  of  the  several  diameters,  as  obtained  by  Tarnier  and  Clian- 
treuil,  are  given  as   follows: 

('I'litimclcTs.  Iiii'lii's. 

Occiiiilo-iiifiitiil  (liaiiH'ter {'A  oj 

Oc'ci|iilii-fri>iitiil         "            11.5  ^  4.] 

Siili()(ci]iilo-lin<,'iiiiiiii' (liaiiietcr !)..')  =  3if 

jiipiuiutaldiaiiiftor 9,5  =:  3:} 

r>itciiip<ii'al  (liaiiu'lor 8  =rT  .'{j 

Itiniastiiid  (liaiiH'ier 7.5  ^=  3 

l'"nmtn-iiiL'iUal  iliaiiu'tcr S  =:  3j 

(.'iTvicK-ln-eginalu'  dianiutor .      9.5  ^^  3:{ 

These  diameters  may  be  divided  into  classes  in  two  ways:  (1)  by  their  com- 
jiressibility,  and  (2)  by  the  degree  of  ditticnlty  with  which  they  may  be  expected 
to  pass  the  pelvis.  The  compressibility  of  the  fetal  head  as  a  whole  is  not 
only  a  very  variabli'  factor,  but  the  diU'crent  parts  of  tlie  same  head  vary 
witlcly  in  both  the  case  and  the  safety  with  which  compression  can  be  applied 
to  them. 

The  biparietal  an<l  bitemporal  diameters  are  safely  and  easily  compressible. 
The  suboecipito-bregmatic,  occipito-frontal,  and  occi]>ito-mental  diameters  an; 
almost  e(|ually  compressible,  but  the  degree  of  danger  to  tiic  Ictus  that  com- 
]>ression  of  these  diameters  involves  is  vastly  greater  than  is  the  case  with 
the  biparietal  and  bitemporal  iliameters  ;  and  with  obliijtie  compression  the 
degree  ol'  danger  inci'cases  as  the  direction  of  the  force  approaches  to  the 
antero-posterior  diameters,  '{'he  bimastoid  and  bizygomatic  diameters  arc  I'or 
j)ractical  purposes  totally  incompressible. 

The  Relative  Value  of  the  Diameters  of  the  Head  as  Compared  with 
the  Diameters  of  the  Pelvis. — It  will  be  observed  that  the  lengths  of  the 
suboccipitip-i)rcgm;itic  and  biparietal  diameters  are  nearly  equal,  so  that  a  cross- 
section  of  the  head  through  these  diameters  { I'^ig.  227,  A)  is  very  nearly  cinui- 
lar  ;  an<I  from  this  fact  and  from  tlicii'  size  this  cross-section  is  capable  of  pass- 
ing ;uiv  diameter  of  thi'  pelvis  when  pr(>sented  to  it  in  any  obstetrical  position. 
Since  this  is  the  cross-section  which  is  always  jiresented  to  the  jielvis  by  wcll- 
llcxcd  heads,  the  study  of  position  would  !)e  of  litth'  im|)ortance  if  the  exist- 
oneo  of  Hexion  could  alway.s  be  depended  upon  and  if  the  remainder  of  the 


lom- 
Ivitli 

tlic 

tin- 

n.r 

ath 

he 

Ircu- 

liiss- 
ruin- 
Icll- 
;ist- 
iUv 


THE   MECHAXJSM    OF  LAJiOIi. 


405 


lioad  could  be  iu'<;locto(l  ;  but  two  factors  in  labor  equally  contribute  to  render 
this  cross-section  of  the  licad  bv  no  means  the  only  one  which  nnist  be  con- 
sidered. In  the  first  j)lacc,  we  nuist  be  prcjiared  to  consider  the  mechanism 
of  brow  and  face  cases,  and,  in  addition,  those  cases  of  vertex  labor  in  which 
the  Hexion  of  the  head  is,  from  one  cause  or  another,  imperfect ;  and,  moreover, 
even  in  the  best  vertex  labor  good  flexion  is  seldom  attained  in  the  early  stages 

A  1! 


Fif:.  2J7.— niiiiiu'tcrs  (if  tlie  fotal  lioiid :  A,  rrosssrctinn  nf  the  fi'tnl  head  tlir(Hii;li  tlio  snlxK'ripito- 
l]rff,'mati<'  ami  hiparictiil  diaiiictiTs  ,  H.cross-scctinii  of  the  fetal  licail  tliniiii;li  the  hiparii'lal  and  dccipito- 
fnnital  diaiMctiTs;  (',  iTciss-si'c'iiai  cif  the  fi'lal  head  llirouuli  tlir  liiparii'tal  and  ()('ci|>ili)-nic'ntal  diaiu- 
iliTs;  1),  cross-sL'ction  of  tlio  fotal  head  tlir  ■^^dl  tlii'  siibuccipilnCrnnlal  and  bitruipural  diaincti'i-s, 

ol"  engagement  at  the  brim.  Secondly,  even  when  good  flexion  is  present  and 
this  circular  cross-section  is  in  the  inferior  strait  or  excavation,  the  brim  is 
occupied  by  the  fnmtal  portion  of  the  head  in  combination  with  the  neck — a 
by  no  means  luiimportant  factor  in  the  mechanism  of  even  the  most  normal 
cases. 

It  is  therefore  important  to  renunnber  the  shape  and  dimensions  of  the 
cross-sections,  which  include,  first,  the  biparietal  and  oceipito-frontal  diameters 
(Fig.  227,  b)  ;  second,  the  biparietal  and  occipito-mental  diameters  (Fig.  227,  c); 
third,  that  which  cuts  th(>  head  and  neck  through  wiiat  might  be  called  the 
"  suboccipito-frontal"  diameter*  and  the  bitemporal  diameter  (Fig.  227,  d).  If 
the  diameters  of  thes(>  cross-sections  be  compared  with  those  of  the  pelvis,  it 
will  be  seen  that  all  the  transverse  diameters  are  ca|iable  of  an  easy  ])assage 
througli  any  of  the  diameters  of  the  pelvis.  The  occipito-frontal  and  sub- 
occipito-l'rontal  are  too  large  to  ])ass  any  of  the  conventional  f  diameters  except 
the  oblique  diameters  at  the  superior  strait  and  the  dist('nsii)Ie  anteni-postcrior 

*  A|i|)r().\iinii(('lv  (lie  ('ci'vico-lnvfjnuUii'  [iliis  the  tliickiu'ss  of  tlio  lu'ck. 
t  'I'liost'  wiiicli  liavu  iianu's. 


;.a^ 


'if-.- 


1 1 


;   i     , 


1.* 


':  ji 

u 

1 

,.,„,  il 

^^;  ■? 

wiit 


I 


4()f; 


amehivax  Ti:xT-ji(K)K  of  oiisrirrnns. 


(Iiaiiu't(M's  of  till'  iiiCci'iur  strait  ;  wliilc  tlu'  occipito-iiiciital  is  toit  larfi'c  cvt-n  tin- 
these,  and  may  coiiscmieiitk  l»e  rei;ar(Ic(l  as  an  ini[)i'artit'al)k'  ur  impossiljle 
(liaiiieter, 

A  careful  reiiiemhraiiee  of  tlie  relative  values  of  tliest;  diameters  will  he 
found  of  nfeat  service  in  the  comprehension  of  normal  laltor,  and  of  still  more 
valne  in  mider-tandinu;  ahnormal  lahor. 

The  Articulations  between  the  Head  and  the  Spinal  Column. — The 
articidations  hy  which  the  head  is  joined  to  the  tnmk  are,  it  will  he  remem- 
bered, the  occipito-atlantoid,  the  atlanto-axial,  and  those  hetween  the  other 
cervical  vertchra*.  The  oci'ipito-atlantoid  articulation  admits  of  hnt  little 
motion  except  that  of  extension  and  llexioii,  while  even  that  motion,  when 
carried  to  extremes,  is  lifcatly  assiste(l  hy  a  similar  mov(MMent  in  the  other 
cervicai  arti(  illations.  So,  too,  the  rotatory  movement  which  alone  is  possihlo 
in  the  atlanto-axial  Joint  is  nrcatly  assisted  i)y  the  movements  in  the  other 
articulations  of  the  iiech.  The  capacity  tor  lateral  llexion  resides  wholly  in 
the  intervertehral  articulations  and  is  limited  hy  their  liii;aments.  iiotatioii 
of  the  heail  to  either  side  is  safely  possihie  only  tliroiii:li  an  are  of  ahoiit  !)()^  ; 
that  is,  when  the  chin  of  the  ll'tiis  is  in  the  jilaiie  of  the  shoulders  the  limit 
of  ^aftly  ill  rotation  has  heeii  reached.  ^ViitcM'o-posterior  flexion  is  limited 
only  hy  contact  hetween  the  chin  and  the  hreast.  Extension  can  he  carried 
to  a  point  at  which  the  occi|nit  rests  airainst  the  hack  of  the  neck  and  the  chin 
is  in  a  line  with  its  anterior  surface. 

The  Fetal  Body. — The  compressihility  of  the  fetal  trunk  renders  impossihle 
and  worthless  any  statement  of  the  ahsolute  len<>th  of  the  diameters  which  the 
fetal  hody  presents  to  the  ])elvis  diirini;'  lahor  ;  hnt  the  relative  leiiuths  of  the 
transverse  and  aiitero-jiosterior  diameters  as  compared  with  each  other  is  of 
importance,  and  is  constant  in  at  lca<t  two  parts  of  tin;  trunk — namely,  in  the 
regions  of  the  shoulders  and  the  hips.  The  transverse  diameter  in  hoth  these 
regions  is  always  longer  than  the  antero-posterior  diameter. 

TItv  Sliouldcrti. — The  relation  of  the  shoulders  of  the  infant  to  the  mechan- 
ism of  lahor  is  somewhat  altered  hy  their  movahility.  The  shoulders  may  he 
])reseiited  to  any  portion  of  the  pelvis  in  one  of  two  positions:  First,  they 
mav  enter  together,  with  the  line  of  the  clavicles  approximately  at  right  angles 
to  the  spine — that  is,  in  the  position  ordinarily  assumed  hy  adults.  Second, 
one  shoulder  may  lie  elevated  and  the  other  depressed,  so  that  the  one  enters 
in  advance  of  the  other,  hoth  clavicles  hcing  still  approximately  in  the  same 
line,  hut  this  line  now  foriuiug  an  ohlitpu;  angle  with  that  of  the  ^'crtehral 
column.  In  the  second,  which  is  the  usual  and  normal  position,  the  transverse 
diameter  never  loses  its  su|)eriority  of  length  over  the  antero-posterior  diametei'. 
When  hoth  siioiildcrs  cuter  together,  this  superiority  of  the  transverse  diam- 
eter is  always  somewhat  less  marked,  and  is  occasionally  so  much  diiiiinished 
as  to  lead  to  interruptions  of  the  mechanism  Iiy  which  the  delivery  of  the 
shoulders  is  normally  aci'omplished. 

'/'//c  ///'/<N. — The  pelvic  hones  of  the  infant  are  sunicieiitly  rigid  to  |)revcii( 
anv  coiisidcrahle  moulding  of  vhe  hrcech,  and  the  transverse  diameter  of  tin' 


THI-:    MI'X'IIAXISM    OF    LMIOU. 


407 


hips  i.s  alwiiys  considcnil)!}'  }:;r('atf'r  than  the  aiitci'o-postcrioi'  diamctor  of  the 
sum,'  portion  <it'  tho  hody. 

The  Trunk. — Tlic  intt'rnuHliato  portions  of  the  inlant's  trunk  arc  so  soft  and 
coinprossihle  tliat  its  dianictcrs  arc  totally  inconstant.  The  shajic  of  the  cross- 
section  of  the  trunk  corresponds  witli  the  shape  of  that  portion  of  tlie  [)clvis  in 
wliich  it  lies,  and  even  the  prescuce  of  the  linil)s  in  juxtaposition  with  it 
makes  but  little  diircrcnee,  since  its  softness  permits  the  liud)s,  nuder  the  pres- 
siu'o  of  labor,  to  intlent  it  at  any  point. 


Diagnosis,  Frequency,  and  Prognosis  op  the  Several  Varieties 

OP  Labor. 

|)lA(iN(»sis.* — In  obstetric  (liauiiosis  we  are  furnished  with  two  methods  of 
examination  of  almost  e(|iial  importance — namely,  examination  of  the  abdomen 
and  examination  of  the  vatfina — which  must  be  described  separately. 

The  abdominal  examination  unist  be  subdivided  into  iuspectiou,  palpation, 
and  auscultation.  In  the  w^ii  of  this  method  of  examination  it  is  l)est  for  the 
bej;'inner  to  ijiuore  tlu,'  possibility  of  ().  L.  P.  and  ().  D.  A.,  on  aecoimt  of 
their  <j;reat  infre(piency  and  of  the  excessive  complications  that  an  ellbrt  at 
their  recognition  would  involve. 

The  value  which  the  individual  obstetrician  places  upon  an  abdominal 
examination  is  generally  proportionate  to  the  experieuce  he  has  enjoyed.  The 
!)cgiuner  should  be  urged  to  avail  himself  of  every  oj)portunity  for  practising 
this  method,  for,  while  he  will  find  in  his  early  practice  many  cases  in  which 
the  obesity  of  the  patient  or  the  rigidity  of  the  abdominal  muscles  and  uterus 
renders  abdominal  palpation  of  no  value,  a  large  muni)er  in  which  the  exam- 
ination is  inconclusive,  and  oidy  a  few  in  which  he  can  attain  a  clear  diagnosis 
In-  this  means,  yet  as  his  ex]ieri(  nee  enlarges  the  first  class  will  steadily  decrease 
in  nund)cr  and  the  latter  two  will  increase  proportionately,  if  he  is  faithful  in 
])ractising  palpation  upon  every  case  that  comes  under  his  charge;  and  the 
value  which  attaches  to  facility  in  making  a  diagnosis  by  this  means  iu  many 
difficult  operative  cases  can  be  a|>preciatcd  only  by  those  who  possess  it.  It  is 
ccrtaiulv  a  liict  that  to  the  experienced  hand  abdominal  pal|)ation  yields  rcsidts 
fully  as  valuable  as  those  which  can  be  obtained  by  digital  examination  per 
vaginam,  and  that  ther(>  are  but  few  cases  iu  which  rept'ated  examinations 
during  the  progress  of  labor  will  fail  to  establish  a  diagnosis  by  palpation  and 
auscultation  alone. 

Abdominal  Inspection. — Insjicction  is  mainly  valuable  as  affordiug  a  hint 
of  the  existence  of  ti'au-^vcrsi'  presentations  and  of  nndtiplc  pregnancy. 

Abdominal  Palpation. —  Palpation  is  the  most  important  part  of  the 
abdominal  (wamination  ;  it  .-liould  hv  performed  only  iu  the  intervals  between 
the  pains,  all   |tressure  of  the  hand   being  intermitted  with  the  appcaraiic(,'  of 

*  Aitli(Mi<;li  lilt'  iiictli(i(ls  wliicli  iiuist  ln'  n-.r(l  In  luiikiiiL;  tlir  ili;i'^ii(i>is  of  pfi'^t'iiliitinu  mihI 
|insitiiii\  ;irc  iiidiciilod  in  Mimtlu'r  (iMil  nf  tiii-  wmk,  siicli  w  ili;ii:'iiii>is  is  so  fS'-t'iili;il  tii  tlie 
iiu'cli;iiiii"il  iii;in;ii;(im'iit  nf  IiiImii-  tli;il  it  si'i'iiis  wisr  to  i\'[)i.';a  tlu-  tcciiniiiiu'  of  tin-  .several 
ItU'llloils   of  rXMIllilliltiiill    ill    lili>   svclioll. 


1v 


a 


ii 


I 


I  II 


I  f. 


<  1      ! 


1 


408 


AMKlilCAX    TEXT-liOOK    OF   OJiSTKTUHS, 


cacli  coiitrat'tioii.  'I'lic  |tliysi('iiin  slioiild  stand  l)y  tlic  patient's  side  fa<'ing 
toward  licr  litad,  and  slioidd  apply  the  palm  of  each  hand  flat  aL^ainst  tlic  cor- 
I'cspondini;;  side  of  tlic  nt(  rns.  'riiroii<;li()iit  tlio  examination  it  is  all-important 
tiiat  the  motions  of  tlu'  haiul  shoidd  he  slow  and  j>;entle,  uny  (puck  or  jerky 
imj)nlse  heinir  almost  certain  to  result  in  rijiidity  of  the  ahdondnal  walls  and  the 
litems,  tints  frnstratini:-  tli"  purpose  of  the  examination.  Kvery  elfort  slionld 
l)e  made  to  divert  the  attention  of  the  |)atient,  t()  soothe  her  fears,  and  to  assure 
her  that  the  examination  will  not  he  painfnl.  It  not  infrecpu  ntly  happens  that 
the  first  attempt  will  he  a  total  failure,  while  the  second  will  yield  satisfactory 
results  owintr  to  the  chanu'cd  mental  condition  of  the  patient. 

D'HKjuoHix  (if  Prcsfnfdfioii  Itj/  J'd/jxtHon. — The  fiiiiicr-tips  of  eacii  hand 
should  l)c  ])ressed  with  a  i!;ra<lual  and  <i;entle  motion  downward  behind  the 
.syniphysis  pubis  in  search  of  the  fetal  head  (Fig.  228),  which  in  cephalic  j)res- 


Flii.  li'JH.— Diatjiiiisis  nf  iirL'Si'iitiitinii  liv  |iiil|iiitii)n. 

ontations  is  almost  always  to  he  felt  in  thi<  situation  as  a  marked  transverse 
check  to  the  examininu'  hand.  In  this  examination  care  sliould  he  taken  to 
note  on  which  side  the  head  is  most  plainly  perceived,  since  with  a  wcll-ilcxed 
head  the  frontal  extremity  is  nuich  the  more  easily  reached,  with  the  pai'tialiy 
extended  head  lint  little  din'erence  is  to  he  noticed,  and  in  face  ])resenlation> 
the  occi)>ut    is  nnich  the  more  di>tinct. 

The  fundus  should  then  he  pal])ated  carefully  as  a  I'urthcr  means  of 
excluding  the  possibility  of  a  breech  jiresentation.  The  head  may  be  <lis- 
tinguished  from  the  breech  at  the  fundus  by  its  greater  si/e  and  mobility, 
bv  its  I'onnded  contour  as  opposed  to  the  tapering  form  of  the  smaller 
breeeh,  and  bv  an  easilv  distinguished  sulcus  which  correspon<ls  with  the  neck 
of  the  child  ;  but  the  best  evidence  of  the  jiresencc  of  the  breech  at  the  fundus 


-MSttm 


mvmmammmmri^r^ 


•rsc 
I  to 


Ixcil 


lilly 


litv. 


THE    MHCIIAMSM    OF    l.AIKH!. 


409 


is  ahvays  the  recogiiitiuii  of  a  head  prosi'iitatioii  l»y  (Iccp  palpation  Ix'tiiiid  tlio 
svinpiiysis. 

J>i()'('rt)iti((l  Diiif/noxix  of  I'rixcnldtionK  hi/  Pii/patinn. — ('cj)hii(ic  J'lrsnittt- 
tloiis. — Tliu  most  (listiiKJtivc  si^ii  of  licad  prcsoiitatioiis  is  to  be  found  in  tlio 
recognition  of  the  licad  by  deep  jialpation  bcliind  tlio  symphysis.  Tlic  diat;- 
nosis  should  tlu'U  hv  clici-Ucd  by  asirrtainin<5  the  absmcc  of  the  signs  clianu'- 
t('risti(!  of  tlic  head  at  the  fundus. 

J'ilrii-  ]'irfifiital!<))iti. —  In  Iji-cccli  presentations  the  obstetrician's  attention 
is  generally  first  arrested  by  the  absence  of  the  transverse  cheek  to  the  fnigcrs, 
due  to  the  presence  of  the  head,  on  ticep  palpation  behind  the  symphysis. 
Ho  should  then  be  able  to  recognize  the  presence  of  the  head  at  the  fundus  by 
the  signs  just  emimeratcd. 

7Vo/(.N7V/'.sv  Pr<x>iif(tlio)is. — In  transverse  presentations  the  long  axis  of  the 
child  is  felt  to  be  transverse.  The  din'erential  <liagnosis  between  the  head 
and  the  breech  is  always  of  importance,  and  is  to  be  made  by  the  signs  emi- 
meratcd above  as  characteristic  of  the  head.  -* 

I)la(/iiiixiK  of  I*onHioii  hi/  J'dlpaHoii. — The  hands  should  be  j)lace(l  along 
the  sides  of  the  uterus  and  should  make  geiitl(>  but  deep  pressure  toward  each 
other  (Fig.  221)) — that  is,  with  the  uterus  and  child  directly  between  their 


Kli:.  JJ'.I.  — |lill'_Mlnsi«  nf  pn<iti(ill  \'\  |i:ll|iiltiiill. 

palms — in  the  elVort  to  es^  mate  tiie  relative  resistance  atlbnlcd  l)y  the  right 
ami  left  sides  of  the  uterr  .  the  Hal,  tirm  back  of  the  child  usually  presenting 
a  resistance  to  |)ressure  .iiat  is  mai'kedly  greater  than  that  of  the  yielding 
abdomen  and  the  movable  lindis. 

The  diil'ering  resistances  having  iteen  estimated,  the  lingers  should  bo 
applicnl  to  the  sides  of  the  uterus,  not  with  the  lip<  deepiv  iudeuled  into  the 
alulomcn,    but    with  their   whole   palmar  surface   press(>d   linnly   against  the 


'^M 


I      k 


Wtfi 


1i>, 


^       ▼^  .Q.         v'  C 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


1.0 


1.1 


1.25 


Himm 


2.5 
2.2 


^   1^    12.0 


•UUu 


1.4 


1^ 

1.6 


v3 


V] 


/ 


fliotographic 

Sciences 

Corporation 


33  WfST  MAIN  STREET 

Wi:itST»i^  N.Y.  MSSO 
(716)  873-4S03 


'*> 


%^ 


& 


^Iff 


410 


AMERICA y    TEXT- HOOK   OF   OBSTETRICS. 


uterus ;  the  luuul.s  slimikl  then  be  niovctl  gently  up  ami  down  along  the 
uterine  wall  in  an  endeavor  to  recoirnize  the  irregularities  due  to  the  presence 
of  the  fetal  limbs.  During  this  search  it  is  necessary  to  guard  against  the 
error  of  nustaking  either  of  the  round  ligaments  for  the  fetrd  nicnil)ers.  These 
ligaments,  which  at  term  are  of  nearly  the  size  of  the  adult  finger,  extend 
obli(|uely  from  the  coriuia  of  the  uterus  downwaril,  outward,  and  Ibrward  to 
the  pelvic  brim.  They  may  be  recoguizeil  by  their  situation  and  by  the  pain 
of  which  the  patient  invariably  complains  when  they  are  rolled  about  tnider 
the  fingers.  Tlu;  existence  of  small  subperitoneal  fibroids  is  another  jiossiblo 
source  of  error.  With  thin  and  flaccid  abdominal  walls  it  is  sometimes  possi- 
ble by  this  method  to  recognize  the  fetal  lind)s  with  the  utmost  distinctness, 
but  in  the  majority  of  cases  an  irregularity  in  the  contour  of  the  fetus  is  all 
that  can  be  hoped  for. 

liy  palpation,  then,  we  can  hope  to  distinguish  not  only  the  presentation,  but 
also  the  position,  since  the  latter  must  correspond  with  the  quarter  of  the  pelvis 
in  which  the  letal  back  is  Ibiuid.  Owing  to  the  infrc(piency  of  O.I).  A.  and 
O.  L.  P.  posititms,  it  is  generally  safe  to  call  all  cases  in  which  the  back  of  the 
child  is  found  ttnvard  the  left,  O.  L.  A.,  and  those  in  which  it  is  found  toward 
the  right  of  the  mother,  ().  D.  I*. 

Abdominal  Auscultation. — Auscultation  of  the  fetal  heart  givTS  confirn;- 
atory  evidence  about  the  presentation  and  position,  informs  us  of  the  condi- 
tion of  the  child,  and  is  the  most  important  sign  in  the  recognition  of  nudtiple 
pregnancy. 

In  vertex  p;.'sentations  the  heart  is  most  plainly  heard  over  the  back  of 
the  child  and  below  the  mother's  umbilicus;*  in  breech  presentations  the 
heart  is  heard  over  the  back,  but  its  greatest  intensity  is  generally  above  the 
mother's  umbilicus  ;  while  in  presentatitms  of  the  face  it  is  most  readily  heard 
over  that  portion  of  the  uterus  which  corresponds  with  the  chest  of  the  child, 
ibut  is  again  below  the  umbilicus.  In  transverse  presentations  the  heart  is 
usually  plainly  audible  when  the  back  is  anterior,  but  is  often  found  with 
difficulty  in  the  ])osterior  varieties,  and  is  of  comparatively  little  value  in  the 
diagnosis  of  position. 

In  interpreting  the  evidence  of  position  furnished  by  the  situation  of  the  fetal 
heart  it  must  not  be  forgotten  that,  owing  to  the  fiict  that  sound  is  better  con- 
ducted by  solids  than  by  li<p)ids,  the  exact  situation  of  the  letal  heart-sounds 
corresponds  with  that  portion  of  the  back  or  chest  which  happens  at  the  moment 
to  be  in  cor.tact  with  the  uterine  wall ;  the  situation  of  the  fetal  heart-sounil, 
therefore,  may  vary  temporarily  with  the  position  of  the  mother,  as  one  or 
the  other  shoulder  rests  against  her  soft  parts,  or  it  may  temporarily  be  absent 
(especially  when  the  patient  lies  upon  her  back),  owing  to  the  intervention  of 
tiie  li(|iior  amnii  between  the  fetal  chest  and  the  physician's  ear. 

*  Owiiiff  I')  the  <il)liiiiio  pnsiliini  whicli  tlic  slioiildcrs  norninlly  occnpy,  tlic  dividinfj-line 
llictwccn  the  rijilit  iiml  the  U'i'f  iiositioii  (if  the  lu'iirf-souiids  in  lliis  iind  in  all  longitiidiniil  piTs- 
cntitlionH  slmuld  \w  tlint  dniwii  )i('t\v('t.'n  tliu  iindiiliciis  and  the  right  anterior  Hiiperior  ttpini' 
ol'  tlie  ilinin  nitlii'r  \.\vm\  ihi'  ini-dian  line  of  the  bodv. 


Ictal 

C'Oll- 

Luiuls 
linent 

|)UIul, 

lie  or 
l)seiit 
\\\  of 

Is-lini' 
luvs- 


THE   MECHANISM   OF   LABOR. 


411 


In  addition  to  tlio  value  of  aiisenltation  in  the  diagnosis  of  jmsition,  its 
iMi|)ortan('e  in  the  recognition  of  the  eonditioti  of  the  fetus  ean  hardly  be  over- 
estimated, any  fatigue  of  iniportanee  being  (|ui('Uly  shown  by  alteration  of  the 
rate  and  regularity  of  the  heart-soinids.  In  addition  to  the  fetal  heart-sounds, 
the  so-called  "uterine"  or  "  i)laeental  souffle"  is  generally  heard  as  a  soft 
blowing  sound  synchronous  with  the  mother's  pulse  ;  this  sound  is  of  no 
practical  value. 

Summary  of  Diagnostic  Signs  Aimished  by  the  Abdominal  Exami- 
nation.— At  the  conclusion  of  the  abdominal  examination  its  results  shoidd 
be  summed  up  and  a  diagnosis  be  made  by  some  such  mental  process  as  the 
following : 

The  first  j>rocess  of  palpation,  describe*!  on  page  409,  enables  one  to  deter- 
mine whether  the  presentation  is  cephalic,  pelvic,  or  transverse,  and  this  result 
is  cheeked  by  the  j)ositi(jn  of  the  fetal  heart  as  obtained  by  auscultation  ;  that 
is,  in  cephalic  presentations  the  heart  is  found  below  the  umbilicus,  in  breech 
presentations  al)t)ve  it,  and  in  transverse  presentations  a  little  toward  that  side 
of  the  abdomen  to  which  the  hea«l  is  directed. 

The  position  is  determined  by  the  situation  of  the  fetal  back,  as  established 
by  the  second  method  of  palpation,  <leserii)ed  on  jiage  409,  and  by  the  position 
of  tiie  fetal  heart,  which  position  should  correspond  with  that  of  the  fetal  back.* 

If  the  presentation  is  either  breech  or  transverse,  no  further  determination 
is  neccs.' ary,  or  indeed  possible,  by  the  abdominal  examination;  but  if  the  pres- 
entation is  cephalic,  it  is  both  necessary  and  possible  to  determine  whether  it 
is  a  presentation  of  the  vertex,  the  brow,  or  the  face.  In  vertex  presentations 
the  end  of  the  head  that  corresponds  with  the  fetal  abdomen — that  is,  the  face — 
is  found  at  a  higher  level  than  the  opposite  or  occii)ital  end,  and  the  fetal  heart 
is  heard  over  the  back.  In  face  presentations  the  end  of  the  child's  head  that 
(•orrespt)nds  with  the  abdomen — that  is,  the  face — is  palpated  less  readily  than 
the  dorsal  (occipital)  end  of  the  head,  and  the  heart  is  heard  over  the  front  of 
the  ciiild.t 

In  brow  presentations  both  ends  of  the  head  arc  easily  reached  by  palpation. 
The  heart  is  usually  heard  over  the  back. 

Vaginal  Examination. —  Tcchtuijitc  nf  the  E.ramhtafinu. — In  obstetric  work 
it  is  usually  best  to  avail  (»ue's  self  of  the  extra  length  of  the  middle  finger 
by  employing  two  fingers  fitr  all  examinations,  except  in  those  cases  in  which 
the  extremely  narrow  vulva  of  a  primipara  makes  the  introduction  of  the 
second  finger  painful  to  the  patient.     Most  American  obstetricians  prefer  to 

*  Exivpt  ill  fiioi'  iirescntiilions  isfo  p.  4591. 

t  It  will  bo  perceived  tliiit  the  (listiiictioii  ln't\veen  vertex  mul  liiee  presentiitions  by  iiiidoiu- 
innl  extuniiintion  is  likely  to  lie  ditru'iilt,  since  in  :i  left  antcrioi'  position  nf  either  pr'iscntiition 
the  most  ai'ces-iible  end  of  the  lieiid  will  be  foinid  in  the  riij;ht  ])osteri()r  (jnarter,  wlrle  in  both 
presentations  the  heart  is  let't  anterior;  the  only  distinction  is  to  be  t'onnd  in  the  position  of 
the  fetal  limbs  us  comimred  with  the  heiirt,  and  in  the  perception  of  the  Kroator  si/.c  and  more 
rciiMided  contour  of  the  occiput  as  opposed  fo  the  face;  but  the  ^rreat  infrcipiency  of  face  pres- 
entations and  the  ease  with  which  they  are  distiiifjuished  on  vaginal  exuininutiun  make  liiis 
sonrt'e  of  error  a  matter  of  small  importance. 


m 


!5-  r  ' 


I. 

v: 


r\.     4'^ 


i  \ 


'ii'     1.; 


I  i 


'■A 
I 


WF^' 


% 


412 


A  Mi:  arc  AX  riLxr-nooK  of  obstetrics. 


examine  tlic  patient  wlion  in  tlio  loft  lateral  dooiibitiis,  but  it  is  woU  to  accustom 
one's  self  to  exaniiniiij;  in  all  positions,  not  only  in  the  interest  of  the  patient's 
comfort  and  convenience,  but  also  biniause  it  is  often  possible  by  changing  the 
decubitus  lo  reach  a  portion  of  the  chilil  that  has  before  lieen  unattainable. 

The  vulva  being  aseptic,  the  hand,  having  been  thoroughly  disinfected  and 
anointed  with  an  aseptic  lubricant,  should  be  intUKluced  under  the  iMnl-clothcs, 
which  should  be  so  held  up  by  the  other  hand  as  to  protect  theni  from  contact 
with  the  examining  fingers ;  these  should  be  placed  against  the  genital  cleft, 
and  be  swept  gently  forward  until  they  find  the  entrance  of  the  vidva  and 
come  in  contact  with  the  fourchette,  friction  against  the  vestibule  and  clitoris 
being  carefully  avoided  in  the  process. 

As  the  examining  finger  enters  the  vagina  it  should  note  sticcessively  the 
size  of  the  vulvar  orifice,  the  position  of  the  coccyx,  the  shape  of  tlie  sacrum,* 
and  the  condition  of  the  rwtum — whether  full  or  empty.  These  points  having 
been  ascertained,  the  finger  should  be  pass'nl  upward  into  the  posterior  fornix, 
and  be  swept  forward  over  the  sofl  and  yielding  vault  of  the  vagina  in  the 
effort  to  find  the  external  os,  which  is  usually  situated  in  the  median  line  and 
near  the  centre  of  the  pelvis.  In  case  of  failure  to  find  the  os  readily,  the  field  of 
the  pelvis  should  becpiartcred  systematically  by  the  examining  finger,  much  after 
the  fashion  employed  by  a  pointer  dog  in  searching  a  field  for  game.  If  the 
cervix  be  not  yet  taken  up,  it  is  recogni/e<l  as  a  roundinl  prominence,  on  the 
summit  of  which  is  found  the  orifice  of  the  os  if  the  patient  be  a  primipara ; 
in  multipane  the  lacerated  and  ragged  condition  of  the  cervix  frequently  makes 
the  external  os  indistinguishable  from  an  early  stage  of  .'abor,  but  the  finger 
ill  such  cases  may  usually  be  passed  into  the  cervical  canal,  and  will  then 
recognize  the  ])resence  of  the  internal  os.  If  the  cervix  has  been  wholly 
taken  up,  the  os  is  best  recognized  by  passing  the  finger  through  it  and  into 
the  space  between  the  cervix  and  the  presenting  part.f 

The  physician's  ability  to  reach  the  upper  j)ortious  of  the  pelvis  is  more 
dependent  upon  the  position  in  which  his  hand  is  held  than  upon  the  length 
of  his  fingers.  When  he  desires  to  reach  the  tipjier  and  j)osterior  parts  of  the 
pelvis,  his  hand  shouhl  be  held  in  the  position  indicated  in  Figure  230,  the 
2)erineum  being  strongly  retracted  by  the  pressure  of  the  web  between  the 
second  and  third  fingers.  When  the  object  sought  for  lies  nearer  the  anterior 
wall  of  the  pelvis,  the  position  of  the  hand  should  be  altered  by  rotation  of 
the  forearm  into  the  position  represented  in  Figure  231.  The  upper  border 
of  the  second  finger  is  now  pi'cssed  firndy  against  the  edge  of  the  pubic  arch, 
and  the  pulp  of  the  finger  is  directed  anteriorly. 

*  The  writer  stronjfly  recoiniiien<ls  tlie  priictice  of  roiijrhly  nieasiiring  tlie  conJuKiite  diameter 
l)_v  reiicliiiiR  upward  for  tiie  i)roiii()ntory  of  the  siicrnni,  as  a  routine  measure,  at  tlie  conelusion 
of  the  first  examination  in  eacii  ease,  nnd  he  believes  that  many  operative  difliculties  may  lie 
avoided  by  this  simph-  prociMJui-e. 

t  Unless  this  precaution  of  hooking  the  linger  about  the  edge  of  tlie  os  be  observed,  tlie 
beginner  is  liable  to  mistake  a  fold  of  the  vaginal  wall,  or  in  breeeh  presentations  the  anus,  for 
the  OS  uteri,  both  of  which  mistakes  have  been  made  by  medical  students  in  the  presence  of 
the  writer. 


^i^iii 


THE  MECIIAXISM   OF  LABOR. 


41S 


The  OS  liaviuj;  been  reached,  tlio  fiiij^er  .slioiiM  note  its  size,  the  thickness 
of  its  edffe,  and  its  consistency,  wiicthcr  hard  or  si)t"t,  and  by  very  gentle  stretch- 
ing shonld  endeavor  to  ascertain  its  (h'grec  of  dihitability  ;  in  tiiis  hist  luaneu- 
vre  it  is  necessary  to  enjploy  tiie  greatest  gentleness  in  order  to  avoid  tlie  inex- 


FlG.  'JoO.— I'dsiton  (if  the  liiuid  in  digitiil  cxiiiiiiimtinii  of  tiK'  fetus  along  the  posterior  wall  of  the  pelvis. 

cnsable  accident  of  a  manual  hiceration  of  the  os  during  exatnination.  Tlie 
<'liaractcristicallv  diiferent  sensati(»ns  vicldc<l  to  the  fiii";er  bv  the  smooth  and 
velvety  cervix,  the  rough  but  slippery  niciubrancs,  and  the  iiairv  scalp  is  a 
matter  with  which  it  is  important  to  become  i'amiliar,  for  it  is  easy  to  recognize 


f.^ 


7  *. 


Fici.  2;!1.— I'osition  of  the  hand  in  digital  examination  of  the  fetus  alonj;  the  anterior  wall  of  the  jielvis. 

these  ditferenees  if  the  physician  has  trained  himself  to  observe  them  in  even 
a  comparatively  small  number  of  cases,  an<l  the  possession  of  this  faculty  may 
at  some  time  preserve  him  from  the  dangerous  t»r  even  liital  error  of  making 
an  application  of  the  forceps  to  the  intact  membranes  or  over  an  undilated 
cervix. 

If  the  cervix  is  thin,  it  may  be  possible  to  recognize  the  presenting  part 


'''if 

nil 


V'' 


wM 


tr 


i.  1 


!'  M 


iPW 


414 


A.VKRff'A.X    TEXT-noOK    OF   OliSTF/riilCS. 


throii^rli  its  sub.stiince ;  but  in  ordinary  cases  it  is  nccossarv  to  introduce  tlio 
fin»'er  tlirous^li  the  os  in  order  to  distiuiruish  between  the  difl'ercnt  parts  of  the 
child.  The  finger  should  be  passed  up  until  it  conies  in  eontaet  with  the  pre- 
sentinjj;  part,  an^it  should  then  seek  systeniatieally  for  u.arks  by  which  the 
character  of  this  part  can  be  determined.  The  jiresenee  of  the  head  is  to  be 
determined  by  the  perception  of  one  or  more  sutures ;  that  of  the  face,  by  the 
presence  of  the  raouth  and  nose  ;*  that  of  the  breech,  by  the  rccoornition  of 
the  spinous  ])rocesses  of  the  sacrum,  the  j^enitals,  and  the  anus.  The  tid)eros- 
ities  of  the  ischia  and  the  i)ubic  arch  are  also  easily  recognizabl(\  The  shoidder 
jiresents  no  very  distinctive  marks,  and  the  diagnosis  of  a  transverse  jiresenta- 
tion  is  not  easil\  made  by  vaginal  examination  din-ing  the  early  stages  of 
labor  unless  a  hand  and  an  arm  are  prolapsed,  but  it  shoidd  always  have  been 
recognized  by  abdominal  palpation  before  the  vaginal  examination  is  made. 
The  various  distinctive  marks  of  each  of  the  presentations  must  be  sought  for. 
and  the  diagnosis  is  to  be  made  in  accordance  with  those  founil  to  be  present. 

Summary  of  Sigrns  of  each  Presentation. — The  diagnosis  of  presentation 
bvvaginal  examination,  though  ordinarily  easy,  is  sometimes  ditficult  when  the 
j)resenting  ])art  is  still  high  in  the  pelvis.  It  would  be  supjiosed,  a  priori. 
that  the  distinction  between  the  hard  head  and  the  yielding  breech  could  be 
made  in  all  cases  with  the  greatest  ease,  but  a  considerable  experience  in  the 
superintendence  of  students  has  convinced  the  writer  that  this  pt)int  of  consist- 
ency is  a  most  unsafe  and  unsatisfactory  gui('c,  and  some  personal  experiences 
Jiave  le<l  him  to  adopt  the  rule  of  never  permitting  himself  to  diagnose  a  head 
unless  it  is  possible  to  recognize  at  least  one  suture,  nor  to  commit  himself  to 
the  diagnosis  of  a  breech  without  inserting  the  examining  finger  into  the  anus 
and  recognizing  the  presence  of  the  coccyx. 

Vcrtc.v  lWi«nt(ifinun. — In  vertex  j^resentations  the  finger  shonld  first  recog- 
nize the  convergence  of  the  lambdoidal  and  sagittal  sutures  forming  the  small 
fontanelle.  The  finger  should  ^^  n  pass  along  the  sagittal  sutiu'e  until  it 
reaches  the  large  fontanel^  .  .  .v.gnizes  the  four  sutures  which  enter  it.  It 
should  next  search  for  the  ears,  the  mastoid  processes,  and  the  lateral  fontanelles, 
all  of  which  may  usually  be  found  by  following  the  hnnbdoidal  sutures  to 
their^^w'minations.  The  ear  is  always  recognizable,  the  mastoid  and  the  lateral 
fontai»t4l«^  are  less  constantly  conspicuous,  and  all  these  niarks  are  usually  less 
easily  w*ached  upon  the  posterior  than  tipon  the  anterior  side.  The  car,  when 
reached,  always  points  toward  the  occipital  end  of  the  head,  unless,  as  sometimes 
hapjiens,  it  is  folded  forward  against  the  scalp — a  fact  which  is  easily  recognized 
if  the  finger  is  passed  backward  and  forward  a  fi'w  times  across  the  ear.  A\'ith 
a  well-flexed  head  the  posterior  fi)ntanello  is  lower  in  the  pelvis  than  is  the 
bregma,  and  the  upper  and  posterior  part  of  the  ear  is  generally  the  more 
easily  accessible.  When  the  head  is  somewhat  extended  the  fi)ntanelles  are 
upon  about  the  same  level  in  the  pelvis,  and  the  anterior  edge  of  the  ear  is 
most  easily  reached.     AV^ith  extreme  extension  of  a  vertex  presentation  the 

*  Care  nuist  be  taken  not  to  miHtnke  the  Ruprnorhital  ridpos  of  a  face  presentation  for  tlie 
Biiboccipital  ridges  of  a  well-flexed  vertex  presentation. 


TJIi:    .VFA'IIAXJSM    OF   LAliOIi. 


41  Tr 


(■\ (brows  are  not  infreciuoiitly  accessible  (soo //ro/r  iVcsf/i/^^/oo.-*).     Tlic  <liag- 
iiii-is  of  ])ositioii  in  vertex  j)reseiitations  is  made  by  ascertaining  the  position 
(it  the  occijMit ;  this  is  obtained,  first,  by  comparing  tlie  positions  ot"  the  small 
and  large  fbntanelles  in  the  pelvis,  and,  seconil,  by  observing  the  direction  in ' 
which  the  flaps  of  the  ears  point. 

Brow  Presentations. — When  the  extension  is  so  extreme  that  the  small 
fdiitanellc  is  reached  with  difficnlty  and  the  supraorbital  ridges  and  the  bridge 
of  the  nose  are  Avell  below  the  brim  of  the  pelvis,  the  presentation  is  that  of 
a  l»row.  By  very  high  examination  the  mouth  can  occasionally  be  touched  in 
binw  presentations.  The  position  is  named  after  the  position  of  the  small 
i'diitanelle,  but  care  should  be  taken  to  check  the  diagnosis  by  an  independent 
oliservation  of  the  root  of  the  nose,  which  should,  of  course,  be  in  the  opposite 
(|ii;u"tcr  of  the  pelvis. 

Face  J*re.se7ifafinn.s. — When  the  supraorbital  ridges  are  found  upon  one  side 
of  the  pelvis  and  the  point  of  the  chin  upon  the  other,  the  presentation  is  a 
face.  Before  the  diagnosis  is  considered  assured  the  fingers  should  recognize, 
in  addition  to  the  chin  and  the  supraorbital  ridges,  the  mouth,  the  nostrils,  the 
(yes,  and  the  root  of  the  nose  in  their  ])roper  pi>sitions  ■  and  it  is  even  well  to 
a<lnpt  the  precaution  of  always  inserting  the  finger  intt»  the  mouth  and  ascer- 
taining the  presence  of  the  maxillary  ])rocesses  and  the  tongue,  which  can  be 
mistaken  for  nothing  else.  The  position  is  indicated  by  the  position  of  the 
chill,  and  should  be  checked  by  an  observation  of  the  position  of  the  frontal 
suture. 

Breech  Presentations. — In  breoch  j)resentatio!is  we  must  distinguish,  during 
the  vaginal  examination,  between  presentations  of  the  whole  breech  and  foot- 
ling presentations.  In  presentations  of  the  whole  breech  the  finger  should 
rt'Cdgnize  the  spinous  processes  of  the  sacrum,  the  anus,  and  *he  genital  cleft. 
In  boys  the  scrotum  often  becomes  eno  "',  "'sly  distended,  and  this  may  lead 
tn  confusion   if  the  possibility  of  the  f.  not  borne  in  mind.     When   a 

l)i('cch  presentation  is  found,  the  finger  should  always  be  inserted  into  the 
anus,  and  be  made  to  recognize  the  tip  of  the  coccyx,  the  tulx^rosities  of  the 
ischium,  and  the  pubic  arch.  The  position  is  named,  as  has  been  said,  after 
tilt'  jiosition  of  the  sacrum,  and  it  is  most  easily  determined  by  finding  the 
])()sition  of  the  tip  of  the  coccyx  of  the  fetus  by  rectal  examination.  ■hHH^I 
ling  presentations  one  or  both  ankles  or  feet  protrude  through  the  os. 

Presentation  of  a  HamJ  or  a  Foot. — If  the  membranes  be  rupturecT 
sciiting  hand  or  a  foot  may  easily  be  drawn  outside  the  vidva  and  be  recognized 
by  the  eye  ;  if  this  be  impossible,  it  may  easily  be  differentiated  by  ihe  touch 
tliroiigh  the  membranes  by  observation  of  the  following  points :  The  foot  is 
to  be  distinguished  from  the  hand  by  the  presence  of  the  malleoli  and  of  the 
])niminence  of  the  heel,  and  by  the  facts  that  the  great  toe  is  of  equal  or 
jrnater  length  than  the  others  and  is  j)lac(Hl  in  the  same  plane  with  them ; 
while  the  hand  is  recognized  by  the  absence  of  the  heel,  by  the  fact  that  it 
can  be  placed  in  direct  continuation  of  the  line  of  the  lind)  to  which  it  is 
attached,  and  that  the  thumb  is  shorter  than  the  fingers  and  can  be  opposed 


ndinff  the 
"cci^^ffe- 


416 


AMERICA  X   TEXT- HOOK   OF   OnSTETRICS. 


to  thoni.  Tlio  ini|K>rtaiice  of  avoidiiif;  rupture  of  the  membranes  in  such 
presentations  is,  however,  so  great  that  it  is  usually  best  to  trust  to  the  results 
of  external  palpation. 

Presaifdfious  of  the  Kiire  and  the  FJbnv. — The  knee  may  sometimes  be  dis- 
tinguished from  the  elbow  by  the  presenc'  of  the  patella;  but,  sinee  the  latter 
is  small  and  not  always  easy  of  recognition,  it  is  best  to  distinguish  between 
these  two  joints  by  following  the  course  of  the  limb  to  its  termination  in  a 
hand  or  a  foot  as  the  case  nuiy  be. 

TranHvcrse  Pirfimtutioua. — The  shoulder  is  liable  to  be  mistaken  only  fur 
the  breech,  from  which  it  may  be  distinguisheil  by  the  presence  of  but  (uic 
limb  in  place  of  the  two  which  are  attached  to  the  jielvis,  and  by  recognitidii 
of  the  smooth  riilge  of  the  scapula  as  opposed  to  the  rough  spines  of  tlic 
sacrum  ;  recognition  of  the  clavicle  and  the  ribs  will  also  assist  the  diagnosis ; 
but  tlio  recognition  of  a  shoulder  by  vaginal  examination  is  extremely  dilli- 
cult,  and  the  existence  of  the  presentation  is  ])ractically  ascertained,  in  tlic 
majority  of  cases,  by  external  palpation,  without  assistance  from  vaginal 
examination. 

In  presentations  of  the  hand  it  is  sometimes  possible  to  make  a  diagnosis 
of  position  by  observation  of  the  hand  alone ;  to  this  end  it  is  first  necessary  to 
determine  which  hand  of  the  fetus  presents,  this  being  best  ascertained  bv 
attempting  to  shake  hands  with  the  presenting  part,  the  right  hand  of  the  fetus 
coming  into  position  to  shake  hands  with  the  right  hand  of  the  physician,  and 
the  left  with  tiie  left.  If  the  presenting  hand  be  turned  by  rotation  of  the 
forearm  into  forcetl  supination,  the  thumb  points  to  the  side  on  which  lies  tlic 
fetal  head,  and  the  back  of  th.e  hand  corresponds  with  the  back  of  the  fetus  ;  l)nt 
in  actual  practice  the  attitude  of  the  chihl  so  seldom  corresponds  exactly  to  any 
one  of  the  four  classical  positions  that  this  evidence  is  of  comparatively  slight 
value,  and  is  only  to  be  use<l  as  confirmatory  of  the  results  of  palpation. 

FuKQUENTY. — The  vertex  ])resents  in  about  97  per  cent,  of  all  labors,  the 
breech  presents  in  about  2  per  cent.,  and  the  remaining  1  per  cent,  is  niado 
up  of  brow,  face,  and  transverse  presentations,  the  latter  two  being  the  more 
frequent. 

f'jyjfijapsis. —  Vertex  Presentatlont^. — In  vertex  presentations  the  jn'ognosis 
lother  and  child  is  better  than  in  any  other  variety  of  labor.  It 
Jwever,  to  some  slight  degree  with  the  position,  being  better  in  antc- 
rKn^nuTn  in  posterior  positions,  on  account  of  the  somewhat  longer  and  more 
difficult  labors  which  are  to  be  expected,  as  will  be  seen,  in  the  latter. 

Face  Prenentntions. — In  face  presentations  the  prognosis,  though  not  neces- 
sarily bad,  is  always  worse  for  both  mother  and  child  than  in  vertex  cases; 
for,  although  the  majority  of  face  labors  are  terminate<l  with  safety  and 
rapidity  by  tiic  efforts  of  nature,  yet  in  the  comparatively  small  number  of 
^  cases  in  which  an  arrest  occurs,  and  in  which  art  must  step  in,  the  delivery  is 
often  extremely  difllicult.  The  prognosis  for  the  mother  is  that  of  the  opera- 
tion indicated,  but  in  the  operative  delivery  of  face  cases  the  dangers  to  the 
fetus  are  always, iwctiliarly  great. 


THE  MKCHANISM   OF  LABOR. 


417 


Brow  PresmtationH. — In  brow  prpsontations  the  prognosis  for  both  patients 
is  tliat  of  ilio  ojKiration  i)y  which  tije  case  is  delivcral.  It  is  therefore  neces- 
,«;iriiy  worse  than  that  of  vertex  presentations. 

Breech  Presentations, — In  breech  presentations  the  prognosis  for  the  mother 
is  only  altered  from  the  normal  by  the  fact  that  the  rapid  extraction  of  the 
:ifter-coming  head  and  arms  that  is  very  freqnently  necessary  is  attended 
l)v  a  greatly  increased  liability  to  perineal  and  cervical  lacerations.  The 
prognosis  for  the  child  is  always  bad,  especially  among  primiparse  or  with 
women  who  for  any  other  reason  have  rigid  soft  parts. 

Transrerse  Presentations. — Transverse  presentations  must  always  be  termi- 
nated by  art,  and  the  prognosis  varies  with  the  period  of  labor  at  which  inter- 
li'i'once  is  undertaken.  In  uncomplicated  transverse  jiresentations  an  early 
version  is  Jisually  easy,  and  the  prognosis  for  both  patients  is  therefore  good. 
In  neglectal  cases  the  operation  is  always  difficult,  and  the  prognosis  for  both 
]):itients  is  bad.  ^  t^ 

1.  Yertkx  Presentations. 

Frequency  of  Cephalic  Presentations. — At  the  end  of  pregnancy  the 
ccplialic  end  of  the  child  presents  in  about  97  |)er  cent,  of  all  cases.  In 
!I7,871  births  in  private  practice  Spiegelberg  found  head  presentations  in 
over  97  per  cent.  In  23,000  tases  confined  in  Guy's  Hospital  Lying-in 
Charity  the  percentage  of  head  presentations  was  9G.9.  Premature  delivery 
and  stillbirth  of  the  fetus  decrease  greatly  the  proportion  of  head  pres- 
entations. Thus,  Collins  found  that  head  presentations  occurred  in  97  per 
cent,  of  living  children  amitng  about  16.000  deliveries  at  term,  and  in  only 
about  80  per  cent,  among  500  births  of  putrid  fetuses.  Churchill  found  that 
at  seven  months  only  83  per  cent,  of  living  and  53  per  cent,  of  dead  children 
are  born  by  cephalic  presentation.  DuRois  found  83  to  be  the  percentage  for 
living  children  and  45  for  dead  children  at  the  same  perio<l. 

It  is  found  that  (hiring  the  latter  months  of  pregnancy  changes  in  the 
jiresonting  pole  of  the  fetus  occur  once  or  more  in  from  35  to  40  per  cent,  of 
all  eases.  The  change  from  a  pelvic  or  a  transverse  jiresentation  to  a  cephalic, 
however,  is  very  much  commoner  than  the  loss  of  a  cephalic  presentation. 
The  latter  would  therefore  seem  to  be  the  position  of  more  stable  equilibrium, 
and  it  will  be  found  that  these  observations — namely,  the  decreased  percentage 
of  head  presentations  among  premature  and  stillborn  children,  and  the  greater 
stability  of  head  presentation  as  compared  with  any  other — have  an  important 
hearing  upon  the  etiology  of  the  presentations. 

Relative  Frequency  of  the  Four  Positions. — In  about  75  per  cent,  of  all 
cephalic  presentations  the  occiput  is  found  upon  the  left  side  of  the  mother, 
and  in  more  thf  i  73  per  cent,  of  this  75  ])cr  cent,  the  position  is  anterior — 
that  is,  O.  L.  A.  In  the  remaining  25  per  cent,  the  occiput  is  of  course 
(lirocted  to  the  right  side  of  the  mother,  but  the  determination  of  the  relative 
frequency  of  right  anterior  and  right  posterior  positions  is  not  so  easily  do- 
tcrniined,  there  being  great  differences  of  opinion  upon  this  point  among 

27 


V"*>^_,, 


...-4J 


418 


AMERICAN   TEXT- HOOK   OF   OJiSTETRICS. 


different  olwervors,  the  key  to  tliis  tlifferencc  of  opinion  beinj;  probably 
found  in  their  adoption  of  different  pcrimls  of  labor  for  the  deternii nation  of 
the  position. 

In  a  larj^e  proportion  of  those  cases  in  whieh  the  occiput  is  to  the  rifrh^ 
and  somewhat  anterior  at  the  vc  'v  lK«jjinninjj  of  labor — that  is,  before  the 
head  is  even  pressal  iiito  the  superior  strait — the  position  becomes  right  j)os- 
terior  as  soon  as  engagement  owiu's.  It  is  probable  that  some  observers  have 
classified  such  cases  as  O.  I).  A.,  and  others  as  C).  D.  P.  Again,  the  enormous 
majority  of  right  posterior  positions  become  right  anterior  by  rotation  during 
the  sec(md  stage  of  labor.  An  observer  who  made  his  diagnosis  only  during 
the  latter  part  of  the  second  stage  would  class  all  such  cases  as  anterior  posi- 
tions. It  is  certainly  a  fiict  that  the  vast  majority  of  right  positions  are 
right  posterior  positions  at  the  time  when  the  greatest  diameter  of  the  head 
occupies  the  sujKTior  strait ;  and  if  this  peritxl  of  labor  be  selected  as  the  time 
when  the  j)osition  should  be  determined,  it  is  safe  to  say  that  nearly  75  per 
cent,  of  all  cases  are  primarily  O.  L.  A.,  and  almost  20  per  cent,  are  primarily 
O.  D.  P.  Of  the  small  remainder,  almost  4  per  cent,  are  primarily  O.  D.  A., 
and  but  a  little  over  1  jier  cent,  are  O.  L.  P. 

Etiology  of  Presentations. — Three  conditions  have  Iwen  urged  as  chiefly 
contributing  to  the  fre(iiiency  of  cephalic  presentations,  and  it  seems  probable 
that  the  true  cause  must  be  found  in  a  combination  of  all  three  conditions, 
which  probably  vary  in  their  importance  in  individual  cases.  These  three 
causes  are — first,  the  effwt  of  gravity  ;  second,  the  easier  adaptation  of  the 
fetus  to  the  uterine  cavity  in  head  presentations;  and  third,  the  effect  of  active 
movements  on  the  part  of  the  fetus. 

In  estimating  the  relative  im|)()rtance  of  these  factors  in  the  etiology  of 
head  presentations,  it  is  evident  that  to  attain  the  truth  it  is  necessary  to  reach 
a  conclusion  which  will  explain  the  results  of  clinical  observation  recorded 
aoove,  and  whieh  will  make  evident  not  only  the  reasons  for  the  great  prepon- 
derance of  cephalic  presentations  of  the  fetus,  but  also  for  its  variability  in 
accordance  with  the  period  of  delivery  and  the  condition  of  the  fetus. 

The  lujfuence  of  Gravity. — It  has  been  found  by  experiment  that  if  a  re- 
cently-dead fetus  at  term  be  immersed  in  a  saline  fluid  of  the  specific  gravity  of 
the  liquor  aninii,  it  tends,  under  the  influence  of  gravity,  to  assume  an  obli(|ne 
position,  with  the  head  lower  than  the  breech  and  the  right  side  lower  tliiiii 
the  left.  This  fact  is  exj)laincd  by  Matthews  Duncan,  who  has  shown  that  the 
specific  gravity  of  the  fetal  head  is  greater  than  that  of  the  decapitated  trunk, 
and  that  the  greater  specific  gravity  of  the  right  side  is  due  to  the  enormous 
relative  size  of  the  liver  in  the  new-born  child.  It  is  evident,  then,  othtT 
conditions  being  equal,  that  we  may  expect,  in  a  preponderance  of  cases,  to 
find  the  head  and  right  shoulder  of  the  fetus  in  that  portion  of  the  uterus 
which  is  horizontally  lowest  in  the  ordinary  positions  of  the  mother. 

The  ordinary  positions  of  the  mother  may  be  considered  in  this  connectidu 
to  be  three — the  vertical  position  of  the  trunk,  the  horizontal  position  in  a 
dorsal  decubitus,  and  the  horizontal  position  in  a  lateral  decubitus.     Wlun 


THE  MECHANISM   OF  LABOR. 


419 


obably 
ion  of 

^  rl^lit 
)re  th(( 

it    JHtS- 

rs  have 
ormous 

(luriiifr 

<luriii«!; 
or  posi- 
0118  arc 
lie  head 
the  time 
f  75  per 
riinarilv 
).  D.  A., 

„s  chicHy 
])robal)ie 
lulitioiis, 
esc  tlint' 
n  of  tlie 
of  active 

ogy  of 

to  reacli 

reconleil 

prepon- 

)ility  in 

us. 

if  a  re- 
avity  of 
oblitiue 
er  tluiH 
tliat  tlie 
trunk, 
iiormoiis 
1,  other 
ases,  to 
uterus 

lincctioii 
m  in  a 
1  When 


the  tnuik  is  erect  the  anterior  uterine  wall  is  inclined  to  the  horizon  at  an 
.•in«?Ie  of  about  35°,  and  the  lowest  portion  of  the  uterine  cavity  is  to  be 
|()und  in  the  neighborluMxl  of  the  pubes.  Most  pregnant  women  are  in  this 
position — that  is,  either  standing  or  sitting — for  about  two-thirtls  of  the  twenty- 
four  hours,  and  it  is  consequently  the  most  important  of  the  three  positions  in 
this  connection.  In  this  position  of  the  mother  the  child  would  tend  to  assume, 
iHider  the  influence  of  gravity,  precisely  tiie  ix)8ition  in  which  it  is  usually 
liiuiid — that  is,  a  vertex  presentation,  O.  L.  A. — and  in  the  absence  of  disturbing 
elements  it  will  l)e  in  this  relation  to  the  mother  about  two-thirds  of  the  time. 

When  the  woman  lies  upon  her  back  the  posterior  uterine  wall  is  inclined 
t(i  the  horizon  at  an  angle  of  about  55°,  and  the  lowest  portion  of  the 
uterus  is  in  the  neighborho<Ml  of  the  promontory.  Thus,  in  this  position  also 
the  influence  of  gravity  tends  to  maintain  a  cephalic  presentation.* 

When  the  woman  lies  upon  her  side  the  lowest  point  of  the  uterine  cavity 
is  usually  near  the  fundus  and  toward  the  side  upon  which  she  reclines.f  In 
this  position,  then,  the  influence  of  gravity  would  be  exerted  against  the 
maintenance  of  a  cephalic  presentation  ;  and  since  the  lateral  decubitus  is 
maintained  by  most  pregnant  women  for  the  greater  part  of  that  third  of 
tiic'ir  time  which  is  spent  in  bed,  it  is  evident  that  the  influence  of  gravity 
would  not,  by  itself,  be  a  suflicient  cause  for  the  appearance  of  a  cephalic 
])r('sentation  in  so  large  a  number  as  ninety-seven  out  of  every  one  hundretl 
labors ;  but  since,  from  the  influence  of  gravity  alone,  it  is  probable  that  the 
head  would  maintain,  other  influences  being  excluded,  a  cephalic  presentation 
(hiring  the  greater  part  of  the  time,  it  is  fair  to  assume  that  this  furnishes  a 
predisposition  toward  the  existence  of  a  cephalic  presentation  in  any  given 
case.  When,  moreover,  we  investigate  the  relation  of  this  factor  to  the  varia- 
tion in  percentages  due  to  premature  births  and  stillbirths,  we  find  its  influ- 
ence so  entirely  in  accord  with  the  results  of  clinical  observation  as  to  add 
still  further  proof  of  its  importance.  Thus,  Dr.  Duncan  found  that  when  a 
child  dies  in  utero  before  labor,  the  specific  gravity  of  its  head  is  less  than 
tliat  of  a  living  child,  and  the  body,  when  uncontrolled,  often  actually  floats 
head  uppermost  in  a  saline  fluid.  Again,  it  is  highly  probable  that  the  rela- 
tive difference  between  the  specific  gravity  of  the  head  and  that  of  the  body 
is  less  among  premature  than  among  full-term  children,  since  we  know  that 
the  proportionate  development  of  the  brain  and  the  cranial  bones,  in  compari- 
son with  that  of  the  body,  is  much  less  during  the  early  months  of  pregnancy 
than  it  becomes  at  term. 

It  may  with  propriety  be  coneetled  that  the  greater  specific  gravity  of  the 
cephalic  pole  of  the  fetus  is  a  predisposing  cause  of  head  presentations,  and  it 
only  remains  to  be  determined  whether  the  other  causes  arc  sufficient  to  main- 
tain this  position  when  once  established. 

*  Tliongli  with  the  back  of  the  fetus  toward  the  back  of  the  mother  (see  Etiology  of  Posi- 
tion, p.  422). 

t  When  the  woman  lies  njion  her  riffht  side  the  influence  of  gravity  tends  to  tnrn  the  back 
of  the  child  forward,  and  when  slie  lies  upon  her  left  side  tends  to  turn  it  backward. 


rV    'is 
4    i^ 


mM 


420 


AMKIilVAX  rKXT-nOQK  OF  oustethics. 


Athtjdaiion  between  Ftinx  (iiul  I'teruti. — It  is  iisiiul  to  coiisiilor  the  ntonis 
as  a  flaccid  mass  which  rcatlily  iiiuulds  itself  to  the  sha|K'  of  its  oontoiits  or  its 
surroundings ;  hut  when  we  renjenilK'r  that  during  each  contracrtion  the  uterus 
straightens  itself  and  tends  to  a.s8unic  a  definite  form,  and  tliat,  moreover, 
there  is  undoid>tedly  a  |>r(XM;ss  of  slight  rhythmic  contraction  going  on  through- 
out the  whole  of  the  latter  part  of  pregnancy,  it  is  evident  tiiat  the  uterus 
must  be  regarded  as  a  IkmIv  which  has,  to  some  extent  at  least,  a  definite,  in- 
trinsic sha]H>.  It  has,  moreover,  Ixjen  determined  by  post-niortom  examina- 
tions that  tiiis  8ha|H<  is  one  which  alters,  and  alters  in  a  definite  direction, 
during  the  development  of  tiie  uterus. 

At  and  for  sonic  time  Ixjfore  the  fifth  month  tlie  uterine  cavity  is  nearly 
spherical  (Fig.  232),  and  is  very  large  as  compared  with  the  still  small  and 
undeveh)i)e<l  fetus ;  but  from  this  time  on  the  cavity  becomes  progressively 


i\f^ 


•,"f 


I  i  < 


Fio.  232.— Kclativf  sizeipftlii'  fctUMiiid  tlio  utiTine 
ciivity  lit  till'  tillli  niiiiitli. 


Fi(i.  2:!;t.— Adaiitmiiiii  lntwH'i'ii  till'  uttTiis  and  till' 
feliis  at  tiTiii  in  vortix  pri'sentatioii. 


more  and  more  ])yriform,  until  toward  the  end  **  pregnancy  it  assumes  the 
ilvfinitely  pyriform  shajK?  shown  in  Figure  233.  The  uterine  cavity,  at  term 
and  under  normal  conditions,  is  but  little  larger  than  the  fetus. 

It  is,  moreover,  evident,  on  comparing  the  shape  of  the  fetus  in  its  ordinary 
iiftitudc  with  the  shape  of  tho  uterus  at  term,  that  in  head  presentations  (Fig. 
233)  the  fetus  and  tiie  uterus  are  extremely  well  adajited  to  each  other,  i)iil 
vhat  in  breech  (Fig.  234)  or  in  transverse  ])resentations  one  ])ortion  of  tiie 
uterine  muscle  is  subjected  to  an  undue  amount  of  tension,  while  other  por- 
tions are  unduly  relaxed  ;  therefore  any  change  from  the  cephalic  to  either  :i 
brcHH'h  or  a  transverse  presentation  will  be  op))osed  by  the  contractile  power 
of  that  portion  of  the  uterine  muscle  that  would  he  overstretched  in  the  new 
]>resentations ;  that  is,  we  may  assume  that  the  shape  and  contractility  of  tiie 
uterine  walls  tend  to  ])reserve  a  cei)halic  presentation  whqji  this  is  once  well 
established,  and  that  the  rhythmical  contractions  would  probably  tend  to  rc- 
eatablish  it  when  lost.  It  is  safe  to  assume,  then,  that  the  shajKi  of  the  uterus 
may  be  considered  an  imjiortant  factor  in  preserving  a  cephalic  presentation 


THE  MECHANISM  OF  LAJiO/i. 


421 


Fin.  2^.— Adaptation  J>cfwpoii  the  fetus  and  the 
\itt'ru.s  Hi  term  in  breeiii  prenvntHtlon. 


when  tliis  has  once  l)oen  estnblishal  by  the  inflnencc  of  gravity,  and  that  its 
in.sonsil>le  contractions  fnrnisii  an  influence  of  ini|)o;tan(rf>  in  re-establishing  a 
hcatl  presentation  when  this  has  been  lost. 

Injliient'c  of  the  Feiul  Movemenl»f, — Since  the  fetal  movements  arc  accidental 
and  independent  of  any  volitional  impulse,  it  is  probable  that  their  occurrence 
would  be  insufficient  to  effect  any  con- 
siderable change  in  the  relation  of  the 
fetus  to  the  uterus  unless  in  an  ex- 
tremely relaxinl  condition  of  the  uterine 
mid  abdonunal  walls,  and  that  even  in 
siurh  uteri  the  change  would  Ihj  likely 
to  (K-cur  oidy  when  the  position  of  the 
mother  addcnl  the  influence  of  gravity 
to  the  effect  of  fetal  movements.  It  is 
evident  tiiat  even  in  such  cases  the 
operation  of  the  same  causes  would 
probably  tend  to  a  spee<ly  assumption 
of  the  cc;ib;>|ic  presentation. 

Couehmonii. — It  is  now  necessary  to 
Oil.  ider  how  far  the  ctmditions  just 
enumerated  explain  the  observed  facts 
quototl  at  the  beginning  of  this  section  .  First,  that  cephalic  presentations  pre- 
ponderate in  tiie  proportion  of  97  to  3 ;  necond,  that  this  preponderance  is 
much  decrease<l  by  both  premature  deliveries  and  stillbirths ;  third,  that  the 
change  from  a  pelvic  or  a  transverse  presentation  into  a  wphalic  is  very  much 
more  common  than  the  loss  of  a  cephalic  presentation  ;  and  fourth,  that  both 
abnormal  presentations  and  changes  of  presentation  are  much  commoner 
among  multiparte  and  when  the  quantity  of  liquor  anuiii  is  large.  X 

First. — The  existence  of  a  condition,  the  influence  of  gravity,  that  tends 
to  establish  a  cephalic  presentation,  and  that  is  operative  for  two-thirds  of  the 
time,  in  combination  with  other  conditions  which  render  any  other  presentation 
unstable,  and  which  are  operative  all  the  time,  is,  in  the  absence  of  anything 
which  favors  any  other  presentation,  sufficient  to  account  for  almost  any  per- 
centage of  preponderance  of  cephalic  presentations. 

Second  mid  Third. — In  the  middle  of  pregnancy  the  shape  of  the  uterine 
cavity  is  nearly  spherical  and  its  size  is  greatest  as  compared  with  that  of  the 
fetus;  the  latter  is  but  little  developed  and  the  presentations  are  totally  un- 
certain. During  the  sixth  and  seventh  months  the  conditions  ajiproach  nearer 
to  those  observed  at  ter  ""i ;  but  even  in  the  eighth  and  ninth  months  tlie  differ- 
ence in  the  specific  gravity  t)f  the  cephalic  and  pelvic  ends  of  the  infant  is 
less  marked  than  at  term ;  the  pyriform  shape  of  the  uterus  is  less  strongly 
marked,  and  the  adaptation  between  the  uterus  and  the  fetus  is  less  close ; 
that  is,  all  the  factors  which  we  have  been  considering  as  im])ortant  in  the 
production  of  the  preponderance  of  cephalic  presentations  have  less  value  than 
at  term.     We  find  by  observation  that  at  these  periods  the  preponderance  of 


•«■ 


i    i 


;  1 ;        i 


in 


iii 


422 


AMERICAN  TEXT-BOOK  OF   OBSTETRICS. 


r  1  ,! 


I 


ill 


I 


I  i:'itfl  ^1 


I' •    vm 


M>r 


V  ''■>^- 


cephalic  presentations  is  oorresponilingly  decreased,  and  that  spontaneous 
changes  of  presentation  arc  corresiM)ndingly  muc'h  more  frequent  than  at  the 
end  of  pregnancy ;  we  a'^>,  then,  justifietl  in  onr  belief  in  the  importance  of 
these  factors. 

Fourth. — These  considerations  are  in  fidl  accord  with  the  observed  fact  that 
both  abnormal  presentations  and  changes  of  presentation  occur  most  frequently 
in  multipara)  with  relaxetl  uterine  and  abdominal  walls,  and  are  but  rarely 
seen  in  the  more  rigid  condition  of  the  muscles  that  is  characteristic  of  first 
pregnancies.  So,  too,  it  is  fully  establishe<l  that  these  changes  and  abnormal 
presentations  occur  much  more  frequently  when  the  quantity  of  liquor  amnii 
is  relatively  so  great  that  the  uterus  tends  tlu'ough  distention  to  acquire  a 
more  nearly  spherical  shape,  and  when  the  limbs  of  the  fetus  ave  accordwl 
much  greater  freetlom  of  movement. 

As  a  result,  it  seems  safe  to  assume  that  the  influence  of  the  relatively 
greater  specific  gravity  of  the  cejihalic  pole  of  the  fetus  is  the  predisposing 
cause,  and  that  this,  together  with  the  intrinsic  shape  of  the  uterine  cavity 
and  the  influence  of  the  movements  of  the  fetus,  are  the  maintaining  causes 
of  the  great  preponderance  of  cephalic  presentations. 

Etiology  of  Position. — It  has  already  been  observed  (p.  419)  that  in  the 
erect  j)osture  of  the  trunk,  iisually  assumed  by  the  woman  for  two-thirds  of 
the  twenty-four  hours,  the  influence  of  gravity  tends  to  the  production  of 
an  O.  L.  A.  position,  and  in  the  remaining  one-third  of  the  twenty-four  hours 
the  influence  of  gravity  varies  with  the  decubitus  which  the  woman  assumes 
in  bed.  Therefore  it  may  safely  be  assumed  that  any  conservative  factors 
which  appear  late  and  ten«l  to  fix  the  child  in  any  position  in  which  they 
find  it  are  more  likely  to  find  it  O.  L.  A.  than  in  any  t)ther  jiosition.  Sucli  a 
factor  is  to  be  found  in  the  shape  of  the  suj)erior  strait.  The  jireseuce  of  th(> 
rectun^in  the  left  ilio-saoral  notch  renders  the  second  oblique  diameter  of  the 
pelvis  less  ample  than  the  first,  so  that  if  the  oblique  cross-section  of  the  head 
that  is  ordinarily  ])resentetl  to  the  pelvis  at  the  inlet  rests  with  its  long  diam- 
eter in  correspondence  with  the  second  oblique  diameter  at  the  brim,  the  head 
is  less  easily  areommodated  than  if  it  is  presentetl  to  the  first  oblique  diameter. 
It  will,  then,  as  the  adaptation  becomes  progressively  tighter  and  tighter,  tend 
to  remain  in  the  first  oblitpie  diameter  for  longer  periods  than  in  the  second  ; 
that  is,  it  will  be  dislodged  with  diffit-ulty  from  the  first  oblique  diameter,  and 
with  ease  from  the  second  by  any  slight  cause ;  and  since  the  influence  of 
gravity  tends  during  the  greater  part  of  the  time  to  turn  the  occiput  forward, 
a  head  which  occupies  either  an  O.  D.  A.  or  an  O.  L.  P.  position  will  tend  to 
become  ().  L.  A.  rather  than  anything  else.  The  maintenance  of  an  O.  D.  P. 
position  is,  moreover,  rendei-(Hl  comparatively  unlikely  from  the  fact  that  the 
shape  of  the  head  is  loss  well  adapted  to  that  of  the  pelvis  in  this  jiosition. 
Changes  of  position  are,  in  fact,  extremely  I'requent  until  within  the  last  few- 
weeks  before  delivery,  and  the  position,  moreover,  is  never  finally  determineil 
until  the  head  engages  at  the  brim. 

Diaernosis. — On  abdominal  examinatUm  the  head  is  found  at  the  inlet ;  the 


TUK   MF.VIIANli^M   OF  LABOR. 


423 


fotal  liiul)s  ami  the  most  nocossiblc  end  of  tho  head  arc  found  on  one  side  of 
tlie  alnlonien,  and  the  heart  on  the  otiier.  On  vof/inal  examhiafion  the  finger 
^honld  recognize  the  small  fontanelle  on  one  side  of  the  pelvis,  and  bv  follow- 
ing the  sagittal  sutnre  should  find  the  large  fontanelle  on  the  other.  The  ears 
should  always,  and  the  mastoids  and  lateral  fontanelles  shoidd  usually,  be 
felt  at  the  ends  of  the  lanibdoidal  sutures. 

Prognosis. — The  prognosis  for  both  mother  and  child  is  better  than  in  any 
other  variety  of  labor."^ 

A.  Mechanism  of  the  First  Stage  of  Labor. 

It  is  customary  to  divitle  labor  into  three  stages.  Tlie  first  stage  comprises 
the  time  occupied  in  the  dilatation  of  the  os  ;  the  second,  that  expended  in  the 
descent  and  expulsion  of  the  child ;  while  the  third  is  occupied  by  the  birth 
of  the  placenta. 

For  purposes  of  description  it  is  well  to  consider  the  three  stages  as  being 
sharply  divided  from  one  another,  but  it  must  bo  remembered  that  clinically 
tiie  division  between  the  first  and  second  stages  is  often  difficult  and  indefinite, 
since  the  final  stages  of  dilatation  are  not  infre<|uently  accomplished  only 
dtu'ing  the  descent  of  the  head  ;  and  for  clinical  ])urposes  it  is  well  to  define 
the  end  of  the  first  stage  as  occurring  whenever  the  os  is  fully  dilated  or  dilat- 
able, it  being  understood  that  the  expression  ''  fully  dilatable"  refers  to  a  con- 
dition in  which  the  os,  though  still  iii'.perfectly  dilated,  has  become  so  soft  and 
elastic  as  not  to  offer  any  efficient  obstacle  to  the  descent  of  the  presenting  part. 

To  understand  exactly  the  njcchanisni  of  labor  it  is  necessary  to  discuss 
first  the  forces  by  which  the  process  is  accomplished,  and  next  the  manner  in 
which  each  force  acts  during  the  different  stages  of  labor. 

The  forces  by  which  labor  is  effectetl  are  those  produced  by  the  contraction 
of  the  uterine  antl  abdominal  muscles,  together  with  such  inHucnce  as  can  be 
effected  by  the  weight  of  the  child  and  the  waters. 

The  uterine  muscle  acts  in  two  ways:  first,  by  diminishing  the  intra-uterine 
urea  and  thus  creating  a  general  intra-uterine  fluid-pressure  due  to  ti»e  contrac- 
tion of  the  uterus  upon  the  fluid  contents  of  the  utn'uptured  ovum  ;  second,  by 
the  fi)rce  of  dii'cct  contact  between  the  breech  and  the  fimdus  of  the  uterus 
whenever  a  rupture  of  the  membranes  and  the  consequent  escape  of  the  waters 
jiermit  this  contact  to  occur.  Direct  contact  may  also  occasionally  oc(!ur,  as 
will  be  seen  later,  before  the  rupture  of  the  membranes. 

The  abdominal  muscles  when  set  into  voluntary  contraction  reinforce  both 
forms  of  action  of  the  uterine  muscle.  When  the  uterine  muscle  is  in  direct 
contact  with  the  breech,  the  abdominal  nniscles,  lying  in  close  contact  with  the 
uterus,  add  their  force  to  that  which  the  uterus  itself  exerts  against  the  child  ; 
when  the  child  is  protected  from  contact  with  the  uterine  walls  by  the  ])resencc 
of  a  quantity  of  liquor  amnii,  the  contraction  of  the  abdominal  muscles  again 
adds  ii,  elf  to  that  of  the  uterine  wall,  and  thus  adds  its  incrcn)ent  to  the 
general  intra-uterine  fluid-pressure.  The  force  of  gravity  is  inactive  in  many 
positions  of  the  mother,  and  is  at  most  an  increment  of  but  small  importance. 


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AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


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In  considering  the  manner  in  which  the  above-mentionetl  forces  are  employed 
in  effecting  the  dilatation  of  the  os  during  the  first  stage  of  labor,  it  is  neces- 
sary to  consider  several  variations  which  may  occur  in  the  mechanical  con- 
ditions. When  the  waters  are  abundant  and  the  membranes  persist  unbroken 
throughout  the  first  stage,  the  dilatation  is  usually  accomplished  by  the  action 
of  the  membranes  only.  This  may  be  considered  the  normal  mechanism  of 
dilatation,  and  must  be  describe<l  first,  after  which  it  will  be  proper  to  take 
up  the  various  conditions  in  which,  from  one  cause  or  another,  the  membranes 
cease  to  act  their  proper  part,  and  tlie  dilatation  must  be  accomplishetl  by  the 
pressure  of  the  fetal  head  against  the  cervix. 

Normal  Mechanism  of  Dilatation. — In  the  first  instance — that  is,  when 
the  waters  are  abundant  and  the  menibranes  are  intact — the  position  of  the 

fetus  is  unaffected  by  the  intra-uterine 
fluid-pressure.  It  is  an  axiom  in  phys- 
ic-s  that  fluid-pressures,  however  pro- 
duced, are  invariably  equal  and  oppo- 
site in  all  directions,  from  which  it  fol- 
lows that,  the  pressures  A  (Fig.  235) 
being  equal  and  opposite  to  the  pres- 
sures B,  the  child  will  be  uimioved  by 
the  uterine  contraction.  Similarly,  the 
fluid-pressure  upon  any  one  portion  of 
the  uterine  wall  being  equal  to  that  ex- 
erted upon  any  other  portion  of  equal 
area,  there  would  be  no  effect,  even 
upon  the  shape  of  the  uterus,  if  its 
entire  surface  contracted  at  once  and 
if  its  walls  were  of  uniform  strength 
throughout.  The  initial  stages  of  dila- 
tation of  the  OS  are  in  reality  to  be 
referred  to  the  fact  that  the  lower 
uterine  segment  possesses  less  muscular 
strength  than  the  upper  part  of  the  uterus,  and  to  the  character  of  the  uterine 
contractions.  Neglecting  for  the  moment  the  latter  factor,  and  limiting  the 
discussion  to  the  effect  of  the  different  strengths  of  the  upper  and  lower  uterine 
segments,  we  shall  see  that  the  contraction  of  the  more  powerful  upper  part  of 
the  uterus  forces  the  less  j)owerful  lower  portion  open,  notwithstanding  its 
efforts  at  contraction. 

The  total  force  exerted  by  the  uterine  contractions  results  in  the  application 
of  a  uniform  centrifugal  pressure  upon  all  portions  of  the  containing  wall. 
The  amount  of  this  pressure  upon  any  given  unit  of  surface — as,  for  example, 
a  square  inch — will,  of  necessity,  be  ecpial  to  the  average  force  exerted  by  tiic 
same  superficial  extent  of  the  uterine  wall ;  hence  it  follows  that  at  any  portion 
of  the  viscus  where  the  strength  of  the  wall  is  greater  than  the  average  the 
contracting  centripetal  force  will  tend  to  overcome  the  resulting  centrifugal 


/.v. 


Fir..  235.— Diagram  illustrating  the  ab.sence 
of  altLTQtion  in  the  nttitudo  of  a  child  by  the 
actiun  of  opposite  and  equal  fluid-pressure.s. 


THE   MECHANISM    OF  LABOR. 


425 


force,  and  the  result  will  be  a  decrease  in  the  extent  of  the  uterine  walls  at 
that  point.  Similarly,  at  any  point  where  the  strength  of  the  uterine  wall  is 
below  the  average  the  expanding  centrifugal  force  of  the  fluid-pressure  will 
be  greater  than  the  centrijwtal  force  of  the  contracting  muscles,  and  at  such 
points,  therefore,  the  expanding  force  of  the  fluid-pressure  will  tend  to  over- 
come the  contracting  force  of  the  uterine  muscles,  and  there  will  be  a  conse- 
quent increase  in  the  area  of  those  portions  of  the  uterine  wall.  Now,  the 
lower  uterine  segment  is  by  all  odds  weaker  than  any  other  portion  of  the 
uterus ;  it  therefore  tends  to  expand  during  the  contraction  from  the  action  of 
the  general  intra-uterine  fluid-pressure. 

The  circular  portion  of  the  uterine  area,  which  is  opposite  to  the  lumen  of 
tiie  vagina,  is,  moreover,  unsupporte<l  by  the  general  intra-abdominal  pressure 
and  by  the  force  of  the  tonicity  of  the 
al)dominal  muscles  that  is  exerted  upon 
all  the  other  portions  of  the  uterus — a 
fact  which,  by  decreasing  the  centripetal 
force,  still  further  increases  the  surplus 
of  the  centrifugal  element  at  this  point. 
As  a  matter  of  fact,  at  the  beginning  of 
labor  the  first  influence  of  the  uterine 
contractions  is  seen  in  the  assumption 
by  the  lower  uterine  segment  of  a  more 
expanded  shape,  such  as  shown  by  the 
(lotted  outline  in  Figure  236.  Moreover, 
since  at  one  point  in  the  lower  uterine 
segment  the  cohesion  of  its  substance 
is  still  further  lessened  by  the  existence 
of  a  solution  of  continuity,  the  lumen 
of  the  OS  uteri,  it  is  evident  that  there 
will  be  a  still  more  marked  tendency 
to  expansion  at  this  weakest  spot,  resulting  in  a  tendency  to  dilatation  of 
the  OS. 

To  these  considerations  must  be  added  the  effect  of  the  peculiar  composition 
of  the  uterine  muscle  and  of  the  peculiar  character  of  its  contractions.  It  is 
essential  to  remember  that  this  highly  composite  muscle  is  made  up  of  inter- 
lacing fibres,  whose  action  may  mechanically  be  divided  into  one  set  of 
longitutlinal  and  one  of  circular  stresses;  that  is,  if  the  action  of  those  fibres 
having  an  oblique  direction  be  resolved,  as  is  physically  allowable  and  proper, 
into  their  longitudinal  and  transverse  resultants,  the  action  of  the  whole  will 
U  found  precisely  c(jual  to  that  which  would  be  exerted  by  two  hypothetical 
sets  of  fibres,  of  which  the  first  and  m(»st  powerful  set  directly  encircle  the  ute- 
rus in  horizontal  zones,  while  the  second  and  less  powerful  set  extend  upward 
through  the  margin  of  the  os,  cross  the  fmidus,  and  thence  passing  down  to 
reach  the  margins  of  the  os  at  points  opposite  to  their  origins. 

If  a  uterine  muscle  so  composed  were  set  into  action,  it  will  be  seen  that, 


Fin.  2.'i6.— Diagrams  showing  tl)e  diminution 
of  tlie  iippiT  uterine  scKiiiont  aiui  tlie  expansion 
of  tlie  lower  segment  during  eaeli  eontraction. 


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426 


AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 


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from  a  mechanical  standpoint,  the  circular  fibres  surroundinj^  the  os  would  by 
their  contraction  tend  to  keep  it  closed,  while  the  longitudinal  fibres,  acting  in 
opposition  to  these,  would  by  their  contraction  tend  to  open  the  os  by  drawing 
its  margins  apart  over  the  contained  ovum.  This  conception,  though  somc^- 
what  more  simple  than  the  actual  anatomical  fact,  is  mechanically  essentially 
correct;  but,  since  the  circular  stresses  are  the  more  powerfiil,  it  is  evident 
that  this  arrangement  cannot  result  in  the  dilatation  of  the  os  unless  compli- 
cated by  the  presence  of  some  additional  factor.  This  factor  is  found  in  the 
circumstance  that  the  contractions  of  the  uterine  muscles,  like  those  of  all  the 
hollow  viscera  of  the  body,  are  peristaltic,  and  that  the  rhythmic  contraction 
of  the  uterus  begins  at  the  fundus  and  passes  gradually  down  to  the  cervix. 
Each  contraction  of  a  given  part  of  the  uterus  is  preceded  and  followed  by  a 
relaxation ;  but  since,  from  t!ie  interlaced  arrangement  of  the  fibres  of  the 
uterus,  the  contraction  of  any  portion  of  its  surface  necessarily  exerts  a  longi- 
tudinal strain,  it  will  be  found  that  the  outward  stress  upon  the  margins  of 
the  OS  remains  nearly  constant,  while  its  circular  contraction  is  intermittent ;  it 
is  probable  that  the  initial  dilatation  of  the  os  is  largely  due  to  the  constancy 
of  the  longitudinal  and  the  intermittoncy  of  the  circular  strain  ;  that  is,  the 
first  gains  in  dilatation  are  made  at  moments  when  the  uterine  muscles  of  the 
lower  uterine  segment  and  the  cervix  are  relaxetl,  but  when  the  general  fiuid- 
pressure  is  maintained  by  contractions  of  the  unper  ])ortions  of  the  uterus. 

As  the  internal  os  and  the  upper  ])ortion  of  the  cervix  dilate  under  the 
action  of  these  forces,  a  new  mechanism  comes  into  play  through  the  elasticity 
of  the  membranes,  which  bulge  through  the  circle  of  the  os  and  enable  the 
intra-uterine  fluid-pressure  to  take  direct  effect  upon  its  margins.  As  this 
process  continues  the  internal  os  becomes  effaced,  the  cervix  is  shortened  and 


■m 


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Fif!.  237.— DiiiKram  illustrntiiiK  the  dilatntion 
of  the  OS  by  tlic  niumbrancs.  If  the  npplication  of 
the  lliiid-pressure  to  tlio  os  {(it  riKht  nntiles  to  the 
surface  of  tlie  nieinbranes  at  tliis  point)  is  repre- 
sented by  the  direction  of  the  arrow,  and  the 
amount  of  the  force  liy  the  length  of  tlie  diagonal 
line  wliieli  continues  the  arrow,  the  amount  of 
force  tliat  Is  api>licable  to  tlie  dilatation  of  the  os 
is  represented  by  tlie  length  of  the  line  A. 


Fiii.  2.18.— Diagram  illustrating  the  dilata- 
tion of  the  OS  by  the  membranes.  All  the  con- 
ditions are  identical  with  those  of  Figure  'Jl!7,  ex- 
cept that  the  membranes  have  a  greater  con- 
vexity;  tlie  direction  of  the  arrow  is  therefore 
more  obli<iue,  and  the  force  ellicient  for  dila- 
tation, represented  by  the  line  a,  is  greatly  In- 
creased. 


disappears,  and  finally  the  external  os  itself  is  in  direct  contact  with  the  mem- 
branes and  begins  to  receive  directly  the  effect  of  the  longitudinal  stresses.  As 
the  external  os  dilates  the  membranes  again  bulge  forward  into  its  lumen,  and 
the  force  of  the  fluid-j)ressure  becomes  directly  active  upon  its  margins.  The 
force  so  exerted  is  directly  proportional  to  the  convexity  of  the  membranes, 
and  increases  as  the  convexity  increases — a  fact  which  is  explainable  by  well- 


THE   MECHANISM   OF  LABOR. 


427 


known  physical  laws  as  follows :  The  force  of  fluid-jiressuro,  in  addition  to 
being  opposite  and  equal  at  all  points,  is  always  exerted  at  right  angles  to 
any  surface  against  which  it  is  applied.  If  it  is  necessary  to  ascertain  what 
portion  of  the  force  is  exerted  in  any  given  direction,  it  is  only  necessary  to 
break  up  the  internal  force  into  its  elements  by  the  construction  of  a  parallelo- 
gram of  forces,  such  as  is  described  in  all  elementary  treatises  on  niechanics  and 
illustrated  in  Figures  237  and  238.  Figure  237  exhibits  the  influence  of  the 
general  intra-uterine  fluid-pressure  when  the  conditions  of  the  case  allow  but  a 
slight  convexity  to  the  unsupported  portions  of  the  membranes.  The  expan- 
sive element  of  the  fluid-pressure  is  here  represented  by  the  line  A,  while  in 
Figure  238,  where  the  convexity  of  the  unsu])p()rted  membranes  is  much 
greater,  the  expansive  element  of  the  force  will  be  represented  by  the  length 
of  the  much  longer  line  A  :  from  this  it  follows  that,  other  things  being  equal, 
the  rapidity  of  dilatation  will  be  proportional  to  the  degree  to  which  the  mem- 
branes project  through  the  os.  As  will  be  seen  later,  the  same  considerations 
are  equally  applicable  to  the  action  of  the  head  in  producing  dilatation  after 
the  rupture  of  the  membranes.  The  familiar  clinical  fact  that  the  closing 
stages  of  dilatation  are  usually  much  more  rapid  than  the  beginning  stages  is 
fully  explained  by  the  foregoing  considerations,  taken  in  connection  with  the 
equally  familiar  fact  that  the  contractions  of  the  uterus  tend  normally  to 
become  stronger  and  stronger  throughout  the  process  of  labor. 

In  the  more  normal  form  of  the  mechanism  of  the  first  stage — that  is,  so 
long  as  the  membranes  remain  intact — the  progress  of  the  first  stage  of  labor 
is  dependent  maiidy  upon  the  first  form  of  force  which  the  uterine  muscle  is 
capable  of  exerting — that  is,  the  force  of  the  general  intra-uterine  fluid-pres- 
sure— and  the  membranes  are  the  dilating  agent. 

The  second  form  of  force,  that  of  the  direct  pressure  of  the  uterine  muscle 
against  the  child,  is  under  these  circumstances  inoperative,  while  the  fact^that 
the  voluntary  muscles  of  the  abdominal  walls  are  but  seldom  brought  into 
j)lay  by  the  patient^ reduces  the  action  of  the  remaining  or  auxiliary  forces,  in 
this  form  of  the  mechanism  of  the  first  stage,  to  the  small  reinforcement  of 
the  general  intra-uterine  fluid-pressure,  which  is  due  to  the  general  intra- 
alxlominal  pressure  constantly  exerted  by  the  tonicity  of  these  muscles. 

Mechanism  of  Dilatation  of  the  Os  after  Rupture  of  the  Membranes, 
with  Partial  or  Complete  Escape  of  the  Waters. — Partial  Encape. — After 
the  rupture  of  the  membranes  the  liquor  amnii  tends  to  drain  away  until  its 
escape  is  stopped  by  the  contact  of  the  presenting  j>art  with  the  margins  of 
the  OS  (Fig.  239).  In  this  condition  the  presenting  i)art  forms  with  the  circle 
of  the  OS  a  ball-valve ;  the  general  intra-uterine  pressure  is  concentrated  upon 
its  upper  surface,  and  its  descent  is  opposed  only  by  the  comparatively  feeble 
resistance  of  the  cervix.  When  this  condition  occurs  the  portions  of  the 
fetus  that  correspond  with  arrows  marked  A'  and  li'  are  still  affected  by  pres- 
sures whicih  are  opposite  and  exactly  equal  to  the  propelling  force  exerted 
upon  the  portions  which  correspond  with  the  arrows  A  and  B,  but  the  propel- 
ling force  represented  by  the  arrow  C  is  opposed  only  by  the  resistance  of  the 


mm  I 


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428 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


unsupported  cervical  and  vaginal  tissues,  against  which  the  head  is  pressed  by 
a  force  equal  to  the  effect  of  the  intra-uteriue  fluid-pressure  upon  an  area 

c 


Fio.  239.— DiaRram  illustratlnf;  the  mnnner 
in  which  the  gviieral  intru-utiTiiie  fluid-pri'ssure 
lioconu's  propulsive  after  the  rupture  of  the 
memlinmes. 


Fig.  240.— PiaRram  illustrating  the  dilatation  of 
the  OS  by  the  head.  The  total  force  is  again  repre- 
sented by  the  oblique  line,  and  the  force  which  is  ap- 
plicable for  dilatation  is  represented  by  the  line  .rl. 


equal  to  the  transverse  area  of  that  zone  of  the  uterus  whore  the  head  Hrst 
conies  in  contact  with  the  walls — that  is,  the  surface  R  to  R'. 

From  the  coni])arative  rigidity  of 
the  spherical  head  it  can  exert  but  little 
direct  expan.^ive  force  upon  the  margins 
of  the  OS  during  the  early  stages  of 
dilatation  (Fig.  240) — a  fact  which  ex- 
plains admirably  the  relatively  slow 
progress  of  dilatation  after  early  rup- 
ture of  the  membranes.  When,  how- 
ever, the  OS  has  so  far  dilated  as  nearly 
to  admit  the  greatest  circumference  of 
the  head,  its  action  is  that  of  a  slightly 
tapering  wedge,  by  which  almost  the 
whole  power  of  the  propelling  force  is 
transmitted  into  an  outward  pressure 
of  the  margins  of  the  os,  and  which 
must  compel  an  extremely  rapid  com- 
pletion of  the  dilatation  *  (Fig.  241). 
It  will  be  seen  that  in  this  second  form  of  the  mechanism  of  the  first  stage 
the  force  employed  i.s  still  that  of  the  general  intra-uterine  fluid-pressure,  but 
that  the  dilating  agent  is  now  the  head. 

*  It  will  be  seen  tliat  this  fact  is  an  adequate  explanation  of  the  greater  frequency  of 
laceration  of  tlie  cervix  when  a  rupture  of  the  membranes  results  in  the  completion  of  the 
dilatation  by  the  direct  pressure  of  the  rigid  head. 


Fio.  241.— PiaRram  illustratinR  the  diliitation 
of  the  OS  by  the  head.  The  total  force  is  repre- 
sented by  tlie  obli<iue  line,  and  the  force  applic- 
able for  dilatation  is  represented  by  the  line  A. 


THE  MECHANISM   OF  LABOR. 


429 


After  Complete  Escape*  of  the  Waters. — The  escajie  of  auy  considerable 
quantity  of  tlie  waters  usually  results  in  contruotiou  of  the  uterus  sufficient  to 
iKjrmit  of  firm  contact  between  the  fundus  and  the  breech  of  the  child.  The 
ibrce  of  this  contact  is  then  transmitted  to  the  head  through  the  vertebral 
(ioluinn  of  the  fetus.  At  first  sight  it  seems  unlikely  that  any  considerable 
force  could  be  transmitted  through  so  flexil)le  a  rod  as  the  vertebral  column  of 
an  unborn  child.  This  transmission  is,  however,  rendered  possible  by  the 
ibllowing  conditions:  It  is  an  observed  fa(!t  that  during  a  contraction  the  long 
diameter  of  the  uterus,  far  from  being  decreased,  is  actually  lengthened.  This 
l)henomenon  is  due  to  the  superior  strain  of  the  circular  stresses,  which  by 
tlieir  greater  force  decrease  the  antero-posterior  diameter  of  the  uterus  and 
thereby  f  increase  its  length  (Figs.  242,  243) ;  the  lateral  uterine  walls,  at  the 


Fio.  242.— Diagram  illustrating  the  alteration  Fio.  213,— Diagram  illustrating  ttic  alteration 
i^the  shape  of  a  oross-seetion  of  a  uterus  during  in  the  shape  of  a  sagittal  seetion  of  the  litems 
its  eontraetions.  The  heavy  line  represents  the  during  its  eontraotions.  The  heavy  line  repre- 
non-eontracted,  the  dotted  line  the  contracted,  sents  the  non-contracted,  the  dotted  line  the  con- 
uterus  (compare  Fig.  213).  tracted,  uterus. 

same  time,  come  into  strong  contact  with  the  siu'face  of  the  fetal  body,  and  so 
straighten  out  the  child,  thus  increasing  the  violence  of  the  contact  between 
the  breech  and  the  fundus,  and  affording  a  firm  supporting  surface  which  pre- 
vents any  bending  of  tlie  vortebne,  and  converts  the  backbone  for  the  moment 
into  a  mechanically  rigid  rod  which  is  fully  capable  of  the  transmission  of 
force.  When  this  form  of  mechanism  obtains,  the  head  acts  as  the  dilating 
wedge,  and  the  second  form  of  force,  that  furni.shed  by  direct  contact  between 
the  breech  and  the  finidus,  is  alone  active. 

Mechanism  of  Dilatation  of  the  Os  with  Originally  Scanty  Waters. — 
It  occasionally  happens  that  the  waters  are  originally  so  .scanty  in  amount  as  to 
])ermit  direct  contact  between  the  breech  and  the  fmidus  to  occur  early  in  the 
first  stage.  Under  these  circumstances  the  head  is  brought  into  close  contact 
with  the  OS  at  the  beginning  of  labor.  The  nuH^hanical  conditions  are  now 
clo.sely  similar  to  those  which  obtain  after  the  escape  of  the  waters,  with  the 
single  exception  that  if  the  membranes  are  tough  and  inelastic  their  tension 
may  somewhat  impede  the  progress  of  the  head. 

*  This  term,  though  conventional,  is  inaccurate,  tis  tliere  is  almost  always  some  liquor  left  in 
the  uterus. 

t  The  ovum  being  incompressible. 


I 


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AMERICAN   TEXT-BOOK  OF   OBSTETRICS. 


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Mechanism  of  Dilatation  with  Undue  Elasticity  of  the  Membranes. — 

If  the  membranes  are  unusually  elas- 
tic, it  may  sometimes  happen  that  after 
the  formation  of  a  considerable  pouch 
of  membranes  in  advance  of  the  head, 
the  volume  of  the  uterine  contents 
may  be  lessened  sufficiently  to  permit 
the  head  itself  to  be  brought  into  close 
contact  with  the  margins  of  the  os, 
by  the  force  of  a  perhaps  temporary 
direct  contact  between  the  breech  and 
the  fundus.  In  this  jiosition,  if  the 
head  is  in  contact  with  the  entire  mar- 
gin of  the  OS,  it  forms  with  it  a  ball- 
valve  by  which  the  "  fore-waters  "  are 
entirely  cut  oif  from  the  uterine  con- 
tents. The  pressure,  C  (Fig.  244),  is 
now  opposed  only  by  the  elasticity  of  the 
membranes  and  of  the  vaginal  tissues. 
The  general  fluid-pressure  is  no  longer 
exerted  against  the  margins  of  the  os, 
and  the  conditions  are  mechanically  sim- 
ilar to  those  illustrated  in  Figure  239. 


Fio.  244.— ningrain  illustratiDg  the  formation 
of  a  biill-valve  by  fontact  between  the  lieail  and 
the  edges  of  the  os.  The  waters  behind  the  head 
are  exposed  to  the  general  intrauterine  fluid- 
pressure,  while  the  fluid-pressure  in  advaneeof 
the  head  is  only  created  by  tlie  elasticity  of  the 
fetal  membranes. 


B.  Mechanism  of  the  Second  Stage  of  Labor  in  Vertex  Presentations, 

O.  L.  A. 

The  second  stage  of  labor  is  commonly  dividal  into  three  sub-stages : 
The  descent  and  expulsion  of  the  head ;  external  restitution  ;  and  the  delivery 
of  the  trunk. 

The  adaptation  between  the  normal  head  and  the  pelvis  is  so  close  that  for 
the  accomplishment  of  the  de.«icent  and  expulsion  of  the  head  there  is  retpiired 
the  occurrence  of  a  set  of  somewhat  complicated  movements  which  are,  in  fact, 
e.s.sentially  one  single  complex  motion.  This  motion  consists  of  three  elements : 
(1)  The  descent  of  the  head  tiirough  the  pelvis;  (2)  a  change  from  the  partially 
extended  position  which  the  head  normally  occupies  at  the  beginning  of  labor 
to  one  of  complete  flexion ;  and  (3)  lateral  rotation  of  the  head  within  the 
canal,  from  the  oblique  j)osition  which  the  suboccipito-bi'egnmtic  diameter 
occupies  at  the  brim  to  the  antero-posterior  position  in  which  it  emerges  from 
the  outlet.  Although  it  is  necessary  in  discussing  this  motion  to  describe  its 
components  separately,  it  must  not  be  forgotten  that  no  one  of  its  parts  am 
proceal  to  its  accomplishment  without  the  coexistence  of  the  others.  Thus, 
descent  can  be  accomplished  only  during  the  existence  of  flexion,  while  flexion 
is  produced  only  by  tlie  act  of  descent.  So,  too,  the  final  stage  of  descent, 
known  as  expulsion,  is  normally  imj)ossible  without  rotation,  while  rotation 
occurs  only  during  the  descent  of  a  fully-flexed  head.     The  most  intelligible 


THE   MECHANISM   OF  LABOR. 


431 


wav  of  (loscribing  these  highly  complex  phenomena  is  by  a  chronological  study 
of  the  mechanical  conditions  which  occur  and  succeed  each  other  during  the 
stage  of  descent  and  expulsion. 

Descent. — It  is  necessary,  in  doscyibing  the  mechanism  of  the  second  stage, 
to  iK'gin  by  considering  tlie  action  of  tiie  forces  by  which  the  mechanism  of 
this  stage  is  effected.  So  long  as  the  fetus  is  exposed  on  all  sides  to  contact 
with  the  liquor  amnii,  the  contractions  of  the  uterine  and  alxlominal  muscles 
can  produce  no  effect  upon  it  other  than  that  of  subjecting  it  to  a  uniform 
fluid-pressure,  equal  and  opposite  in  all  directions.  In  point  of  fact,  the  mech- 
anism of  descent  does  not  begin  until  the  presenting  part  is  cut  off  from  the 
liquor  amnii  by  coming  into  apposition  with  the  edges  of  the  os.  As  was 
implied  in  the  last  section,  this  contact  may  happen  in  cither  of  two  ways: 

First :  AVhen  the  mechanism  of  the  fii-st  stage  is  such  that  the  head  comes 
into  close  contact  with  the  margins  of  the  os  before  any  considerable  quantity 
of  the  liquor  amnii  has  escaped  from  the  uterus,  it  forms  with  the  os  a  ball- 
valve  (p.  430),  by  which  the  remaining  part  of  the  waters  is  retained  witiiin 
the  uterus;  and  the  occurrence  of  descent  is  then  the  result  of  the  action  of 
tlie  intra-uterine  fluid-pressure.  Tiiis  is  the  nomial — that  is,  the  most  usual 
and  the  most  favorable — rnechaniwi  of  descent. 

Second  :  AVhen  close  contact  between  the  head  and  the  os  does  not  occur 
luitil  after  tiic  complete  escape  of  the  waters,  the  uterine  muscle  contracts  upon 
the  child,  and  the  force  of  the  circular  stresses  (p.  425)  is  lost  so  far  as  the 
production  of  descent  is  concerned,  but  the  breech  and  the  fundus  of  the  uterus 
come  into  contact  with  each  other,  and  the  force  of  the  longitudinal  stresses  is 
thus  still  available.  This  second  form  of  the  njechanism  of  the  second  stage 
is  commonly  called  a  "dry  labor,"  and  such  labors  are,  with  reason,  much 
dreaded  by  obstetricians,  because  the  loss  of  the  powerful  circular  stresses 
usually  leads  to  a  protracted  second  stage. 

Normal  Mechunmn  of  Descent. — The  portion  of  the  head  that  is  without 
the  uterus  (/J,  R',  Fig.  239)  is  opposed  only  by  the  resistance  of  the  vaginal 
tissues.  Every  other  portion  of  the  fetus  is  exposed  to  the  general  intra-uterine 
fluid-pressure.  If  it  is  remembered  that  fluid-pressures  are  always  equal  and 
opposite,  it  will  be  seen  that  the  forces  A  and  B  are  directly  neutralized  by  the 
forces  A'  and  B\  and  that  the  force  C  is  opposed  only  by  the  comparatively 
trifling  resistance  of  the  vaginal  tissues.  This  force  (C)  is  then  practically 
unop])osed,  and  is  therefore  efficient  for  descent. 

Mechanism  of  Descent  in  Dry  Labors,— When  the  escape  of  the  waters  has 
permitted  the  uterus  to  contract  upon  the  child,  the  advance  of  the  present- 
ing part  is  opposed  only  by  the  vaginal  tissues,  and  is  favored  by  the  force 
of  all  the  longitudinal  stresses  of  the  uterine  muscle;*  but  unless  the  descent 
progresses  rapidly  a  localized  contraction  (p.  429),  due  to  the  unopposed  action 
of  the  circular  stresses,  leads  to  a  lessening  of  the  calibre  of  the  uterine  canal 
at  any  point  where  the  diameter  of  the  child  is  small — for  example,  the  neck 
(Fig.  245) — and  the  descent  of  the  child  is  then  further  opposed  by  the  fact 
*  And  by  the  auxiliary  eflbrts  of  the  abdominal  muscles. 


415-^ 


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i-f) 


iV.  <V' 


432 


AM  ERIC  AX   TKXT-JiOOK   OF   OliSTETRICS. 


that  the  shouklors  must  bo  niado  to  dilato  this  riiij; — that  is,  to  overcome  the 
tonic  contraction  of  tlie  circMilar  stresses.  In  dry  labors,  then,  the  force  of  the 
circuhir  stresses  is  not  only  lost  as  a  factor  in  the  jiroduction  of  descent,  but 
niay  sometimes  also  be  opposed  to  it.  ^ 

Flexion. — At  fii*st  sight  it  would  seem  that  the  only  result  to  be  expected 
in  either  case  would  be  tiie  occurrence  of  descent,  and  that  as  the  head  is 
normally  somewhat  extended  at  the  beginning  of  lal)or,  this  descent  would 
oppose  to  the  iielvic  diameters  the  always  ditH<'ult  and  frequently  impossible 
occipito-frontal  diameter.  A  somewhat  more  careful  examination  will  demon- 
strate, however,  that  the  propelling  and  opposing  forces  are  already  so  dis- 
posed upon  the  head  as  to  favor,  from  the  start,  the  occurrence  of  flexion,  and 
that  the  first  movement  of  descent  will,  under  normal  circumstances,  tend  to 
bring  to  the  brim  the  much  smaller  suboccipito-bregmatic  diameter.  To  this 
end  two  factors  contribute  :  first  and  most  important,  the  articulation  of  the 


\^l 


V 


W\  '    ! 


Fi(!.  21').— Constru'tion-rinn  about  tho  lu'ck  of  tlie  child 
(oni'-.>iixtli  niitiiral  size). 


Fig.  'J4(>.— Piannnn  of  head  lover. 


vertebral  column  to  the  skull  at  a  point  much  nearer  to  the  occipital  than  to 
the  frontal  end  of  the  head  ;  second,  the  mechanical  effects  of  the  irregular 
shajjc  of  the  skull. 

Unequal  Lenyths  of  the  Ends  of  the  Hmd, — The  effects  of  the  excentric 
position  of  the  occipito-atlantoid  articulation  iiujst  be  investigated  separately 
for  each  of  the  three  forms  of  force  that  may  be  active — that  is,  for  the  force 
of  gravity,  the  general  fluid-pressure,  and  the  force  of  direct  contact  with  the 
uterine  muscle. 

Force  of  Grarlti/. — Whenever  the  force  of  gravity  is  active,  it  is  evi- 
dent that  the  weight  of  the  body  will  be  transmitted  to  the  skull  through 
the  occipito-atlantoid  articulation.  If  the  fetal  head  is  supjmsed,  at  the  begin- 
ning of  this  motion,  to  occupy  a  position  midway  between  extension  and 
flexion,  the  occipital  and  sincij)ital  ends  of  the  head,  marked  o  and  F  resjK>ct- 
ively  (Fig.  246),  will  rest  against  the  uterine  walls,  while  the  force  A  is  applied 
at  the  occipito-atlantoid  articulation.     Since  the  force  is  applied  nearer  to  the 


THE   MKCUANISM   OF  LAJiOJi. 


433 


occipital  end  of  the  head,  it  is  evident  that  a  greater  nmoimt  of  impulse  will 
be  conuminicatetl  to  the  occiput;  and  since  the  resistances  an;  of  nc(!es,sity 
(■(pial,  the  occij)ut  will  tend  to  advance  more  rapidly ;  hut  advance  of  the 
occiput  with  relative  delay  of  the  sinffput  is,  in  effect,  flexion.  The  head,  in 
fact,  becomes  a  lever  of  the  third  class,  in  which  tiie  pressure  of  the  resist- 
ances applied  to  tiie  longer  end  is  more  effective  in  delaying  progress  than  the 
cijual  pressure  applied  to  the  shorter  end  of  the  lever. 

It  is  further  to  be  noticed  that  as  flexion  progresses  the  relation  between 
the  lengths  of  these  arms  is  so  altered  as  to  make  them  progressively  more 
unequal,  so  that,  as  the  head  flexes,  the  point  at  which  the  pressure  of  the 
resistance  is  applied  to  the  occipital  end  of  the  head  becomes  progressively 
nearer  to  tlie  vertebral  articulation. 

General  Infra-uterine  FtuUl-pressurei — If  Figure  247  represents  the  situ- 
ation of  the  child  at  the  end  of  the  first  stage,  we  see  that  the  forces  A  and  B 
are  applied  directly  and  with  equal 
force  to  the  ends  of  the  head  ;  but  it  is 
evident  that  the  pressure  (C)  exerted 
upcm  the  breech  of  the  infant  will  be 
transmitted  to  the  head  more  readily 
by  the  vertebral  column  than  by  the 
soft  tissues  of  the  trunk,  and  that  a 
large  portion  of  this  force  (C)  must 
therefore  be  conceutrated  on  the  con- 
dyles. So  far  as  this  force  (C)  is  con- 
cerned, the  argument  used  in  ex{)lain- 
ing  the  i)roduction  of  flexion  by  the 
influence  of  gravity  applies,  then,  with 
ecjUiU  force  to  this  condition. 

Direct  Contact  between  the  Breech 
(tnd  the  Fundus. — The  whole  effect  of 
a  direct  pressure  upon  the  breech  by  the 
fundus  will  be  applied  to  the  condyles 
of  the  occiput,  and,  the  resistances  ujion 
the  occiput  and  sinciput  being  of  neces- 
sity equal,  w'hile  the  o])posing  forces 
are  concentrated  at  a  point  much  nearer 
tiie  occiput,  it  is  evident  that  the  occipital  end  of  the  head  will  tend  to 
advance  more  rapidly  than  the  frontal  end  ;  but  advance  of  the  occiput  with 
relative  or  absolute  delay  of  the  sinciput  of  course  results  in  flexion. 

Irregidar  Shape  of  the  Fetal  Skidl. — The  occurrence  of  flexion  is  like- 
wise aided  by  the  second  factor  referred  to  above,  the  irregular  shape  of  the 
skull.  As  will  be  seen  by  analysis  of  the  opposing  forces  exerted  at  R  and  B' 
(Fig.  248),  if  the  effect  of  the  equal  resistances  at  R  and  B'  be  represented  by  the 
length  of  the  equal  lines  S  and  S'  drawn  perpendicular  to  the  surface  of  the 
skull  at  these  points  (the  direction  in  which  these  resistances  must,  according 
28 


Fio.  247. —Diagram  illustrutint?  the  upplicdtion 
of  n  prepoiidurnncL'  of  tlii'  intra-uterini'  Huid- 
prossnro  to  the  occipital  cml  of  tlio  licad.  It  is 
evident  from  tlie  condition  of  tlie  lioad  lever  (see 
FiR.  2lti)  tliat  the  sinciimt  is  exposed  to  Ihe  force 
H,  ])lns  a  small  proportion  of  the  force  C,  while 
the  occiimt  receives  the  force  .1,  plus  the  greater 
part  of  the  force  C. 


•I ;' 


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434 


A^fi:iU('AX  TKXT-jiooh'  OF  oiisrKTiirrs. 


\\ 


to  wi'll-kimwii  inccliiiiiical  laws,  Itc  i-xcrtod),  the  coiistnictioii  of  tlu;  imrallcl- 
of^ram  of  fonrs  sliows  that  tlic  line  T  (wliose  length  represents  the  |)ortioii 
of  the  resistance!  H  which  is  exerted  in  direct  opposition  to  desc<!nt)  is  much 
greater  than  that  of  the  line  T*  (which  represents  the  efficient  proportion 
of  the  resistance  A'').  From  this  it  is  (;vident  that  the  occipital  end  (tf  the 
head  is  exposed  not  only  to  greater  force  from  ahove,  hut  also  to  less  resistance 
from  below,  while  the  sincipital  end  is  opposed  by  greater  resistance  and 
receives  u  less  amount  of  propulsive  power — conditions  which  can  only  result 
in  a  more  rapid  advance  of  the  iK'ciput. 

As  soon  as  partial  flexion  has  heen  acconijdished  a  second  etlect  of  the 
irregular  shape  of  the  head  comes  into  play,  and  there  must  he  accorded  stich 
importance  as  is  due  to  it,     Figiu'e  241)  represents  a  partially-flexed  head 


t  \ 


I; 


•  w 


if/ 


Fki.  248.— DlnRrnm  illustrntlnir  the  Influonco  of  Vw.  249.— DinKrnin  illustrating  thi-  sccoml- 

the  irreKiilnr  shape  nf  the  skull  in  imHlueiuK  tlexidu,  iiry  etleet  of  the  irregular  shiipc  of  the  head  in 

hy  the  eonstruetion  of  the  parallelonrani  of  forees.  i)roniotlng    ilexion   after   partial    flexion    \\i\s 

It  i.s  seen  that  the  forre  whieh  dilates  the  siiieiput,  once  been  produced, 

represented  hy  the  line  T,  is  greater  than  the  foree 
whieh  dilates  theoeriput,  represented  by  the  line  T, 
which  represents  tlie  sinciput. 

engaged  in  the  elastic  canal  formed  by  the  lower  uterine  segment  and  the 
vagina.*  The  forces  A  and  B,  due  to  the  con.striction  of  the  ela,stic  canal  in 
which  the  head  lies,  and  acting  neces.sarily  at  right  angles  to  the  surface  of 
contact,  will  then  form  a  pair  of  equal  but  not  opposite  forces — in  mechanical 
language  "  a  couple  " — the  effect  of  which  is  to  rotate  the  head  upon  a  tnms- 
ver.se  axis  at  C,  thus  increasing  its  flexion. 

It  will  be  noticed  that  all  these  causes  of  flexion f  are  dependent  for  their 
existence  on  the  presence  of  resistances  acting  in  opposition  to  the  vis-a-tcrr/o 
M-hich  urges  the  head  downward,  and  it  necessarily  follows  from  this  fact  that 
flexion  occurs  most  rapidly  and  becomes  most  marked  when  the  resistances 
are  best  developed — a  theoretical  consideration  which  is  in  thorough  accord 
with  the  observed  fact  that  there  is  often  a  temporary  lo.ss  of  flexion  in  the 
excavation,  where  the  space  is  the  greatest;  that  i.s,  that  flexiolTis  generally 
better  marked  while  the  head  is  experiencing  the  well-developed  resi.stapces  of 

*  The  fiict  that  the  vaginal  walls  pos-ses-s  at  the  end  of  pregnancy  intrinsic  muscles  of  con- 
siderable development,  though  too  often  wholly  neglected  in  the  consideration  of  the  mechan- 
ism of  labor,  is,  notwithstandini;,  an  element  in  the  production  of  flexion  that  must  not  he 
forgotten. 

t  Except  the  last  and  least  important. 


77/ A'   MHCJIAXISM    OJ'    hMiOli. 


435 


tlic  fdiperior  stniit  than  in  the  excavation,  where  the  nwistanees  are  less.  So, 
too,  Hexioii  ajjaiii  increases  when  the  heail  reaches  the  inferior  strait.  Flexion 
is,  in  iiict,  nurnially  more  marked  in  this  part  of  tiie  pelvis  than  in  uny 
other;  Imt  here  another  factor  comes  into  play. 

We  have  previonsly  seen  Hexion  produced  by  the  action  of  the  pro|)ellinj; 
(iirces  ajj;aiiist  resistances  which  were  exerted  with  approximately  eipial  force 
im  hoth  the  occij)nt  and  the  sinciput ;  but  when  the  head  reaches  the  inferior 
strait  its  occipital  end  rapidly  frees  itself  from  the  pressures  of  the  bones,  and 
is  opposed  only  l)y  the  resistances  of  the  soft  parts  of  the  pelvic  floor,  while 
the  sinciput  is  still  exposed  to  the  firm  resistance  of  the  l)ony  sacrum.  It  is 
evident  that  when  the  greater  pressure  is  exerted  on  the  longer  arm  of  the 
lever  extreme  flexion  is  a  necessary  result.  The  mechanical  explanation  is 
tliiis  in  complete  agreement  with  the  clinical  fact  that  the  deeper  is  the  engage- 
ment of  the  head,  the  more  marked  is  the  tendency  to  flexion  and  the  greater 
is  the  certainty  ^■>i'  its  accomplishment.  ^ 

Rotation.-  f he  movements  of  descent  and  flexion  make  up  the  whole 
iiK'chiuiism  of  the  earlier  part  of  the  second  stage  of  labor ;  but  another  factor 
— rotation — is  necessary  to  its  completion. 

The  mechanism  of  rotation  is,  unfortunately,  extremely  difficult  of  com- 
])rehension ;  and,  as  nothing  is  more  difficult  than  to  teach  mechanical  prob- 
lems involving  the  use  of  three  dimensions  without  the  aid  of  models,  the 
student  will  be  wise  if  he  supplements  the  words  and  figures  of  any  written 
description  by  a  constant  inspection  of  the  dried  pelvis  and  by  the  results  of  the 
iiitrapelvic  touch  in  actual  clinical  work.  A  complete  comprehension  of  the 
mechanism  of  rotation  is  seldom  acquired  in  any  other  way.  The  student 
iiuist,  at  all  events,  grasp  the  fiuidamental  flict  that  it  does  occur,  and  nuist 
(ihcuj/n  occnr,  before  expulsion  can  take  place. 

The  hea<l  enters  obliquely  because  the  oblicjue  diameters  are  the  largest  at 
the  superior  strait,  but  it  must  emerge  in  an  antero-posterior  position — that 
is,  with  the  sagittal  suture  opposed  to  the  antero-posterior  diameter  of  the 
outlet — because  the  antero-posterior  diameter  is  the  largest  at  the  outlet.  The 
movement  by  which  the  oblique  position  at  the  brim  is  converted  into  an 
antero-posterior  position  at  the  outlet  is  known  obstetrically  as  rotation. 

To  understand  the  mechanism  of  rotation  it  is  necessary  to  remember,  first, 
that  with  good  flexion  (without  which  rotation  does  not  occiu')  the  occipital 
end  of  the  head  is  on  a  lower  level  than  the  sincipital ;  that  is,  the  occiput 
receives  the  pressure  of  the  loicev  portion  of  the  anterior  part  of  one  lateral 
wall,  while  the  sinciput  receives  the  pressure  of  the  tipper  portion  of  the  pos- 
terior part  of  the  other  lateral  wall.  Secondly,  it  is  necessary  to  remember 
accurately  the  shape,  depth,  and  direction  of  the  spiral  grooves  described  on 
page  396  (Fig.  218).  Thirdly,  it  must  not  be  forgotten  that  whenever  one 
end  of  the  head  executes  a  movement  of  rotation,  its  other  end  must,  of  course, 
move  simultaneously  in  the  opposite  direction.  As  the  head  enters,  ().  L.  A., 
in  the  usual  position  of  moderate  flexion  at  the  brim,  the  occiput  is  necessarily 
ill  contact  with  the  upper  part  of  the  anterior  groove  upon  the  left  side  of  the 


'^Jl'n 


w 


r 


436 


AMERICAN   TKXT-liOOK    OF    OJiSTETRICS. 


pelvis ;   tlioufifli  the  jrrodvo  is  Ium'o  slitillow,  the   occiput  is  unable  to  move 
away  from  it,  because  the  bregiuatic  rej^ion  lies  at  this  time  in  the  deep  sacro- 


'¥/'        C-rTix  ,Hlat,,i.  Ii.-iui , 


O^^'***^^ 


l'"iu.  aw,— rositioii  111'  till'  lu'iid  in  tho  iiil'iTior  strait  al'tiT  (tiiiipli'te  mtaticiii.  Tlio  tnl)eri)sitios  of  llic 
ischi;i  )ir»^voiit  any  furtlicr  mtiuy  nuivoincnt,  wliilr  liirtliiT  (k'M'ont  is  oppusoil  mily  l)y  tlie  soft  |mits 
(one-tliiril  natural  si/.i'). 

iliac  notch  on   the   rii^ht  side.     As  descent   sjoes  m\  the  occiput  enters  the 
anterior  ijroove  more  fully — that  is,  it  reaches  the  j)oint  at  which  the  i:;roovc 


Flu.  ■-'.M.— Forward  motion  of  tln'  licad  diirlnn  tlu'  stauo  of  cximlsion  iindiT  the  iiitluiMifL'  of  tlic  forwiird 
thrust  uf  tlu'  sacniin  and  tlic  pilvic  lioor  (ono-slxtli  natural  size). 

is  too  deep  to  permit  an  easv  escape  of  the  occiput  from  its  guidance — and  l)v 
the  time  the  occiput  approaches  the  point  where  the  groove  turns  forward,  aii<l 


THE   MEVIIANJSM    OF   LA  HOP. 


437 


where  it  imi^t  itself  turn  lorward  to  avoid  tlie  pressure  of  the  projoeting  iliac 
spine,  the  suboecipito-froutal  diameter  is  in  the  brim  and  the  sinciput  is  in  the 
sacro-iliae  notch.  With  the  next  movement  of  descent  the  sinciput  slips  below 
ihe  promontory  mid  is  in  contact  with  the  upper  and  shallow  part  of  the  pos- 
terior groove  on  the  right  side.  The  oc^cipito-frontal  diameter  now  occupies 
the  extremely  large  oblique  diameter  of  the  excavation,  and  the  posterior  tnlge 
of  the  groove  in  which  the  sinciput  lies  is  here  so  ill  marked  that,  with  the  great 
space  afforded  by  the  oblicpic  diameter  of  the  excavation,  it  would  be  au 
extremely  easy  matter  for  the  sinciput  to  slip  backward  into  the  hollow  of  the 
sacrum  if  any  forw  tending  in  this  direction  were  ••.pplied.  This  force  is,  in 
fact,  applied  as  a  result  of  the  tendency  of  the  occiput  to  turn  forward  along 
the  course  of  the  anterior  groove  of  the  lel't  side,*  under  the  impulse  furnished 
hv  the  pressure  of  (he  projecting  iliac  spine  against  the  posterior  surface  of  the 
occipital  end  of  the  head.  JJut  when  the  sinciput  has  once  slipped  backward 
in  this  way  into  the  hollow  of  the  sacrum,  there  is  nothing  left  to  prevent  the 
occiput  from  turning  still  farther  forward,  until,  as  it  reaches  the  metliaii 
line,  it  receives  the  thrust  of  the  other  side  of  the  pelvis,  and  is  steadied  in  its 


Kiii.  'J.')'.'.— Ilciut  (liiriiiK  (listontinii  of  tlii'  iH'Ivic  lliior  iiftor  nitiitiun.  witli  lioKinniiiK  oxtonsiim  (Smi'llio). 

median  position  by  its  reception  of  e(pial  pressures  on   each  side  from  the 
descending  rami  of  the  pubes  and  the  tuberosities  of  the  ischium. 

Expulsion. — The  parietal  bosses  now  lie  in  contact  with  the  tuberosities  of 
the  ischium.  The  narrow  temporal  diameter  corresponds  with  the  narrow  trans- 
verse diameter  of  the  pelvis  between  the  iliac  spines.     The  sinciput  is  still  in 

*  It  will  l)c  rcnicmbcrid  tli:it  wln-ii  the  (Hiiiuit  lurti.s  forwanl  tiie  sinciput  must  of  necessity 
lurn  backwiird. 


J  i  \ 


■  toj 


'  u 


tL, 


.1 


ii  ' 


438 


AMERICAN   TEXT-BOOK    OF   OBSTETRICS. 


:';'i 


r>!l;", 


I     :i 


'  --^A  till 


contact  with  the  lower  portion  of  the  sacrum,  and  tlie  occiput,  tliough  steadied 
on  both  sides  by  the  bones,  finds  its  descent  opposed  only  by  the  yielding 
tissues  of  the  vaginal  outlet  (Fig.  250).  Under  these  circumstances  (p.  432) 
the  propelling  force  from  above  concentrates  itself  upon  the  occiput  until  the 
perineum  is  fully  distended.  The  occipital  end  of  the  head  is  then  freed  from 
the  resistances,  while  the  whole  bregniatic  region  and  the  sinciput  form  a  rigid 
slanting  surface  which  is  opposed  to  the  slanting  surface  furnished  by  tlio 
sacrum  and  the  perineal  tissues  (Fig.  251).  As  a  consequence  the  driving  force 
of  the  uterine  j^rcssure  is  converted  by  the  shunt  of  these  shelving  surfaces 
into  a  forward  thrust,  under  the  influence  of  which  the  head,  as  a  whole,  moves 
forward  until  its  progress  is  arrested  by  contact  of  the  nai)e  of  the  neck  with 
the  anterior  pelvic  w-all.  The  large  fontanelle  is  now  at  the  fourchette,  the 
whole  of  the  occipital  half  of  the  head  is  free  from  pressure,  while  the  fore- 
head is  still  exposed  to  the  driving  force  of  the  uterine  muscle  above  and  to 
the  forward  shunt  of  the  posterior  pelvic  wall.  The  necessary  result  is  a  for- 
ward motion  of  the  head  with  arrest  of  the  neck  ;  that  is,  the  head  extends, 
the  bregma,  the  forehead,  and  the  face  successively  pass  the  fourchette,  and  the 
head  is  expelled  by  extension  (Fig.  252).  It  is  then  a  convenient  nniemonic 
that  in  normal  labor  the  hea<l  descends  in  flexion  and  is  expelled  by  extension. 
The  time  occupied  by  the  latter  stages  of  the  expulsion  of  the  head — that 
is,  the  time  between  the  first  appearance  of  the  hairless  forehead  and  the  com- 
pletion of  the  expulsion — is  usually  very  brief.  This  rapid  motion  of  descent 
is  usually  followed  by  a  period  of  inaction,  which  is  due  to  the  fact  that  the 
decrease  in  the  volume  of  the  uterine  contents  has  been  so  great  as  to  exhaust 
the  contractile  power  of  the  uterine  fibres,  and  to  render  progress  impossible 
until  after  the  occurrence  of  the  j)eculiar  phenomenon  known  as  retraction. 

Retraction  of  the  Uterus. — It  is  well  known  that  the  amount  of  shortening 
possible  to  any  given  muscular  fibre  is  very  definitely  limited,  and  it  is  believed 

that  the  extreme  shortening  of  the  uter- 
ine nniscle  as  a  whole  that  is  observed 
during  labor  is  rendered  possible  by  a 
process  of  rearrangement  of  the  rela- 
li  tions  of  the  fibres  of  the  uterine  muscle 

to  one  another,  known  as  retraction. 
The  way  in  which  this  process  is  ef- 
fected is  not  definitely  and  scientifically 
known,  bi.t  the  conception  generally  ac- 
cepted as  a  working  hypothesis  is  that 
the  cells  of  the  uterine  muscle  not  only 
shorten,  but  rearrange  themselves  u|)(in 
one  another  in  some  such  way  as  tiiat 
diagrammaticaily  represented  by  Figure 
253,  A  and  B.  When  retraction  has 
once  taken  place  it  is  usually  permanent,  and  the  distinction  between  contrac- 
tion and  retraction,  whatever  it  may  mean  patiiologically,  is  therefore  clinically 


Kio.  253.— Dinnrams  roproscntiiiKtlio  Iiypotlict- 
ical  roliitions  tjt'twci'ii  llio  utiTiiu'  fihri's  in  \iiiro- 
tmctccl  and  retrartcd  iitcii :  A.arrantii'nu'iit  nf  tlie 
iitcrini;  fibres  in  the  unrrtractcd  ntcrus;  It,  ar- 
raniifmont  of  tlie  iiU'rinu  liljpcs  in  iIk-  rt'trai'tiMl 
uterus, 


SSM 


THE   MECHANISM    OF   LABOR. 


439 


one  which  it  is  important  to  understuiul  and  to  bear  in  mind.  In  the  descrip- 
tion of  the  mechanism  of  hibor  it  is  nccossarv  to  refer  to  retraction  as  an  estab- 
lislied  entity,  notwithstanding  the  unestablished  position  of  the  hypothesis  upon 
which  rests  its  existence. 

When,  after  the  expulsion  of  the  head,  retraction  of  the  uterine  fibres  has 
becMi  effected,  the  rhythmic  contractions  again  set  in  and  the  process  of  expul- 
sion of  the  body  begins. 

Expulnion  of  the  Body :  Rotation  of  the  Shoulders. — The  shoulders  having 
entered  the  pelvis  during  the  expulsion  of  the  head,  they  are  usually  born  with 
the  next  few  succeeding  pains.  The  liead  having  entered  in  the  first  oblique 
diameter,  it  is  evident  that  the  shoulders,  which  normally  lie  at  right  angles  to 
the  antero-posterior  diameters  of  the  head,  will  normally  enter  the  pelvis  in 
the  second  oblique  diameter.  As  the  shoulders  are  driven  down  by  the  pains, 
the  anterior  shoulder  follows  the  curved  line  of  least  resistance,  previously 
travelled  by  the  occiput,  while  the  posterior  shoulder  follows  the  ])ath  of  the 
siniiput.  The  anterior  shoulder  thus  rotates  to  the  arch,  and  the  transverse 
axis  of  the  shoulders  occupies  the  antero-posterior  diameter  of  the  outlet. 

Restitution  of  the  Head. — The  head,  being  now  free  from  j)ressiire,  tends  to 
retain  or  reassume  its  natural  relation  to  the  shoulders,  and  thus  as  they  assume 
an  antero-posterior  diameter  the  already  expelled  head  undergoes  an  external 
rotation  by  which  the  occiput  is  carried  to  a  position  opposite  the  left,  and  the 
sinciput  to  one  opposite  the  right,  buttock  of  the  mother.  This  process  is 
known  as  the  e.vternal  rotation  or  restitution  of  the  head.  The  shoulders  are, 
however,  so  small  and  soft  as  compared  with  the  head  that  the  mechanism  of 
their  rotation  is  not  infrequently  faulty  or  irregidar.  It  may,  moreover, 
happen  that  at  the  time  of  their  entrance  the  action  of  the  intrinsic  muscles 
of  the  child  may  have  so  turned  the  body  that  the  transverse  axis  of  the 
shoulders  lies  at  an  acute  angle  to  the  antero-posterior  axis  of  the  head.  The 
small  and  soft  shoulders  may  from  this  cause  enter  the  pelvis  in  the  transverse, 
or  even  in  approximately  the  first  oblique,  diameter.  The  shoulder  which 
should  normally  have  been  the  posterior  m-iy  thus  become  the  anterior,  and  in 
this  way  icad  to  such  an  excessive  external  rotation  of  the  head  that  the  occiput 
swings  around  to  the  right  buttock  of  the  mother.  This  faulty  ])rocess  is  com- 
monly known  as  super-rotation. 

Expulsion  of  the  Shoulders. — The  shoulders  being  retained  in  the 
antero-posterior  diameter  by  the  pressure  of  the  tuberositio  ,  the  posterior 
shoulder  receives  the  forward  shunt  of  the  jjclvic  floor,  which,  together  witl» 
the  cnrvature  of  the  body  necessary  to  admit  of  the  passage  of  the  ciu'ved 
pelvis,  jams  the  anterior  shoulder  against  the  symphysis  pubis  in  such  a  way 
(Fig.  254)  that  the  posterior  shoulder  sweeps  forwai'd  over  the  perineiun  and  is 
the  first  to  reach  the  vulva.  As  the  body  is  urged  onward  the  perineum 
retracts,  the  anterior  shoulder  a])])ears  from  beneath  the  arch,  the  shoulders 
emerge  from  the  vulva,  following  tiie  direction  of  the  curve  of  (^u-us  (Fig.  219), 
and  the  remainder  of  the  body  rapidly  follows  in  the  same  path.  During  the 
l>rocess  of  expidsion  the  arms  normally  remain  crossed  upon  the  chest  in  the 


11 


uM 


fi  m 


;■ 


i         :| 


I     i 


i.i 


■l 


i'rllt 


i; 


I, 


riiii 


u 


f 


I  I 


Ml  % 


440 


AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


usual  attitude  of  the  fetus,  but  they  are  uot  iufre(|ueutly  helil  hack  by  the  fric- 
tiou  of  the  pelvic  wall,  aud  are  thus  forced  iuto  a  position  of  partial  exten- 
sion  in  which  the  forearms  lie  across  the  abdomen. 

The  mechanism  t)f  the  second  stage  in  O.  D.  A.  positions  differs  from  that 


l'"lii.  J.M.— Expulsidii  of  till'  sIkiuIiUts. 

of  O,  L.  A.   only   in   the  substitution   of  the  word   right  for  the  word   left 
throughout  the  description. 

C.  Mechanism  and  Management  of  the  Third  Stage  of  Labor. 

Mechanism  of  the  Third  Stage  of  Labor. — After  the  expulsion  of  the 
child  the  uterus  shuts  down  upon  the  placenta,  and  there  is  usually  a  period 
of  from  five  to  ten  minutes  during  which  little  or  no  contraction  is  api)arcnt, 
this  interval  being  occupied  by  the  process  of  retraction  of  the  uterine  fibres. 
The  first  active  contractions  of  the  uterus  after  the  expulsion  of  the  child 
necessarily  lessen  the  area  of  the  uterine  surface  over  wiiich  the  placenta  is 
attached,  and  thus  in  ])art  or  in  wlK)le  separate  the  placenta  from  the  uterine 
wall ;  during  the  next  relaxation  blood  escapes  from  the  torn  sinuses  in  the 
placental  site,  and  the  mechanism  by  which  the  placenta  is  expelled  (lei)ends 
upon  the  escape  or  non-escape  (»f  this  blood  from  the  uterus. 

li'  the  first  retraction  is  sulHcient  completely  to  detach  the  placenta,  but 
does  not  succeed  in  exi>elling  it,  any  blood  which  may  be  effused  will  usually 
find  its  way  to  the  external  worhl  by  dissection  of  the  membranes  from  tiic 
uterine  wall  ;  during  the  next  fi'W  contractions  the  uterus  will  be  able  to  shut 
down  nj)on  the  placenta,  and  will  compel  it,  by  the  force  of  direct  contact,  to 
pass  through  the  os  edgewise  and  in  the  most  compact  possible  form — that  is, 
in  the  shape  shown  in  Figure  255,  in  which  the  thin  caUe-like  placenta  is  seen 
to  have  been  folded  upon  itself  in  a  roughly  fusiform  shape. 

When,  however,  the  attachment  of  the  placenta  is  too  firm  to  permit  an 
immediaie  separation,  or  when,  as  probably  more  freipiently  happens,  the  con- 
traction of  the  fundus  is  more  energetic  than  that  of  the  lower  portion  of  the 
uterus,  so  that  only  tlie  upper  ])()rtion  of  the  placenta  is  detached,  the  relaxation 
following  each  contraction  will  be  ai'companied  by  an  effusion  of  blood  whicli 
is  confined  behind  the  placenta.     The  upper  part  of  the  placenta  will  then  Ix; 


THE  MECHANISM   OF  LABOR. 


441 


{'orct'd  downward,  and  as  the  detachment  proceeds  the  position  of  the  phicenta 
will  be  so  far  altered  that  its  fetal  surface  presents  at  tiie  os,  the  uterine  cavity 
heliind  it  being  occupied  by  a  mass  of  blood  (Fig.  256).     When  this  occurs, 


Kio.  255.— The  more  favorable  mechanism  of  expulsion  of  the  placenta  (Varnier). 

tilt'  placenta  presents  in  so  much  more  bulky  a  form  that  it  is  usually  expelled 
so  slowly  and  with  so  nuich  dithciilty  that  the  process  is  not  completed  until 
tiie  elfuscd  mass  of  blood  attains  sufficient  size  to  redistend  tlie  uterus  slightly. 


l"i(i.  250— Tlu'  loss  favornWe  of  the  common  mi'tliods  of  exp\;lsion  of  the  placenta  (Varnier). 

and  thus  permit  of  the  occurrence  of  more  forcible  contractions.  The  placenta 
is  then  expelled,  not  by  the  force  of  direct  contact,  but  by  an  intra-uterine 
lluid-pressure  cxcrteil  through  the  mass  of  ctfused  blood. 

Tliis  second  form  of  the  ii:cchanism  of  the  third  stage  of  labor,  though 
OKsentially  normal,  is  much  the  Ics,-!  easy  and  favorable  f(»r  the  patient ;  although 
the  amount  of  blood  lost  is  not  usually  sufficient  to  etlect  any  perceptible  altera- 
tion in  her  pulse. 

In  either  mechanism  the  elastic  and  collapsible  nature  of  the  membranes 
rciitk'rs  them  less  likely  than  the  ])lacenta  to  be  thoroughly  detached,  and  as 
the  latter  emerges  through  tlu;  h()le  in  the  membranes  tliiit  corres|)onds  with 
the  OS  they,  are  necessarily  invi'rted,  and,  becoming  detached  by  the  traction 
(hie  to  the  advance  of  the  placenta,  follow  after  it  in  a  loose  mass. 


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AMfmiCAN   TJ: XT- BOOK   OF   OBSTETRICS. 


Managrement  of  the  Third  Stage  of  Labor.* — The  iii<iuiry  naturally 
arises:  How  far  is  it  within  the  power  of  the  obstetrician  to  favor  or  to  compel 
the  occurrence  of  the  mechanism  first  described?  To  this  inquiry  it  may  be 
answered  that  the  maintenance  of  a  careftd  watch  upon  the  uterus  by  constant 
touch  of  the  fundus  through  the  abdominal  wall,  and  the  institution  of  rapid 
but  lij;ht  friction  with  the  fingers  upon  the  fundus  during  the  first  ct»ntniction, 
usually  so  far  increase  its  duration  and  force  as  often  to  effect  tlie  com|)l('t(' 
separation  of  the  placenta.  Moreover,  if  this  friction  is  persisted  in  through- 
out the  succeeding  period  of  relaxation,  it  will  usually  maintain  sufficient  <'on- 
traction  to  prevent  any  considerable  effusion,  and  secure  separation  during  the 
first  or  the  immediately  succeeding  pains.  This  most  essential  portion  of  tlie 
method  of  Crede  should  therefore  uniformly  be  adopted. 

The  second  and  less  favorable  mechanism  is  probably  safer  for  the  patient 
than  any  mamial  method  of  removal  of  the  j)lacenta,  but  in  case  a  delay  in 
the  third  stage,  notwitiistanding  the  adoption  of  Cred6's  method  of  expulsion, 
should  require  the  introduction  of  the  hand,  a  digital  intra-uterine  exami- 
nation should  first  be  made,  and  if  the  placenta  is  found  to  present  in  the  way 
."^•'•own  in  Figure  256,  an  effort  should  be  made  to  reach  the  edge  of  the  pla- 
centa with  the  finger.  It  may  then  be  possible  to  draw  the  edge  of  the  after- 
birth into  the  os,  and  thus  permit  its  ready  expulsion  without  the  complete 
introduction  of  the  hand. 

D.  Mechanism  and  Management  of  the  Posterior  Positions  of  Vertex 

Presentations. 

Mechanism  of  Right-posterior  Positions. — In  the  right-posterior  posi- 
tions of  vertex  presentations  the  head  always  enters  the  pelvis  O,  D.  P. ;  it 
.should  invariably  enter  the  inferior  strait  in  a  right-anterior  position ;  l)ut 
the  process  by  which  this  rotation  is  accom])lished  is,  unfortunately,  so  deli- 
cately balanced  that  it  is  always  liable  to  a  failure,  and  this,  if  it  occurs, 
necessarily  results  in  a  persistence  of  the  jiosterior  position,  which,  though  not 
incompatible  with  a  natural  delivery,  is  attended  by  greatly  increased  risks  to 
both  mother  and  child. 

We  have  to  consider,  then,  first,  the  entrance  of  the  head  into  the  j)elni^  in 
posterior  position's  ;  secondly,  the  normal  mechanism  of  the  suhsequent  deliver  if 
by  rotation  ;  and  tiiirdly,  the  (abnormal)  mechanism  of  the  delivery  of  a  persist- 
ently posterior  occiput. 

Labor  in  posterior  positions  is  usually  longer  and  more  difficult  than  in 

anterior  positions,  for  two  reasons ;  first,  l^ecause  the  entrance  of  the  head 

•  iito  tie  pelvis  is  more  difficult;  and  second,  l)ecause,  even  under  the  most 

f.'VOiTible  circumstances,  \x\hov  is  sure  to  be  lengthened  by  the  more  extended 

utai.i  n  of  the  occiput  that  is  necessary  to  its  completion. 

T!ic  Jijicult  entrance  of  the  head  at  the  brim  in  occipito-posterior  positional 
is  due  to  the  existence  of  two  factors,  one  of  which  is  ])hysiological,  while  the 
other  is  mechanical.  The  physiological  factor  is  to  be  found  in  an  irregular 
*  For  tlie  inana^einent  of  the  first  and  ssecond  stages  of  normal  labor,  see  page  3()7. 


Vi3 


THE   ^fK('I^AXISM   OF  LABOR. 


443 


and  imperfect  action  of  the  pains,  that  cliaracterizcs  tlio  first  stage  of  labor  in 
a  larf^e  proportion  of  posterior  positions.  The  exact  cause  of  this  well-marked 
feature  of  such  cases  is  unknown.  Probably  it  is  a  reflex  phenomenon  due 
to  pressure,  from  the  mechanical  mal-adaptation  shortly  to  be  sj)oken  of;  but 
it  is  a  fact  that  a  long  first  staire,  which  is  due  to  irregular,  variable,  and 
ineffective  pains,  is  always  sutrtrestive  of  a  posterior  position. 

The  mechanical  factor  is  due  to  the  irregular  shapes  of  the  fetal  liead  and 
the  pelvic  brim.  If  ])arallel  diameters  ar'>  drawn  across  the  pelvic  brim  (Fig. 
257),  the  cue  (a)  from  the  right  side  of  the  sacral  promontory  to  the  right  ilio- 


Fio.  257.— Adaptation  between  the  fotal  head  and  the  brim  of  the  pelvis  In  anterior  positions  of  the 

iii'cipiU. 


Ifel 


pectineal  eminence,  and  the  other  (i{)  from  the  left  sacro-iliac  notch  to  the 
pubes,  it  will  be  seen  that  when  the  head  enters  ().  L.  A.,  the  wide  biparietal 
diameter  of  the  head  corresponds  with  the  greater  space  affoi'ded  by  H,  the 
longer  of  these  diameters;  while  the  lesser  bitemporal  diameter  is  in  corre- 
sponden(!e  with  A,  the  shorter  of  these  parallel  diameters. 

The  entrance  of  the  head  is  therefore  mechanically  easy  in  anterior  posi- 
tions;  but,  conversely,  when  the  head  enters  ().  D.  P.,  its  wide  bij)arietal 
diameter  is  opposed  to  the  uari-ow  oblique  space  between  the  promontory  and 
the  ilio-pectineal  eminence  of  the  right  side,  while  the  narrow  biparietal 
diameter  is  loosely  fitted  into  the  wiilc  space  afforded  by  the  antei'ior  portion 
of  the  pelvis  (Fig.  258).  Two  factors  of  difficulty  are  tiius  j)rodu(!ed  :  first, 
the  widest  portion  of  the  fetal  head  finds  itself  in  apposition  with  a  nari-ow 
portion  of  the  pelvis,  and  therefore  rcipiircs  a  jiowerful  driving  impulse  to 
force  it  through  the  brim  ;  second,  this  retarded  widest  ])orti()n  of  the  head 
is  situated  on  the  occipital  end  of  the  head  lever,  while  the  sincipital  end  is 
almost  free.  This  situiition,  therefore,  always  tends  toward  a  tt)o  I'apid  descent 
of  the  sinciput — that  is,  toward  the  production  of  extension — but  the  degree 


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444 


AMERICAN    TEXT-BOOK'    OF   OBSTZTRICS. 


of  extension  produced  varies  with  the  relative  sizes  of  the  pelvis  and  the 
head. 

If  the  disproportion  between  the  biparietal  diameter  of  the  head  aud  the 
portion  of  the  pelvis  in  which  it  finds  itself  (that  is,  A,  Fig.  258)  is  not 
extremely  great,  the  protliictioii  of  an  extension  sufficient  to  cause  a  light 
pressure  of  the  forehead  against  the  pubes  may  be  enough  to  equalize  the 


Fig.  208,— Adttptntiou  between  the  fetal  head  and  the  brim  of  the  pelvis  in  posterior  positions  of  the 

occiput. 

resistances  at  the  opposite  ends  of  the  cephalic  lever,  and  may  thus  permit  the 
greater  pr()j)ulsive  force  applied  to  the  occiput  (sec  page  433)  to  accom2)lish 
its  descent  wliile  the  sinciput  is  still  above  the  brim.  The  head  in  this  ease 
will  enter  the  excavation  in  a  fairly  well  flexed  condition. 

If  the  disproportion  between  the  occiput  and  the  jmsterior  portion  of  the 
pelvis  is  more  extreme,  the  process  of  extension  will  continue  until  the  occipito- 
frontal diameter  occupies  the  first  oblicpie  diameter  of  the  brim.  The  head 
may  then  pass  the  brim,  after  long  l;d)or,  in  an  extended  position  ;*  it  may  be 
arrested  at  the  brim  by  becoming  a  brow  presentatit-'.  or  it  may  exceptionally 
be  converted  into  a  face  presentation. 

PatonKje  of  the  Exvandion. — After  its  escape  frt)m  the  superior  strait  the 
head  occupies  the  first  oblicpie  diameter  of  the  excavation  O.  D.  P.,  aud  the 
accomplishment  or  non-accomplishment  of  tiie  remainder  of  the  labor  by  the 
normal  mechanism  of  rotation  depends  wholly,  and  only,  on  the  degree  of 
flexion  ju'csent. 

RoUdinn  in  Wcll-Jfc.ved  RUfhl-posterio)'  Pos'dlom. — When  the  occiput  enters 
the  excavation — that  is,  passes  below  the  promontory — while  the  sinciput  is 
still  delayed  in  or  above  the  brim,  it  occupies  for  the  moment  so  roomy  a  posi- 

*  It  will  l)e  remembered  tli.at  the  ocoii)ito-frontal  diameter  is  too  large  to  pass  even  the 
oblique  diameters  at  the  brim  witii  ease. 


n !  • 


THE   MECHANISM    OE  LABOR. 


445 


tion  that  it  is  enabled  to  (lescen<l  rai)iilly  almost  to  the  floor  of  the  pelvis, 
while  the  sinciput,  delayed  by  the  pressure  of  the  anterior  pelvic  wall,  makes 
but  slight  progress.  The  occiput  then  lies  between  the  sacrum  and  the  right 
ischium,  in  the  hollow  made  by  the  recession  of  the  elastic  sacro-sciatic  lig- 
iiraents — that  is,  in  tlie  deeper  jwrtion  of  the  posterior  groove  of  the  right 
side  of  the  pelvis — while  the  sinciput  is  pressed  against  the  smooth  and  uniform 
surface  of  the  upper  part  of  the  anterior  jwrtion  of  the  lateral  wall  on  the 
left  side.  As  descent  goes  on  the  occiput  follows  the  posterior  groove  forward 
under  the  pressure  of  the  unyielding  bony  edge  of  the  sacrum,  which  presses 
against  its  posterior  surface ;  this  motion  is  unopposed  by  the  sinciput,  which 
in  thoroughly  well  flexed  heads  is  still  so  high  in  the  plvis  that  it  is  free  to 
turn  backward  over  the  smooth  bony  surface  of  the  upjjcr  portion  of  the 
lateral  wall  (portion  A,  Fig.  217,  a  and  n,  Fig.  218).  Rotation  thus  pro- 
gresses smoothly,  and  usually  rapidly,  until  the  occiput  reaches  the  spot  at 
which  the  posterior  and  anterior  grooves  of  the  right  side  join,  and  thus  assumes 
an  anterior  position.  The  sinciput,  which  has  by  this  time  become  well  {)os- 
tcrior,  now  lies  in  the  upper  ])ortiou  of  the  jiosterior  groove  of  the  left  side. 
The  head  is  now  in  an  O.  D.  A.  position  in  the  lower  portion  of  the  pelvis, 


Fig.  i!')9.— Diagram  lUustratinR  the  possible  rcprodiietitin  of  flexion  in  piirtly  extended  posterior  posi- 
tions of  tlie  occiput.  The  force  of  rotation  is  represented  by  tlio  arrow  a;  tlie  portion  of  tliat  force  whicli 
is  applicable  to  flexion,  l)y  the  line  h. 

and  the  remainder  of  the  mechanism,  including  restitution,  is  exactly  similar 
to  that  which  would  have  obtained  in  an  originally  O.  D.  A.  position  (see  pp. 
430-440). 

Mechanism  of  Rotation  when  the  Head  enters  Poorly  Flexed  in  Biffht-pos- 
terior  Positions. — When  more  marked,  but  not  extreme,  extension  occurs  across 
the  brim  before  the  passage  of  the  occiput,  the  releast;  of  the  latter,  as  be- 
fore, permits  it  to  juake  a  rapid  descent  until  it  is  arrested  by  contact  with 


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446 


AMERICAN    TEXT-BOOK   OF    OUSTKTRH'S. 


the  polvif  Hoor;  hut  at  the  time  wlieu  the  occiput  hcgiiis  to  feel  the  forward 
impulse  of  th(!  (K-ep  h)\ver  portion  of  the  posterior  jjroove  of  tiie  right  pelvic 
Mall  the  sinciput  is  not,  as  l)efore,  in  contact  with  the  smooth  surface  of  por- 
tion A  of  the  left  lateral  wall,  hut  has,  on  the  contrary,  already  entered  the 
upper  portion  of  the  anterior  groove  on  that  side.  Under  these  circumstances 
rotation  may  exceptit)nally  be  accomplished.  When  this  does  happen  the 
mechanism  is  as  follows:  As  the  occiput  is  urged  forward,  the  posterior  side 
of  the  sinciput  is  j)ressed  firndy  against  the  slightly  rising  edge  of  the  upper 
portion  of  the  anterior  groove,  and  under  tavorahlecirciunstauces  this  increased 
pressure  may  residt  in  flexion  of  the  heail  in  the  manner  illustrated  in  Figure 
259,  which  is  a  horizontal  section  of  the  jjclvis  through  the  spot  where  the 
sinciput  impinges  against  the  lateral  wall.  The  rotation  force  due  to  the  for- 
ward motion  of  the  occiput  urges  tl»e  sinciput  backward  in  the  direction  (tf 
the  force  represented  hy  the  arrow  A.  If  upon  this  arrow  we  construct  tiie 
parallelogram  of  forces,  we  see  that  by  the  shunt  of  the  shelving  surfaces  of 
the  sinciput  and  the  pelvic  wall  there  is  produced  a  small  pressure  (b)  upon 
the  sinciput  that  tends  directly  to  flexion,  and  that  nuiy,  under  favorable  cir- 
cumstances, actually  produ(;e  flexion  to  a  degree  sutticient  to  permit  the  sincij)ut 
to  slip  by  on  to  the  smooth  surface  of  portion  A  (Fig.  217).  The  sinciput  is 
free  io  then  glide  back  into  the  posterior  groove  as  the  occiput  moves  forward, 
and  tlie  mechanism  of  rotation  described  above  goes  on  as  before. 

This  process,  however,  is  mechanically  so  extremely  difficult  that  it  can 
occur  only  under  the  most  favorable  conditions — that  is,  when  the  adaptation 
is  easy,  when  the  jjains  are  powerful,  and,  nu)st  important  of  all,  when  the 
loss  of  flexion  is  so  extremely  slight  that  but  a  slight  change  is  needed  to 
restore  it. 

Mcclumwti  of  Rotation  vhcn  the  Head  enfrrf*  Cnfiexed  in  Posterior  Poni- 
tious:  the  Mechmmm  of  the  PaHnaf/e  of  the  Hrearation  in  Pemident  Jiight-pot<- 
terior  Positions — When  the  head  passes  the  brim  so  far  extended  that  the 
sincijjut  is  as  low,  or  nearly  as  low,  in  the  pelvis  as  the  occiput,  the  forehead 
reaches  the  deeper  portion  of  the  anterior  groove  at  about  the  same  time  that 
the  occiput  reaches  the  deeper  portion  of  the  posterior  groove.  Both  ends  of 
the  head  are  then  urged  to  rotate  forward  by  the  forward  trend  of  their  re- 
spective grooves ;  since  neither  one  can  rotate  forward  unless  the  other  turns 
back,  there  residts  a  dead-lock  which  can  be  broken  oidy  by  the  intervention 
of  art — that  is,  by  a  manual  or  an  instrumental  flexion  of  the  head.  In  rare 
cases,  however,  this  dead-lcK^k  may  be  avoided  by  the  occurrence  of  a 
second  and  abnormal  mechanism,  by  which  the  occiput  is  rotated  directly 
backward  into  the  hollow  of  the  saerinn.  This  rotation  can  occur  only  when 
the  adaptation  between  the  head  and  the  pelvis  is  exceptionally  easy,  when 
the  sacrum  is  exceptionally  hollow,  and  when  its  lateral  concavity  is  but 
little  marked.  The  occurrence  of  a  backward  rotation  is  then  due  to  the 
fact  that  the  posterior  edge  of  the  anterior  groove,  formed  by  the  isehiatic 
spine,  is  more  prominent  than  the  corresponding  portion  of  the  posterior 
groove,  formed  by  the  edge  of  the  sacrum.     W,  under  these  circumstances, 


THE    MKCHANISM   OF  LMiOR. 


447 


I  he  occiput  iiMil  the  sinciput  arc  at  ('([iial  depths  in  the  pelvis,  it  results  that 
I  he  sinciput  is  more  Hrnily  fixed  in  the  anterior  groove  tiuiii  u  the  (K'cipnt 
ill  the  posterior;  and  if  the  adaptati(»n  is  exceptionally  esv-sy  or  the  lower 
portion  of  the  sacrum  is  wantini;  in  prominence,  the  occiput  may  be  able  to 
escape  from  the  posterior  sjroove  and  turn  backward  over  the  sacrum  as  the 
sinciput  rotates  forward.  This  escape  of  tiu^  occiput  into  the  hollow  of  the 
sacrum  usually  so  far  diminishes  the  pressure  on  the  occiput  as  to  permit  of  its 
rapid  advance,  while  the  descent  of  the  sincij)ut  is  still  delayed  by  the  normal 
resistances  of  the  anterior  wall  of  the  pelvis.  The  rapid  descent  of  the  occi- 
put as  compared  with  the  sinciput  thus  re-establishes  flexion,  with  the  head 
in  a  directly  o(!(!ipito-posterior  position.  Expulsion  of  the  head  in  a  persist- 
ently posterior  ])osition  by  the  natural  forces  or  by  the  aid  of  forceps  is  then 
possible,  thou<!;h  the  conditions  are  much  less  favorable  than  when  the  occiput 
is  rotated  forward,  as  may  be  seen  by  reference  to  Figure  2G0.    On  comparing 


Fi<i. 'JOO.— P'xpulsion  of  thu  heiul  in  persistontly  i>ostorii>r  iiositions  of  tho  occiput;  mcclianism  of  fuce 

to  pubos  delivery. 

Figure  '2G0  with  Figure  251  it  will  be  seen  that  when  the  occiput  is  anterior 
the  curved  axis  of  the  child's  head  and  body  corresponds  with  the  curved  axis 
of  the  pelvis,  but  that  when  the  occiput  is  posterior  these  curves  are  reversed 
iipt)n  each  other,  and  that  to  etfect  t!ie  delivery  in  this  position  the  uterine 
foi'ces  must  alter  the  shape  of  the  child  by  elongating  the  occiput,  by  com- 
pressing the  sinciput,  and  by  imxhu^ing  an  exaggerated  flexion  uniil  the  normal 
curve  of  the  fetal  axis  is  reversed.  Although  the  fetal  head  is  surprisingly 
tolerant  of  the  excessive  compression  necessary  for  this  change  of  shape,  the 
process  always  results  in  the  stillbirth  of  a  large  proporticm  of  the  children; 
while  the  |)rominence  of  the  occiput,  even  after  the  most  extreme  moulding, 
always  exposes  the  soft  tissues  of  the  pelvic  floor  to  a  degree  of  tension  that 
almost  invariably  results  in  deep  laceration  of  these  structures  during  the 
stage  of  expulsion.  The  expulsion  of  a  persistent  occiput  posterior,  more- 
over, always  requires,  iu  addition  to  lax  adaptation,  the  presence  of  very 


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448 


AMERICAN   TKXT-nOOK   OF   OliSTKTIiTCS. 


j)owcrfiil  uterine  contractions  or  tlic  application  of  powerful  traction  by  tlic 
forceps;  and  even  when  tlie.se  conditions  are  present  the  process  is  a  lontr 
one. 

The  head  remains  in  ])osition  nntil  the  |)rocesses  of  the  change  in  its  shape 
and  the  prcHluction  of  extrenie  flexion  are  snfficiently  far  advanced  to  permit 
the  occipnt  to  travel  downward  along  the  median  line  of  the  posterior  wall 
under  the  influence  of  the  pressure  from  above.  The  region  of  the  small  fbnta- 
nelle  finally  appears  at  the  vulva,  and  the  ])erineum  retracts,  or,  more  com- 
monly, tears  across  the  (H'ciput  to  the  base  of  the  neck.  The  occipital  end  of 
the  head  is  then  free  from  pressure,  while  the  sincipital  end  is  still  expost'd  to 
the  driving  force  of  the  uterine  contractions.  The  excess  of  pressure  upon 
the  sincipital  end  of  tlu^  head  then  causes  extension,  by  which  the  fbrehea<l, 
the  eyes,  the  nose,  and  the  chin  successively  appear  under  the  arch,  while  the 
occiput  swings  backward,  and  the  head  is  born  by  extension  (Fig.  200). 

licdUutlon. — During  the  expulsion  of  the  head  the  shoulders  enter  in  the 
second  oblique  diameter,  and  the  rotation  of  the  left  (tiie  anterior)  shoulder  to 


Fill.  261.— Ocpipito-pnstorior  positinii,  with  the  head  hoRinniiiK  to  distend  the  pelvic  floor  (Smellie). 

the  arch  j)roduces  an  external  restitution  to  the  right,  in  accordance  with  the 
general  law  that  external  rotation  or  restitution  restores  the  head  to  its  origi- 
nal position.  Abnormal  or  so-called  "  super-rotation"  is,  however,  of  e.sj)ecially 
common  occurrence  in  these  cases. 

Snmman/. — In  reviewing  the  mechanism  of  posterior  positions  it  is  at  once 
a|)parent  that  the  whole  key  to  the  situation  is  to  be  found  in  the  degree  of 
flexion  presented — that  the  better  the  flexion  the  more  certain  and  the  more 
rapid  is  the  execution  of  the  normal  and  most  favorable  mechanism.     It  is  an 


Tilt:   MKCIIANISM   OF   LAJlOIt. 


449 


cstablisiliwl  liiot  in  pnu^tice  that  in  the  comparatively  tew  cases  in  which  gcxxl 
llcxion  is  established  at  the  start  and  maintained  to  the  end,  posterior  labor  is 
hardly  less  favorable  than  anterior;  and  that  the  degree  of  ditHculty  increases 
as  the  degree  and  persis(en(!e  of  flexion  decrease,  nntil  we  reach  the  fact  that 
when  flexion  is  lost  and  is  not  promj)tly  restoretl  by  art,  posterior  positions 
invariably  yield  long,  difficult,  and  exhausting  labors  for  tlio  mother,  and  a 
liirgc  proportion  of  stillbirths  among  the  children.  It  may  safely  be  said  that 
there  is  no  variety  of  labor  in  which  easily-avoided  ill  results  are  so  commonly 
incurred  as  in  posterior  positions  of  the  vertex  ;  and  there  is  certainly  no  sub- 
ject in  obstetrics  that  better  deserves  the  attention  of  the  student  than  the 
means  of  detecting  extension  and  of  preserving  or  re-establishing  flexion  in 
these  cases.  \ 

Mechanism  of  Left-posterior  Positions. — Of  the  mechanism  of  O.  Ij.  P. 
positions  it  is  only  necessary  to  say  that  it  differs  from  that  of  O.  D.  P.  posi- 
tions simply  in  the  substitution  of  one  side  of  the  pelvis  for  the  other,  and  in 
the  fact  that  failun?  of  rotation  is  more  <!omnu)n  in  left  positions. 

Manaerement  of  Labor  in  Posterior  Positions  of  the  Vertex. — Prophy- 
Id.rln. — Since  posterior  labor  is  so  much  less  favorable  than  anterior,  it  is  evi- 
dent that  every  eftbrt  should  be  made  to  prevent  the  occurrence  of  posterior 
positions,  or,  when  they  do  occur,  to  convert  them  into  anterior  positions 
i)t'l'ore  the  occurrence  of  labor  or  during  its  early  stages.  We  are,  fortunately, 
able  to  effect  this  end  in  the  great  majority  of  cases,  provided  the  position  is 
diagnosticated  before  the  rupture  of  the  membranes  or  the  engagement  of  the 
head.  For  this  reason,  if  for  no  other,  the  obstetrician  should  in  every  case 
endeavor  to  ascertain  the  [)osition  of  the  fetus  by  making  an  abdominal  pal- 
pation some  days  before  the  advent  of  labor.  If  a  posterior  position  is  dis- 
covered at  this  time,  it  is  usually  possible  to  rectify  it  by  postural  treatment 
of  the  patient. 

If  the  patient  is  placed  in  the  knee-chest  position,  the  anterior  wall  and 
the  fundus  are  the  lowest  portions  of  the  uterus.  So  long  as  the  patient 
remains  in  this  position  ihere  is  a  tendency  for  the  child  to  sag  away  from  the 
brim  under  the  influence  of  gravity ;  and  since  the  recession  of  the  head  from 
tlie  brim  leaves  the  child  free  to  turn  upon  its  own  axis,  while  the  presence  of 
the  spinal  column  makes  the  dorsal  side  the  lieavier,  there  is  also  a  tendency 
Iowa  il  a  rotation  of  the  fetus  as  a  whole  until  ita  dorsum  is  in  apposition  to 
the  anterior  wall  of  the  uterus. 

The  woman  should  in  such  cases  be  instructed  to  assume  the  knee-chest 
posture  several  times  daily  during  the  last  few  weeks  of  pregnancy,  to  remain 
as  long  in  this  position  as  is  possible  without  fatigue,  and,  on  relinquishing  it, 
to  recline  on  the  right  side  for  a  short  time  before  rising,  in  the  hope  that  .as 
the  child's  head  again  settles  down  against  the  brim  it  may  become  fixed  in  an 
anterior  position. 

The  enlarged  abdomen  of  the  gravida  at  term  may  prevent  the  assumi)tion 
of  the  true  genu-pectoral  position  and  compel  her  to  adopt  the  knee-elbow  atti- 
tude ;  but  in  either  event  it  is  essential  that  the  abdomen  should  be  free  from 
29 


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AMEIilCAN   TEXT-BOOK   OF   OBSTETRTCS. 


J^ 


SVn 


Fui.  262— Correct  (A^  and  iiicorrt'ct  (H  and 
C)  muthuds  of  assuming  the  genu-pect(>rul  pusi- 
tion. 


pressure  against  either  the  bed  or  the  thighs  of  the  patient ;  tliat  is,  the  thighi* 
siiould  be  vertical  (Fig.  2G2). 

The  postural  treatment  is  especially  powerful  when  instituted  before  aiiv 
labor-pains  \\w'2  occurred.  If  this  treatment  is  conscientiously  carried  out  for 
beveral  days,  the  physician  M'ill  almost  surely  find  the  position  anterior  when 
summoned  to  th^  j^ntient  in  labor. 

Even  if  the  patient  is  not  seen  until  labor  is  present,  it  is  still  worth  while 
to  adopt  a  postural  treatment  so  long  as  the  membranes  are  unruptured  and 

the  head  is  unengaged.  The  patient 
should  then  be  encouraged  to  maintain 
this  position  so  long  as  her  strength 
permits,  or  until  a  vaginal  examination 
without  alteration  of  her  attitude  dem- 
onstrates the  fact  that  rotation  has 
occurred.  She  should  then  be  placed 
in  the  latero-prone  position  upon  .lie 
side  to  which  the  occiput  is  directed, 
and  should  remain  in  that  position 
until  the  head  is  firmly  engaged  in  the 
new  position.  Should  the  head,  after 
once  becoming  anterior,  sliow  any  tendency  to  revert  to  the  posterior  position, 
it  may  even  be  wise  to  ruj)ture  tiie  membranes  in  order  to  prevent  any  such 
reversion. 

Should  the  postural  treatment  fail,  no  special  treatment  is  necessary  until 
after  the  rupture  of  the  membranes  has  occiu'red  ;  but  both  before  and  after 
rupture  frequent  examinations  are  advised,  in  order  to  detect  early  aii\ 
tendency  to  the  production  of  marked  extension. 

Passage  of  the  Superior  Strait. — In  the  majority  of  cases  the  head  in  pos- 
terior positions  passes  the  superior  .strait  by  the  natural  efforts  only  after  some 
delay,  and  often  only  after  the  occurrence  of  some  extension  and  of  considerable 
moulding  of  the  iiead. 

The  attitude  of  the  physician  should  be  determined  by  the  degree  of  exten- 
sion jiresented.  When  the  extension  is  not  extreme,  he  siiould  not  be  alarmed 
by  a  failure  of  progress,  but  should  avoid  interference,  and  expect  the  best 
results  so  long  as  the  condition  of  both  patients  remains  good. 

When  extension  becomes  so  extreme  that  the  eyebrows  are  below  th<' 
brim  of  the  i)elvis,  tliere  is  but  little  prospect  that  the  head  will  pass  the 
superior  strait  by  the  natural  efforts,  and  unless  active  progress  is  present  it 
is  wise,  after  a  single  hoin-  lias  passed  without  alteration  of  the  condition,  to 
abandon  the  expectant  method  of  treatment  and  resort  at  once  to  the  oi>erative 
treatment  of  a  high  arrest  of  the  posterior  occiput. 

Operative  treatment  at  the  superior  strait  sidwlivides  itself  into  the  operative 
re-establishment  of  flexion  and  the  delivery  through  the  superior  strait  of  tlie 
flex(!d  but  arrested  head. 

Operative  Flexion. — If,  at  the  tiuie  when  operative  flexion  becomes  neees- 


THE  MECHANISM   OF  LABOR. 


451 


s!iry,  the  membranes  are  still  intact,  it  may  occasionally  be  possible  to  raise 
I  lie  forehead  by  making  pressure  upon  it  with  two  fingers  placed  within  the 
•ervix,  the  woman  being  in  the  recumbent  or  knee-chest  position,  in  order  to 
all'ord  the  assistaiice  of  gravity  to  the  efforts  of  the  accoucheur.  Since  it  is 
impossible,  however,  to  obtain  complete  flexion  of  the  head  in  this  way,  and 
^ince  the  extension  is  almost  certain  to  recur  if  no  further  change  is  made, 
it  is  essential  that  the  iiead  as  a  whole  should  be  freed  from  the  brim  by  pres- 
sure! upou  the  vertex,  after  flexion  has  been  secured,  in  the  hope  that  on  its  en- 
trance it  may  be  better  situated,  iiud  may  thus  be  able  to  maintain  its  flexion. 

Shoidd  extension  again  recur,  it  is  best  to  etherize  the  patient,  introduce 
tlie  hand  into  the  vagina,  and  dilate  the  os  manually  to  a  degree  sufficient  to 
permit  the  passage  of  tlie  half  hand  within  the  uterus.  Should  the  membranes 
1)0  ruptured  at  the  time  when  interference  is  decided  upon,  this  must  usually 
1)0  the  first  maneuvre.  When  sufficient  dilatation  has  been  attained,  the  half 
iiand  should  be  i)assetl  within  the  os  until  the  fingers  cover  the  forehead, 
which  should  then  be  pressed  gently  upward  until  complete  flexion  lias  been 
secured  and  the  head  has  been  freed  from  the  brim.  The  hand  should  then 
1)0  withdrawn,  the  fingers  placed  as  high  upon  the  forehead  as  possible  iu 
order  to  maintain  flexion,  and  the  head  forced  into  the  brim  by  external  pres- 
sure. The  ether  should  be  removed,  and  the  fingers  should  maintain  pressure 
upon  the  anterior  portion  of  the  head  until  a  firm  engagement  in  a  flexed  posi- 
tion has  been  effected  by  the  efforts  of  the  uterus.  Should  extension  become 
re-established,  an  operative  delivery  of  the  head  is  necessary. 

Operative  Belnrt'i/  of  a  Hiyh  Arrest  of  the  Posterior  Occiput. — If  extension 
is  present,  flexion  should  be  established  by  the  introduction  of  the  half  hand. 
Three  methods  of  delivery  are  then  possible  :  The  child  may  at  once  l)e  turned, 
the  head  may  be  rotatod  manually  and  forceps  applied  to  the  anterior  occiput, 
or  forceps  may  be  used  while  the  occiput  is  still  posterior. 

The  latter  method  is  to  be  recommended  only  when  t!ie  other  methotls  are, 
for  one  reason  or  another,  contra-indicated  or  iiiipi.ssible,  and  the  choice  ordi- 
narily rests  between  the  procedures  or  a  manual  rott>*:iou  of  the  oc:iput  to  the 
front  with  a  subsequent  ap}»lication  of  the  forceps,  anu  version. "« 

Manual  rotation  and  the  application  of  forceps  is  a  difficult,  and  version  in 
nor.nal  pelves  is  an  easy,  operation.  The  head  after  manual  rotation  not 
infrequently  returns  to  its  original  position  during  the  manipulations  incident 
to  the  application  of  the  blades,  and  in  any  event  it  is  necessi.ry  to  apply  the 
forceps  to  the  head  when  freely  movable  above  the  brim,  Widch  operation  is 
always  difficult.  The  writer  believes,  however,  that  aft'  '  'ho  forceps  has 
successfully  been  applied  to  the  head  in  an  anterior  position,  :k\  extraction  with 
it  is  less  dangerous  to  the  sof*^  parts  of  the  mother  than  is  tl  c  extraction  of  an 
after-coming  head  ;  the  forceps  operation  should  (l';'"'^^if'ore,  in  his  opinion,  be 
chosen  by  those  who  are  thoroughly  skilful  iu  tix  n«  of  the  instrument,  but 
the  primary  performance  of  version  should  l)e  el<'cte.l  by  operators  of  small 
experience. 

Should  manual  rotation  and  the  use  ot  forceps  '»(•  d( cided  upou,  the  whole 


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452 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


hand  should  be  passed  into  the  uterus  and  the  licad  be  raised  gently  until  the 
whole  surface  of  the  hand  can  be  applied  to  the  forehead,  the  fingers  lying 
over  the  face  of  the  child  ;  whereupon  the  hand  and  the  forearm  of  the  operator 
should  be  rotated  with  the  head  until  the  occiput  is  well  anterior  to,  and  even,  if 
possible,  to  the  left  of,  the  median  line.  During  the  introduction  of  the  hand 
careful  counter-pressure  must  be  made  at  the  fundus  by  an  assistant  or  by  tlie 
other  hand  of  the  o])erator,  and  during  the  rotation  the  external  hand  nuist  be 
used  to  promote  the  rotation  of  the  trunk.  The  rotation  should  always  be  slow 
and  be  procural  with  the  utmost  gentleness.  Unless  the  rotation  of  the  trunk 
accompanies  that  of  the  body,  the  head  will  return  to  its  original  position  as 
soon  as  it  is  free  from  pressure.  In  ditticult  cases  it  may  occasionally  i)e  per- 
missible to  apply  the  internal  fingers  to  the  shoulder  of  the  child  to  ])roniote 
this  rotation.  The  whole  nianeuvre  is  frequently  so  difticult  that,  unless  the 
waters  have  been  but  recently  evacuated,  it  should  not  be  attempted  until  a  fair 
experience  in  version  has  furnished  the  operator  with  some  adroitness  in  intra- 
uterine manipulations. 

After  rotation  has  been  effected  the  head  should  be  urged  into  the  brim  by 
counter-])ressure  upon  the  fundus,  and  it  should  be  maintained  in  position  by 
gentle  abdominal  pressure  upon  the  head  itself,  from  the  hands  of  an  assistant, 
while  the  forceps  application  is  made.  The  forcejis  should  be  api>lied,  if  pos- 
sible, to  the  sides  of  the  head,  and,  as  in  all  high  operations,  the  use  of  an 
axis-traction  instrument  is  to  be  recommended. 

If  version  is  decided  upon,  the  head  shoidd  be  flexed  before  it  is  raised,  as 
this  always  requires  less  force  thaji  an  attempt  to  raise  the  extended   head. 

If  version  is  absolutely  contra-indicated  and  manual  rotation  fails,  an  attempt 
should  be  made  to  bring  the  head  through  the  sui)erior  strait  by  the  application 
of  forceps  without  alteration  of  the  position  ;  but  as  a  preliminary  even  to  this 
operation  an  extended  head  should  gently  be  flexed. 

In  the  use  of  forceps  while  the  occiput  is  still  posterior,  it  is  inadvisable  to 
make  any  attempt  to  ajiply  the  blades  to  the  sides  of  the  head,  as  the  position 
of  the  parietal  bosses  in  the  narrow  space  between  the  ilio-pectineal  eminence 
and  the  promontory  makes  it  extremely  difficult  to  adjust  the  forceps  to  the 
ends  of  the  biparietal  diameter.  Even  when  it  is  so  adjusted  a  very  slight 
forward  inclination  of  the  line  of  traction  may  cause  the  forcei)s  to  slip  forward 
along  the  head  to  the  temporal  region.  In  this  position  the  forceps  is  extremely 
likely  to  slip  from  the  head  altogether  ;  even  if  the  forceps  holds  its  position, 
the  sole  and  necessary  result  of  tnictiou  is  a  reproduction  of  the  extension,  which, 
of  course,  results  in  an  arrest,  or  at  least  requires  the  use  of  increased  and 
unnecessary  force.  The  blades  should  therefore  be  applied  to  the  sides  of  the 
pelvis,  where  they  will  take  an  oblique  grip  upon  the  head.  This  application 
is  always  very  difficult,  and  the  operation  too  frequently  results  in  a  fi-actuiv 
of  the  skull  or  in  the  birth  of  a  stillborn  child  from  cranial  compression.  A> 
soon  as  the  head  has  passed  the  brim  the  forceps  should  be  removed  ;  if  neces- 
sary, the  forceps  may  be  reapplied  in  the  manner  shortly  to  be  recomr  i  'rded 
f«)r  the  operative  treatment  of  the  loi,  head  in  posterior  positions. 


)lo  to 
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0  the 
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ition, 
hie!.. 

1  and 
if  tht' 
I'ation 
c'turo 

As 

licces- 

lulfi 


THE   MECHANISM    OF  LABOR. 


453 


Management  of  the  Passage  of  the  Excavation  in  Posterior  Positions. — 
Flexion. — Ais  was  said  ia  the  discussion  of  the  mechanism  of  posterior  posi- 
tions, the  maintenance  of  complete  flexion  is  the  first  and  most  essential  con- 
dition of  the  progress  of  the  liead  through  the  excavation.  It  follows  that  the 
maintenance  of  flexion  when  possible,  and  its  re-establishment  when  it  has  been 
lost,  must  demand  throughout  the  case  the  most  careful  attention  from  the 
obstetrician. 

When  the  adaptation  is  easy  and  good  flexion  is  present  from  tho  start, 
descent  and  rotation  to  an  anterior  position  are  sometimes  so  quickly  performed 
that  no  assistance  is  needed  ;  but  in  a  large  proportion  of  cases  the  head  enters 
the  excavation  in  a  condition  of  partial  extension,  and  in  such  cases  an  early 
iidoption  of  certain  very  simple  measures  frequently  makes  the  difference 
between  difficult  and  easy  labors.  The  various  expedients  which  may  be  used 
to  promote  or  to  re-establish  flexion  form,  then,  the  first  and  most  important 
division  of  the  treatment  of  the  low  head  in  posterior  positions;  but,  since  it 
not  infrequently  hapixjns  that  even  a  well-flexed  head  fails  to  rotate  from  over- 
tightness  of  adaptation,  from  relative  inefficiency  of  the  pains,  or  from  minor 
variations  in  the  shape  of  the  head  and  the  pelvis,  it  is  necessary  to  add  thereto 
a  second  division,  which  consists  of  the  expedients  that  may  be  employed  to 
tlivor  or  to  produce  rotation  during  extraction,  whenever,  from  any  cause,  a 
well-flexed  head  is  arrested  in  a  posterior  position  in  the  excavation. 

Maintenance  of  Ffe.vion. — Unless  progress  goes  on  with  unusual  rapidiiy, 
the  maintenance  of  flexion  by  counter-pressure  should  be  undertaken  as  soon 
as  the  head  has  entered  the  excavation  and  the  forehead  is  within  easy  reach. 
As  soon  as  the  degree  of  descent  permits,  the  fingers  should  be  placed  against 
the  frontal  bones  as  far  forward  of  the  large  fontanelle  as  the  pelvic  space  allows, 
and  any  further  descent  of  the  sinciput  should  be  retarded  by  a  ntenance  of 
pnssiirt  against  the  forehead  throughout  the  whole  of  each  pain  until  the  occur- 
rc'i'i'  of  rotation  carries  the  frontal  bones  backward  and  out  of  the  reach  of  the 
tii'gcrs  In  this  process  a  simple  retardation  of  the  descent  of  the  sinci[)ut  is 
{]'.  ihfii  U  to  be  aimed  at  or  desired,  since  flexion  is  supposed  to  be  already 
])resei:  .  and  "ts  maintenance  is  all  that  is  needed.  This  maintenance  of  flex- 
ion, w'.iv.i/  is  unusually  easy,  is  always  a  very  much  more  simple  matter  than  is 
an  attempt  to  raise  the  forehead  by  pressure  after  extension  has  once  occurred. 
If  this  precaution  is  carefully  observed  from  the  start,  loss  of  flexion  is 
extremely  rare,  and  a  recourse  to  the  more  heroic  methods  required  for  its 
re-establishment  may  usually  be  avoided. 

Re-cstahlishment  of  Flexion. — When  extension  occurs,  it  must  be  reduced 
"ifore  any  further  })rogress  is  jiossible.  Flexion  may  be  re-established  either 
in  pushing  the  sinciput  up,  by  drawing  the  occiput  down,  or  by  a  combination 
t>i  ;;o(h  methods.  The  forehead  may  occasionally  be  made  to  recede  by  pres- 
sure upon  the  frontal  l)ones  with  the  fingers ;  it  should  thou  be  held  in  position 
until  the  uterine  efforts  have  effected  complete  flexion  by  descent  of  the  occiput, 
and  until  rotation  has  occurred.  This  method,  the  simplest  and  safest,  is,  how- 
ever, possible  only  in  very  easy  (lases. 


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It  is  occasionally  possible  to  reinforce  this  niethotl  by  hooking  the  fingers 
of  the  hand  around  the  occiput,  and  thus  drawing  down  upon  the  occiput  witli 
one  hand  while  the  sinciput  is  pressed  up  by  the  other  hand.  This  method  is 
possible  only  when  the  extended  head  is  very  low  and  the  soft  tissues  of  the 
outlet  are  very  lax  ;  in  the  majority  of  cases  in  which  extension  has  fully  been 
established  it  is  necessary  to  resort  to  instrumental  methods. 

The  recti's  (Fig.  26.'i),  which  was  the  precursor  of  the  forceps,  was  originally 
used  to  promote  the  descent  of  the  head  by  the  application  of  leverage  motions 

to  the  sides  of  the  head  in  alternation.  The  vectis  is 
never  used  to-day  except  for  the  reduction  of  exten- 
sion, and,  in  the  opinion  of  the  writer,  cannot  be 
recommended  even  for  this  purpose,  since,  in  the  first 
pli;  e,  its  efficiency  depends  on  its  possession  of  an 
ex  cr^'eratcd  cephalic  curve  w'hich  renders  its  intro- 
du(  i  'icult,  and,  in  the  second  place,  it  can  rarely 

be  pre\  r'ed  from  slipping,  without  the  use  of  a 
degree  of  force  which  exposes  both  the  vagina  of  the 
mother  and  the  scalp  of  the  child  to  serious  risks 
of  laceration.  If  employed,  the  vectis  is  passed 
around  the  occiput  and  is  used  to  draw  it  down, 
while  the  delay  of  the  sinciput  is  entrusted  to  the 
friction  of  the  j)elvic  walls  or  to  counter-pressure  by 
the  fingers.  For  this  purpose  the  hand  of  an  assist- 
ant must  be  utilized,  since  the  employment  of  the 
vectis  always  requires  both  hands ;  that  is,  while  one  hand  makes  traction 
on  the  handle  of  the  vectis,  the  fingers  of  the  other  hand  must  always  be 
placed  between  the  vagina  and  the  instrument  to  protect  the  tissues  from 
laceration. 

Beversed  Forceps. — A  far  better  operation,  when  manual  efforts  at  flexion 
have  failed,  is  to  be  found  in  the  application  of  reversed  forceps.  This  opera- 
tion is  in  reality  a  mere  extension  of  the  ancient  jnnnciple  that  the  tips  of  the 
forceps  should  always  be  directed  toward  the  leading  point  on  the  presenting 
part ;  but  when  the  forceps  is  applied  to  an  extended  head  in  a  ])osterior  posi- 
tion with  the  tips  directed  posteriorly,  its  grasp  is  directed  so  far  toward  the 
occipital  end  that  the  instrument  is  almost  certain  to  slip  after  flexion  has 
occurred.  It  is  therefore  important  to  remember  that  this  application  should 
be  utilized  only  for  the  production  of  flexion,  that  during  each  traction  tlic 
fingers  of  the  unemployed  hand  should  carefully  note  the  motions  of  the 
head,  and  that  as  soon  as  flexion  has  been  established  the  blades  should  be 
removed,  if  necessary  being  reapi)lied  for  the  delivery  of  the  head  in  the 
manner  recommended  for  the  delivery  of  a  well-flexed  head  in  posterior 
positions. 

Technique  of  the  Application  of  liei'ei',se(l  Forceps, — The  forceps  should  hv 
placed  outside  the  vulva,  in  the  position  in  which  they  are  to  lie  when  applicil 
to  the  head — that  is,  with  the  transverse  axis  of  the  blades  at  right  angles  to 


Fig.  263.— The  >ectls. 


THE   MECHANISM   OF  LABOR. 


455 


the  sagittal  suture,  and  with  the  tips  directed  backward.  If  the  lock  is  of 
tlie  ordinary  form,  the  handle  of  that  blade  which  would  be  the  left  iu  the 
ordinary  position  should  be  held  in  the  right  hand,  and,  under  the  guidance 
of  two  fingers  of  the  left  hand,  should  be  inserted  into  the  vagina  and  passed 
into  position  as  near  as  possible  to  the  occipital  end  of  the  head  (Fig.  264). 


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Fio.  'J64.— The  iippliciition  of  reversed  forceps.  The  arrow  indicates  the  iiTect  of  the  forceps  in  pro- 
moting the  descent  of  the  occiput  while  the  sinciput  is  delayed  by  friction  against  the  anterior  pelvic 
wall. 

Tlie  other  blade  should  be  adjusted  to  corroppond  with  its  fellow,  and  simple 
traction  upon  the  handles  should  be  made  in  the  direction  of  the  handles,  all 
leverage  motions  being  avoided.  The  force  of  the  instrument  is  then  directed 
against  the  occipital  end  of  the  head  alone ;  the  sinciput  is  delayed  by  the 
friction  of  the  pelvic  walls,  while  the  occiput  descends  under  the  force  of 
traction,  and  flexion  results. 

As  soon  as  the  small  fontanelle  has  been  brought  to  the  centre  of  the  pelvis 
— that  is,  when  the  head  has  been  flexed — the  forceps  should  be  removed  and 
the  process  of  rotation  be  entrusted  to  nature,  since  lacerations  of  the  vagina  are 
far  less  often  |)roduced  wiien  rotation  is  ofl'ccted  by  the  uterine  force  than 
when  it  is  procured  by  instrumental  means ;  unless,  indeed,  the  condition  of 
the  patient  •-lectssitates  an  immediate  delivery. 

Low  Forceps  in  Wclf-ffcxcd  Heads  in  Poftterior  Positioihs. — When  rotation 
fails  notwith  hmding  tlie  ])resence  of  good  flexion — that  is,  when  a  well-flexed 
head  is  delayed  in  a  posterior  position  until  the  signs  of  exhaustion  occur — 
this  failure  is  usually  the  result  of  a  relative  want  of  eis-a-terejo,  which  must 
be  compensated  for  by  the  substitution  of  the  vis-a-fi'onte  of  the  forceps  ;  but 
it  is  the  first  essential  to  success  in  this  operation  that  the  instrument  should 
be  so  applied  that  its  ])resencc  in  the  vagina  ofl'ers  no  impediment  to  the  rota- 
tion of  the  head.  If  in  this  position  of  the  head  the  forceps  is  applied  to  the 
sides  of  the  pelvis,  its  obliiiue  grasp  upon  the  forehead  and  the  occiput  will 
almost  certainly  prevent  rotation  ;  while,  even  if  it  is  applictl  to  the  sides  of 
the  head,  it  is  liable  to  cause  extension  and  consequent  delay,  with  laceration 


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of  the  perineum,  aud  frccniently  the  death  of  the  fetus,  unless  special  precau- 
tions are  taken  to  ensure  its  grasping  the  occiput. 

So  long  as  the  occiput  is  dit.tinctly  posterior  to  the  transverse  line  of  the 
pelvis,  the  forceps  should  he  applied  to  the  sides  of  the  head  with  the  concavity 
of  the  pelvic  curve  toward  the  forehead — that  is,  with  the  tijjs  anterior ;  but 
care  should  be  taken  during  the  aj)plication  of  the  blades  to  keep  the  handles 
well  raised,  or,  to  use  a  better  expression,  to  direct  the  tips  far  backward  into 
the  pelvis,  in  order  to  ensure  their  grasping  the  occiput  aud  thus  promoting 
rather  than  retarding  flexion  during  the  tractions.  The  tractions  should  be 
directed  as  far  backward  as  the  perineum  will  allow,  at  least  until  rotation 
has  occurred ;  since  it  is  sometimes  difficult  to  secure  this  line  of  traction 
in  the  ordinary  position  of  the  hands,  it  is  often  well,  in  the  extraction  of 
posterior  positions,  to  place  the  left  hand  upon  the  shanks  of  the  instrument 
near  the  vulva,  and  with  that  hand  draw  backward  while  the  right  hand 
steadies  the  extreme  end  of  the  handles. 

It  must  not  be  forgotten  that  the  maintenance  of  flexion  and  the  conse- 
quent production  of  rotation  are  essential  objects  of  thio  tirst  application,  since 
descent  is  dependent  on  them. 

The  production  of  forced  rotation  by  a  rotative  movoment  of  the  handles 
of  the  forceps  is  so  extremr 'y  (\.;igorous  to  the  soft  parts  of  the  mother  as  to 
be  permissible  to  none  but  tlie  most  experienced  operator.  The  operator  who 
has  really  acquired  sufficient  skill  to  justify  such  a  maneuvre  will  infallil)ly 
have  acquired  so  active  an  impression  of  its  dangers  as  to  use  it  with  the  most 

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Fio.  205.— Lateral  motion  of  the  handles  of  tlu'  cnrved  forcops  rlurinR  the  rotation  of  a  posterior  posi- 
tion of  t)ie  lu'uil :  A,  position  of  tht'  liuntlles  when  tirst  upplie<l ;  li,  ])osition  of  the  handles  alter  partial 
rotation  has  oeeurred. 

extreme  care ;  but,  though  an  active  rotation  force  is  not  permissible,  it  is 
always  proper,  and  indeed  necessary  to  success,  that  the  operator  should  avoid 
preventing  rotation.  He  should  know  exactly  the  motion  the  handles  will 
make  during  the  rotation  of  the  head,  as  that  occurs  under  the  guidance  of 
the  pelvic  grooves,  and  he  should  be  constantly  on  the  watch  to  promote  and 
favor  this  motion. 

In  this  connection  it  must  be  remembered  that  when  rotation  occurs  it  v  ill 
be  in  the  axis  of  the  blades  and  not  in  that  of  the  handles,  so  that  as  the 
blades  rotate  their  handles  will  move  in  a  laterally  circular  direction  such  as 
is  illustrated  in  Figure  205.     If  a  good  pair  of  straight  forceps  is  at  hand,  it 


THE  MECHANISM   OF  LABOR, 


45V 


is  much  the  better  instriimeut  for  low  operations  in  posterior  positions,  since 
with  it  no  such  lateral  motion  of  the  handles  occurs,  and  the  avoidance  of  the 
necessity  of  watching  for  it  greatly  simplifies  the  ojKjration. 

At  the  conclusion  of  each  traction  the  handles  of  the  forceps  should  be  sep- 
arated slightly,  since,  if  this  is  done,  the  head  not  infrequently  rotates  to  an 
anterior  position  within  the  blades.  This  maneuvre  is  especially  useful  when 
the  original  application  of  the  forceps  has  been  slightly  inaccurate,  and  the 
head  is,  in  consequence,  not  grasped  exactly  on  its  sides.  A  careful  digital 
examination  should  always  be  made  at  the  conclusion  of  each  traction,  in 
order  to  note  exactly  the  mechanism  which  is  going  on,  to  become  aware  of 
rotation  as  soon  as  it  occurs,  and  to  detect  any  tendency  to  extension  which 
may  have  followed  a  faulty  application  of  the  forceps. 

As  soon  as  the  position  is  slightly  anterior,  or  even  when  it  becomes  trans- 
verse, the  forceps  should  be  removed  and  reapplied  to  the  sides  of  the  head, 
but  this  time  with  the  concavity  of  the  pelvic  curve  toward  the  occiput,  since 
any  further  rotation  with  the  blades  in  the  former  position  wo^'''  carry  them 
into  the  position  of  the  reversed  forceps,  in  which  the  grasp  is  unsatisfactory 
and  the  danger  of  laceration  is  great  from  the  too  close  approach  of  the  tips  to 
the  posterior  wall  of  the  vagina.  The  tractions  should  again  be  intermittent, 
rotation  of  the  forceps  with  the  head  should  be  favored,  and  the  compression 
should  be  intermitted  during  the  intervals  between  the  tractions,  to  permit  the 
head  to  rotate  within  the  blades.  When  the  head  has  reached  the  O.  D.  A. 
position  the  forceps  should  again  be  removed,  and  reapplied  in  the  ordinary 
way,  unless  the  application  is  at  tiuit  time  wholly  unsatisfactory.  The  operation 
as  a  whole  is  vastly  more  difficult  than  is  an  extraction  in  an  anterior  position. 

Delivery  in  Persi^ienUy  Posterior  Positions. — When,  from  any  cause,  the 
proper  maintenance  of  flexion  has  been  neglec^ted,  and  the  occiput  has  settled 
into  the  hollow  of  the  sacrum — that  is,  where  it  has  become  directly  posterior 
— a  delivery  "  face  to  pubes "  is  all  that  can  be  hoped  for.  Under  these 
circumstances  delivery  by  the  natural  efforts  necessarily  implies  the  presence 
of  an  unusually  powerful  and  active  uterus.  It  is  necessary  for  the  pains  to 
force  the  head  into  extreme  flexion,  to  mould  it  into  a  much-changed  shape, 
and  to  distend  the  soft  tissues  to  an  extreme  degree  ;  and  the  vis-a-tergo  of  the 
uterus  must  usually  be  reinforced,  before  the  process  is  completed,  by  the  vis-a- 
f route  of  the  forceps. 

The  first  duty  of  the  obstetrician  is  to  establish  an  extreme  flexion  by. 
pressure  on  the  forehead  with  the  fingers  ;  it  will  then  be  maintained  by  nature 
if  the  uterus  is  powerful  enough  to  effect  an  unaided  delivery.  In  this  case 
an  attempt  to  preserve  the  perineum  by  keeping  the  occiput  well  forward 
against  the  pubes  is  his  only  other  duty ;  and  as  the  necessary  change  in  the 
shape  of  the  head  is  to  be  most  safely  effected  by  slow  moulding — that  is, 
during  a  long  second  stage — he  should  be  patient  and  loath  to  interfere ; 
indeed,  in  these  cases  the  use  of  the  forceps  is  never  warranted  unless  the  signs 
of  exhaustion  of  one  or  the  other  patient  are  clearly  present  and  increasing 
and  progress  has  ceased. 


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AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


If  the  forceps  must  be  used,  it  should  be  ai)pHed  to  the  sides  of  the  head, 
aud  the  extraction  should  be  effected  by  means  of  the  so-called  "  pump-handle 
traction."  The  tractions  should  at  first  be  directed  well  backward  until  the 
perineum  distends,  in  order  to  draw  the  occiput  downward  along  the  posterior 
pelvic  wall,  aud  then  should  sweep  forward,  in  order  to  draw  it  forward  over 
tke  pelvic  floor  to  the  vulva  and  the  arch  of  the  pubes.  These  tractions 
should  be  gentle  aud  intermittent,  in  order  to  encourage  a  slow  moulding  of 
the  head,*  and  the  forward  direction  should  be  maintained  until  the  small 
foutanelle  appears  at  the  fourchette  and  the  perineum  retracts  along  the  neck. 
The  handles  of  the  forceps  should  then  be  moved  backward,  but  without  inter- 
mission of  the  traction,  in  order  to  favor  the  appearance  of  the  face  from 
under  the  pubic  arch  by  extension  as  in  natural  labor. 

2.  Face  Presentations. 

Frequency. — A  face  presentation  is  not  a  very  common  anomaly.  Pinard 
found  320  fare  cases  out  of  81,711  deliveries  at  the  Paris  Maternity — a  fre- 
quency of  about  1  in  250.  At  Guy's  Hospital  Lying-in  Charity,  London, 
there  was  a  frequency  of  1  in  276,  or  .36  per  cent,  out  of  23,591  cases  of 
labor.  Churchill  analyzed  about  250,000  cases,  and  found  that  face  presen- 
tations averaged  1  in  231.  Collins  at  the  Dublin  Rotunda  found  the  fre- 
quency to  be  1  in  497.    Spiegelberg  thought  that  in  Germany  it  was  1  in  324. 

Relative  Frequency  of  the  Positions. — M.  L.  A.  is  but  very  slightly  more 
frequent  than  ^I.  D.  P.     M.  D.  A.  and  M.  L.  P.  are  very  rarely  seen. 

Etiology. — Face  presentations  are,  of  course,  ])r()duced  by  the  extension  of 
vertex  presentations  at  or  just  before  the  beginning  of  labor,  and  every  face 
presentation  has  therefore  passed  through  the  stage  of  brow  before  becoming  a 
face  presentation.  Many  factors  may  contribute  to  the  production  of  this  ex- 
tension, and  it  is  probable  that  the  etiology  of  the  anomaly  varies  widely  in 
different  cases.  It  may  be  originated  by  an  abnormal  shape  of  the  head,  by  an 
obliquitji  or  abnormality  of  the  uterus,  by  small  tumors  in  or  about  the  pelvic  brim, 
by  a  (hformiiy  of  the  pelvis,  or  by  an  over-tight  adaptation  between  the  head 
and  the  brim  in  a  posterior  position  of  the  vertex. 

Undue  Lene/th  of  the  Hind-head. — Any  abnormal  prominence  of  the  occi- 
put necessarily  lengthens  the  short  arm  of  the  cephalic  lever,  and  therefore 
tends  to  the  production  of  extension.  The  presence  of  such  an  anomaly  would 
undoubtedly  predispose  to  a  face  presentation,  and  cases  have  been  reported  in 
w'  '  'h  it  was  apparently  the  sole  cause ;  but  in  the  majority  of  face  cases  the 
heaw  is  found  to  be  of  normal  shape  after  the  moulding  of  labor  has  passed 
away,  and  was  therefore  probably  normal  at  the  beginning  of  labor. 

Obliquity  or  Abnormality  of  the  Uterus.. — An  obliquity  of  the  uterine  axis 
by  which  the  fundus  is  inclined  to  the  side  on  which  lies  the  back  of  the  child 
tends  to  roll  the  condyles  to  the  opposite  side  of  the  pelvis  by  altering  the 

*  Since  the  chief  danger  in  this  operation  is  that  of  inhibiting  the  life  of  the  fetus  by  com- 
pression of  its  skull  against  the  pubes,  it  is  well  to  have  the  fetal  heart  watched  by  an  assistant, 
and  to  regulate  the  force  of  the  tractions  by  the  eflect  produced  upon  its  beat. 


THE  MECHANISM   OF  LABOR. 


459 


Fig.  266.— Manner  In  which  an  obliquity  of  the 
uterine  nxis  may  produce  a  face  presentation. 


direction  of  the  uterine  force  (Fig.  266),  in  wliicli  the  condyles  are  urged 
(in  the  direction  of  the  arrow)  by  the  uteru.s,  and  thus  produces  extension. 
Again,  any  irregularity  in  the  contour  of  tne  uterine  wall  on  the  side  to  which 
the  occiput  is  directed — for  example,  a 
cicatrix  or  a  localizetl  tonic  constriction 
— may  delay  its  progress  and  so  pro- 
duce extension. 

Small  Tumorn  in  he  Brim. — A  tu- 
mor which  impedes  the  advance  of  the 
occiput,  but  does  not  interfere  with  the 
sinciput,  may  be  the  cause  of  a  face 
presentation. 

Pelvic  .  Deformities.  —  The  minor 
grades  of  flattened  ])elvis  in  which 
moderate  extension  at  the  brim  is  nor- 
mally present  (see  Di/stoci<i)  are  a  fre- 
quent cause  of  face  presentations. 

Tif/ht  Adaptaticn  in  the  Posterior 
Positions  of  Verte.v  Presentations. — We 
have  seen  (p.  443)  that  there  is  a 
marked  tendency  to  the  production  of  extension  at  the  brim  in  O.  D.  P.  and 
O.  L.  P.  positions.  That  this  is  a  frequent  cause  of  face  presentation  is  shown 
by  the  fact  that,  although  an  O.  D.  P.  occurs  but  about  once  in  every  four 
vertex  labors,  tlie  results  of  its  extension — that  is,  an  M.  L.  A. — make  up 
nearly  one-half  of  all   face  labors. 

Diagnosis. — On  abdominal  examination  the  fetal  limbs,  the  heart,*  and 
the  least  accessible  ])ortion  of  the  head  are  found  on  the  same  side.  On  va/fi- 
nal  examination  with  the  linger,  the  pointed  chin,  the  mouth  with  its  maxillary 
processes  and  the  tongue,  the  no.strils,  the  bridge  of  the  nose,  the  eyes,  and  the 
supraorbital  ridges  should  be  found  and  recognized.  The  position  is  deter- 
mined by  the  position  of  the  chin. 

Prognosis. — The  prognosis  in  face  presentations  for  both  mother  and  child 
is  always  somewhat  worse  than  in  vertex  labor,  but  it  varies  greatly  in  accord- 
ance with  the  position  of  the  diin,  the  prognosis  of  anterior  positions  being 
vastly  better  than  that  of  posterior  positions.  The  mortality  of  face  presenta- 
tions varies  also  between  extremely  wide  limits,  in  accordance  with  the  varia- 
tions in  the  adaptation  between  tlic  head  and  the  pelvis,  and  more  especially 
with  the  degree  of  ossification  of  the  fetal  liead. 

When  the  chin  is  anterior,  when  the  adaptation  between  the  head  and  the 
pelvis  is  moderately  easy,  and  the  fetal  head  is  so  soft  as  to  permit  of  an  easy 
production  of  the  necessary  change  of  shape,  face  labor  is  apt  to  be  rapid.  The 
prognosis  for  the  mother  is  then  unaltered  from  that  of  good  normal  labor, 
and  the  prognosis  for  the  child  is  but  little  worse;  but  this  statement  is  true 
only  when  the  conditions  are  such  that  there  is  rai)id  progress  throughout  the 
*  In  face  presentations  the  heart  is  heard  over  the  ventral  side  of  the  chest. 


V  ii-  '*:: 


W.  '  ifli:-H'^ 


460 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


second  stage :  witli  the  supervention  of  any  delay  tlic  prognosis  for  the  child 
becomes  decidedly  poor,  wiiile  at  the  same  time  the  mother's  prospects  arc 
rendered  less  good  by  the  risks  of  laceration  during  rotation  tiiat  are  always 
involved  in  a  difficult  or  operative  delivery  of  the  face. 

In  posterior  positions  of  the  chin  the  j)rognosis  for  the  child  is  always  poor, 
since  under  the  most  favorable  circumstances  it  is  necessarily  exposed  to  the 
utmost  danger,  both  from  the  marked  compression  of  the  cranium  against  the 
symphysis  that  invariably  occurs  and  from  the  great  tension  upon  the  tissues  of 
the  neck  that  is  implied  in  the  extreme  extension  necessary  to  excite  rotation 
in  posterior  positions  of  the  face.  With  any  but  the  most  extremely  favorable 
conditions  the  prognosis  for  the  child  in  posterior  positions  of  the  face  is 
almost  necessarily  fatal,  while  that  for  the  mother  is  complicated  by  the  proba- 
bility of  extensive  lacerations.  In  the  large  majority  of  such  cases  rotation 
fails,  and  the  child's  case  is  tiien  practirally  hopeless,  since  no  instance  has  yet 
been  I'ccorded  in  which  the  child's  life  was  preserved  during  tiie  extraction  of 
a  persistently  posterior  position  of  the  face.  ^ 

Mechanism  and  Manafirement  of  Face  Presentations. 

Mechanism  of  Face  Presentations. — In  the  mechanism  of  face  presenta- 
tions the  chin  plays  the  same  role  that  the  occiput  does  in  vertex  labor.  Rotation 
is  as  necessary  to  expulsion  in  the  one  case  as  in  the  other,  and  the  occurrence 
of  rotation  depends  on  the  fact  that  under  normal  conditions  the  chin  enters 
more  deeply  into  the  pelvis  tlian  the  most  prominent  point  upon  the  other  side 

of  the  head,  which  in  this  case  is  that 
portion  of  the  forehead  inmiediately 
anterior  to  the  bregma.  This  deeper 
entrance  of  the  chin  is  in  face  presenta- 
tion secured  only  by  the  existence  of 
complete  extension,  and  extension  is 
therefore  as  important  to  progress  dur- 
ing the  second  stage  of  face  labor  as 
is  flexion  during  the  second  stage  of 
vertex  labor. 

Mechanism   of   Face   Presentations, 
M.  L.  A. — Fully-developed   face  pres- 
entations  at    the    beginning   of    labor 
are    comparatively    rare.      The    face 
commonly   starts   as   a   vertex,  passes 
through  the  stage  of  a  brow  while  still 
unengaged,  and  becomes   a   face   presentation   only  during   the   passage  of 
the  brim.     By  reference  to  Figure  267,  which   represents  the  position  of 
the   head  during  the  passage  of  the  brim  by  a  face  presentation,  it   will 
be  seen  that  after  the  point  of  the  chin  has  passed  the  pelvic  brim   the 
ventral  side  of  the  head  and  the  neck  is  so  shaped  as  to  offer  but  little 
opportunity  for  the  engendering  of  friction  against  the  pelvic  wall,  while  the 


Fig.  267.— Presentation  cif  the  face  at  the  pelvic 
brim. 


THE   MKCHAXISM   OF  LABOR, 


461 


sliapo  t)f'  the  prdjec'tiug  forehead  and  bregmatie  region  is  such  as  to  ensure 
lirni  pressure  between  them  and  that  part  of  the  pelvis  opposite.  Tlie  j)osi- 
tiou  of  tlie  head  brings  its  articulation  with  the  spinal  column  tlir  out  to  the 


Fio.  'J08.— Face  prcsontntion  nt  imtlot  after  rotation  (Smelllo). 

ventral  side  of  the  head,  and  we  have  then  ti  9  pressure  of  the  propelling  force 
couceutrated  far  out  to  one  side  in  the  head,  while  the  resisting  force  of  friction 
against  the  jielvic  walls  is  exerted  almost  wholly  upon  the  other  side ;  hence 
good  extension  is  the  rule  in  face  labor.     The  existence  of  complete  extension, 


i| 


I  '- 


II 


* 


^^ 


■■mm 
I  ■mm' 


Fio.  269.— ConfiRuration  of  the  tVtnl  lunil  after  it.s       Fi(i.  JTO.— Configuration  of  tlie  fetal  Viead  after  its 
delivery  as  a  face  preseiitiitioii.  delivery  as  a  vertex  i)resentation. 

however,  places  so  groat  a  strain  upon  the  tissues  of  the  neck  that  its  produc- 
tion is  usually  accomplished  slowly  ;  and  the  diameter  which  must  occupy  the 
brim  as  the  head  descends — namely,  the  eervieo-bregmatic  (Fig.  267) — is  so 


AMKlilVAN   TEXT-BOOK   OF   OliSTETJilCS. 

lurge  that  wiih  reasonably  tight  adaptation  the  deseent  of  tlie  faee  is  iisiiallv 
accomplished  at  the  exj)eii.se  ot"  consi«lerable  niouliling  of  tiie  head  (Fig.  2(Jt)j. 

The  eervieo-breginatie  diameter  of  tiie  head  is  so  far  behind  the  leading 
point,  the  chin,  that  by  the  time  the  head  is  free  from  the  superior  strait — 
that  is,  when  this  great  diameter  passes  it — the  chin  is  already  deep  in  the 
pelvis,  and  does,  indeed,  by  this  time  occupy  the  deepest  portion  of  the  ante- 
rior groove  of  the  left  lateral  wall.  At  tiiis  point  tiiere  is  often  a  temporary 
dead-loek,  since  the  great  elongation  of  the  head  may  still  leave  the  region 
of  the  sagittal  suture  in  the  sacro-iliac  notch,  where  it  is  prevented  by  the 
promontory  from  turning  backward,  although  the  chin  is  being  urgctl  strongly 
forwai'd  by  the  lower  jwrtion  of  the  anterior  gntove. 

Ii(jtation  can  then  occur  only  when  the  propelling  force  is  sufficiently  strong 
to  crowtl  the  chin  downward  to  the  lowest  possible  jK)int,  and  may  even  require 
a  further  lateral  moulding  of  the  head  under  the  pressure  of  the  promontoiv 
agaiust  the  projecting  occiput. 

As  soon  as  the  occiput  slips  under  the  promontory  rotation  i)romptly  occurs. 
The  chin  swings  under  the  pubic  arch  (Fig.  2(38),  and  the  mouth,  the  nose,  the 
eyes,  and  the  forehead  successively  appear  at  the  fourchette.  When  tlie  angle 
of  the  jaw  rests  against  the  descending  rami  of  the  pubes,  the  chin  and  the  face 
)econu'  wholly  freed  from  pressure,  while  the  occiput  is  still  exposed  to  the 
propelling  power  of  the  uterir^  force  from  above.  The  chin  then  sweeps 
upward,  and  as  the  occiput  continues  to  progress,  the  bregma,  the  small 
fontanelle,  and  the  occiput  successively  appear  at  the  fourchette,  and  the  head 
emerges  by  flexion. 

The  mechanism  of  face  labor  is,  then,  extension,  descent,  rotation,  and  hirtji 
by  flexjon.  Restitution  carries  the  chin  to  the  side  to  which  it  was  originally 
directed  during  the  expulsion  of  the  shoulders.  The  mechanism  of  M.D.A. 
labor  is,  of  coui-se,  similar  to  that  of  M.  li.  A. 

The  Mechanism  of  Posterior  Face  Presentations,  M.  D.P. — The  chin 
enters  the  posterior  groove  at  the  brim,  and  should  ti'avel  forward  along  its 
course ;  but  even  when  extension  is  complete  the  production  of  so  extensive  a 
rotation  as  is  necessary  to  bring  the  chin  t(t  the  front  is  rendered  extremely 
difficult  by  the  marked  obstacle  affiorded  to  its  perfcrmance  by  the  resistance 
of  the  very  prominent  bregi^iatic  region,  which,  notwithstanding  its  size  (Fig. 
271),  must  be  made  to  travel  backward  along  the  whole  left  lateral  surface  of 
the  brim — a  motion  possible  only  when  the  propelling  forces  are  sufficiently 
powerful  and  the  head  is  sufficiently  soft  to  permit  the  protluction  of  a  very 
extreme  degree  of  moulding  of  the  head.  When  rotation  has  once  carried 
the  chin  into  i.  i  anterior  position,  the  mechanism,  of  course,  is  that  of  a 
primary  M.  D.  A.  Xo  separate  description  of  the  M.  L.  P.  mechanism  need 
be  given. 

-■■.  Management  of  Face  Presentations. — Mmiarjemcnt  of  Face  Presentatioii>< 
at  the  Brim. — The  measures  which  must  be  considered  in  the  management  of  face 
presentations  when  detecteil  while  the  child  is  still  in  or  above  the  brim  are  as 
follows :  The  case  may  be  left  to  nature;  an  attempt  may  be  made  to  niise  the 


(Fig. 

('(.'  of 

-iitly 

verv 

IT  i  0(1 

of  a 

1100(1 


TllK    Mi:%IlA\IS.V    #/••    LMi^H. 


chill,  and  «o  roston-  a  vcrtox  pnsoiitatioii  l>y  idiiiiikiI  jiexinn  »f  tin'  litail,  aftor 
wliicli  it  may  bo  loft  to  nature  <»r  l)o  dolivorod  l»y  tlio  forcops ;  fonrjtn  may  Ik; 
applied  to  (lie  face  as  aiioli,  or  the  rase  may  at  once  he  delivered  by  irrni(>n. 

NntnrdI  Labor. — The  first   expedient,  that  of  leaving  the  case  to  the  «'are 
of  nature,  is  applioablu  only  under  one  set  (tf  cireiimstaiu'es.     Wlieii  the  chiu 


Fi(i.  '_>7I.— Posterior  position  of  tlie  faro  deeply  engnKed  in  tlie  pelvis  (Smellie'. 

is  anterior ;  when  the  woman  is  a  multipara  who  has  liad  a  succession  of  easy 
labors;  if  the  accoucheur  is  able  to  satisfy  himself  by  a  thorough  examination 
that  the  soft  parts  are  soft  and  dilatable,  that  the  ])elvis  is  ample,  and  that  the 
child  is  small,  the  latter  point  having  been  determined  not  only  by  palpation  of 
the  abdomen,  but  also  by  palpation  of  the  head  with  the  half  hand  introduced 
into  the  vagina ;  when  the  uterus  is  j)owerful  and  the  pains  are  frequent ;  and, 
finally,  when  no  ])athol()gieal  complication  is  present, — it  is  often  wise  to  adopt 
a  conservative  policy ;  but  the  conse(piences  of  delay  are  so  serious  even  in 
anterior  positions  of  the  face,  and  the  prediction  of  an  easy  labor  is  always  so 
(litficult,  that  the  obstetrician  should  feel  that  in  making  this  prediction  and 
adopting  a  policy  of  inaction  he  is  taking  a  very  grave  responsibility.  When 
the  chin  is  posterior,  or  when,  in  anterior  positions,  the  conditions  are  anything 
but  the  most  favorable,  it  should  bo  the  rule  that  the  detection  of  a  face  pres- 
entation at  the  brim  is  to  be  followed  by  immediate  interference. 

Interference  at  the  Brim. — The  choice  of  methods  rests  between  manual 
fcvion  of  the  head  into  a  vertex  presentation,  version,  and  the  application  of 
forceps  to  the  face. 

The  choice  between  version  and  the  production  of  a  head  presentation  by 
manual  flexion  rests  mainly  on  the  position  of  the  chin.  If  the  chin  is  pos- 
terior, flexion  of  the  head  will  result  in  the  production  of  an  anterior  position 


,L! 


-i'-  iV^, 


r-^: 


',:^  d", 


1      ''!?  iLiliJJJ 


m  >  i , 


y    1  ":  ; 


*  I 


!  '  III     '.       '         ! 


I 


^ 


ji:  .       ;    I 


^^ 


AMERICAN    TEXiP-BOOK   O^    OBSTETRICS. 


of  the  vortex — the  most  favorable  position  for  a  subsequent  delivery  by  nature 
or  for  an  extraction  by  the  forceps  ;  if  the  chin  is  anterior,  flexion  can  produce 
only  the  unfavorable  posterior  position  of  the  vertex.. 

In  posterior  positions  of  the  chin  manual  flexion  should  ordinarily  be  the 
first  expedient,  and  the  head,  when  flexed,  should  be  urged  into  the  brim  by 
external  pressure  with  the  hand,  in  the  hope  that  it  may  become  engaged  in 
this  position  under  the  influence  of  the  pains,  after  which  the  case  should,  of 
course,  be  left  to  nature ;  but  if  an  engagement  does  not  follow  promptly,  it  is 
host  to  apply  forceps  at  once,  since  the  conditions  which  originally  produced 
the  face  presentation  may  usually  be  relied  upon  to  reproduce  it.  If  the  manual 
reproduction  of  a  vertex  presentation  proves  difticult  or  impossible,  the  attempt 
should  be  abandoned  and  version  be  performed. 

If  the  chin  is  anterior,  flexion  of  the  head  would  result  in  the  production 
of  a  posterior  position  of  the  vertex ;  and  siuce,  as  has  been  seen,  posterior 
positions  of  the  vertex  at  the  brim  are  usually  best  treated,  when  interference 
is  necessary,  by  a  resort  to  version,  it  follows  that  in  anterior  positions  of  the 
chin,  when  interference  is  necessary,  a  primary  version  is  the  operation  of 
choice.  When  in  such  cases  a  version  is  contra-indicated,  the  choice  lies  between 
an  application  of  the  forceps  to  the  face  and  a  manual  flexion  into  a  poste- 
rior position  of  the  vortex,  to  be  followed  by  an  attempt  at  a  manual  rota- 
tion of  the  occiput  to  the  front  and  the  application  of  forceps.  If  the 
conditions  are  such  as  to  render  this  latter  operation  possible,  it  is  generally 
preferable  to  the  use  of  forcoj)s  to  the  face ;  but  since  the  conditions  which 
contra-iiidicate  version  very  generally  render  manual  rotation  of  the  head  diffi- 
cult or  impossible,  it  will  sometimes  be  necessary  to  resoi't  in  such  cases  to  the 
use  of  forceps  to  the  face. 

The  u„e  of  forcops  to  the  face  at  the  brim  is  always  a  difficult  operation. 
The  delivery  of  the  child  through  the  brim  without  injury  to  either  mother  or 
child  can  be  accomplished  only  by  the  utmost  accuracy  in  the  adjustment  of 
the  blades ;  and  oven  in  anterior  positions  the  prognosis  is  serious.  The  use 
of  forceps  to  the  face  higii  is,  then,  never  permissible  to  any  but  a  thoroughly 
skilled  operator,  and  even  in  such  hands  it  should  be  reserved  for  a  last  resort. 
In  posterior  positions  the  forcops  is  ncvcv  permissible,  and  it  should  be  forbid- 
den both  from  its  inherent  difficulties  and  because  success  in  the  passage  of 
the  brin;  can  (»nly  result  in  the  production  of  that  very  dangerous  condition, 
a  jwstcrior  jiosition  of  the  face  within  the  excavation. 

Manaf/euicnt  of  Face  Frcsentatlonx,  Low. — Chin  Anterior. — When  a  face 
presentation  has  been  allowed  to  pass  the  brim  or  has  not  been  discovered  until 
it  is  within  the  excavation,  its  j)rogress  should  be  watched  with  great  care,  and 
the  utmost  pains  must  be  taken  to  maintain  complete  extension  throjighout  the 
second  stage.  A  constant  watch  over  the  processes  of  nature  must  be  main- 
tained, since  any  considerable  delay  is  attended  by  great  danger  to  the  life  of 
the  child,  from  the  likelihood  that  an  interruption  of  its  cerebral  circulation 
may  occur  as  a  result  of  the  extreme  tension  necessarily  put  u{)on  the  vessels 
of  the  neck  or  of  their  compression  against  the  sides  of  the  pelvis. 


\    y 


THE   MECHANISM   OF  LABOR. 


i!^ 


by  nature 

1  produce 

ily  be  the 

2  brim  by 
ngaged  in 
houlcl,  of 
iptly,  it  is 

produced 
be  manual 
le  attempt 

)roduction 
,  posterior 
iterf'erence 
jns  of  the 
jratiou  of 
is  between 
o  a  poste- 
mual  rota- 
If  the 
!  genemlly 
ions  which 
liead  diffi- 
ases  to  the 

operation, 
mother  or 
istmeut  of 
The  use 
lioroughly 
list  resort, 
be  forbid- 
)assage  of 
couditioii, 

leu  a  face 
ered  until 

care,  and 
ghout  the 

be  main- 
he  life  of 
irculation 
he  vessels 


It  follows  from  these  dangers  that  even  moderate  delay  furnishes  a  sufficient 
indication  for  the  use  of  low  forceps  in  face  presentations.  Complete  exten- 
sion, as  has  been  said,  is  of  the  utmost  importance,  and,  fortunately,  may  easily 
be  maintainetl  by  pressure  with  the  fingers  upon  the  under  surface  of  the  lower 
jaw.  Should  interference  become  necessary,  it  is  absolutely  important  that  the 
forceps  should  be  applied  to  the  sides  of  the  cranium,  and  with  the  tips  so  far 
posterior  as  to  be  entirely  clear  of  the  neck.  In  anterior  positions,  if  this 
necessity  be  borne  in  mind,  the  application  of  forceps  is  easy,  and  the  extraction 
of  the  child  ordinarily  presents  no  great  difficulties ;  but  it  must  not  be  foi"- 
gotten  that  pressure  upon  the  tissues  of  the  neck  by  the  tips  of  the  blades  nmst 
almost  invariably  result  in  loss  of  the  child. 

Chin  Posterior. — As  has  been  said,  the  face  should  never  be  allowed  to  enter 
the  pelvis  chin  posterior.  If  this  abnormality  is  not  discoveral  until  it  has 
occurred,  the  patient  should  at  once  be  etherized,  the  hanvl  be  introduced,  and 
the  possibility  of  raising  the  head  above  the  brim  should  be  tested.  If  this 
is  possible  without  grave  risk  to  the  mother,  it  should  at  once  be  done,  and  the 
face  dealt  with  according  to  the  principles  already  outlined  for  the  operative 
treatment  of  the  face  high  (p.  463). 

If  elevation  of  the  iiead  proves  impossible,  the  obstetrician  should  content 
himself  with  the  maintenance  of  extreme  extension  by  traction  upon  the  chin 
in  combination  with  a  constant  attempt  to  promote  rotation  by  drawing  the 
chin  forward  with  the  fingers.  This  process  should  be  persisted  in  so  long  as 
there  is,  in  his  judgment,  any  possibility  of  rotation.  When  this  prospect 
becomes  hopeless,  forceps  may  be  applied  and  an  attempt  be  made  to  extract 
the  face  as  a  persistently  posterior  chin  presentation. 

Any  atteu'pt  at  rotation  by  the  forceps  must  be  forbidden,  both  because  of 
the  grave  danger  of  j)rovoking  extensive  lacerations  of  the  mother  that  neces- 
sarily attends  this  maneuvre,  and  because  any  slipping  of  the  blades  upon  the 
child  or  any  oblicpie  application  of  the  forceps  would  necessarily  involve  com- 
pression of  the  vessels  of  the  fetal  neck,  and  therefore  the  loss  of  the  fetus.  A 
straight  forwps  should  be  used  if  it  is  at  hand.  It  should  be  applied  care- 
fully to  the  sides  of  the  head  and  with  the  tips  well  anterior,  so  that  the  grasp 
of  the  blades  may  be  wholly  upon  the  cranial  vault.  The  tractions  should  be 
directed  slightly  backward  until  the  perineunj  is  thoroughly  upon  the  stretch, 
tlion  forward  and  upward  until  the  chin  emerges,  and  then  well  downward,  that 
the  occiput  may  emerge  under  the  arch  and  the  head  be  born  by  flexion.  Since 
lacerations  of  the  pelvic  floor  are  inevitable  in  this  operation,  and  since  every 
possible  advantage  nmst  be  taken,  the  j)erineum  should  be  incisal  by  deep  lat- 
eral Incisions  as  a  preliminary  measure. 

This  [)rocess  has  not  yet  been  successful  in  the  extraction  of  a  living  child  ; 
but  since  it  has  never,  so  far  as  known,  been  adopted  while  the  child  was  in 
good  condition,  and  as  it  has  several  tisnes  succeeded  in  extracting  dead  but 
uninjured  children,  it  deserves  a  more  extended  trial  whenever  a  childin  this 
posititm  is  still  in  fairly  good  condition.  If  the  child's  vitality  is  already  seri- 
ously compromised,  its  chances  of  life  are  so  small  that  the  prospect  of  preserv- 


•3; 


• 


» 


J  s 


■fi, . 


fit 


V466 


AMERICAN    TEXT-BOOK    OF   OJiSTI-yTRICS. 


f  ! 


i      '      I   \\^^i 


'  i  i| 


;/ 


ing  the  mother's  soft  tissues  would,  in  the  judgment  of  most  obstetricians, 
justify  the  choice  of  craniotomy.* 

8.  Brow  Presentations. 

Frequency. — As  face  cases  liave  usually,  if  not  invariably,  passed  through 
the  stage  of  brow  in  the  process  of  their  conversion  from  a  vertex  presentation, 
temporary  presentations  of  the  brow  must  be  at  least  as  frequent  as  those  of 
tiie  face;  but  if  only  those  brow  presentations  which  remain  such  until  altered 
by  the  obstetrician  are  included  in  the  list,  the  freijuency  becomes  less — jiro- 
bal)ly  not  more  than  1  in  1500  labors. 

Relative  Frequency  of  the  Ponitious. — Brow  ().  L.  A.  and  brow  ().  D.  P.  arc 
almost  equally  freciuent.     The  others  are  much  less  common. 

Etiology. — Brow  presentations  are  due  to  the  same  causes  th  produce 
])rcsen  tat  ions  of  the  face,  but  it  \s  of  course  a  fact  that  if  the  process  of  exten- 
sion is  arreste<l  in  the  stage  of  brow,  it  implies  a  greater  obstacle  to  the  prog- 
ress of  the  head  than  where  nature  is  able  to  develop  a  face  ])resentation. 

Diagnosis. — On  nInJombial  examination  the  two  ends  of  the  head  are  found 
at  about  the  same  level,  and  the  heart  is  usually  heard  over  the  back.  On 
vaf/inal  examination  the  small  fontanelle  is  found  at  one  end  of  the  field,  the 
large  fontanelle  in  its  centre,  and  the  supraorbital  ridges  on  the  other  side. 

Prognosis. — Since  at  term  and  with  a  normal  head  the  spontaneous  delivery 
of  an  unchanged  brow  presentation  is  possible  only  after  a  degree  of  prolonga- 
tion of  labor  that  is  disapproved  by  modern  obstetrics,  the  prognosis  of  ju^r- 
sistent  brow  presentations  for  both  mother  and  child  is  that  of  the  operation 
chosen.  It  should  be  remembered,  however,  that  when  nature  changes  the 
brow  to  a  face  the  prognosis  becomes  that  of  a  face  presentation. 

Mechanism  and  Management  of  Brow  Presentations. 

Mechanism  of  Presentations  of  the  Brow. — Anterior  Ponition  of  the  lirnir 
-■p"'-'  T-> ..  {that  i,s,  brow  O.  D.  P.  and  brow  ().  J,. 

P.). — In  the  rare  cases  in  which  a  jircs- 
entation  of  the  brow  succeeds  in  enter- 
ing the  pelvis,  this  possibility  is  due  to 
the  fact  that  the  mouhling  of  the  liciid 
lias  [)rogressed  until  the  occipito-mental 
diameter  has  become  sufficiently  sniiili 
to  pass  the  oblique  at  the  brim,  and  this 
change  is  compensated  for  by  a  corre- 
sponding increase  in  the  ocicipito-frontiil 
diameter  (Fig.  272).  The  increase  in 
the  length  of  this  diameter  necessarily 
carries  the  forehead  much  deeper  into  the  pelvis  than  any  other  part  of  the 


Fio.  272.— fonnpurntlon  nf  tlio  fetal  lii-nd  nftiT  its 
(li'livcry  lis  a  brow  pR'ni'iitatioii. 


*  Since  tlie  aliove  w;is  writton  the  greiit  success  of  syniphysiotoniy  has  led  most  ohstetriciniis 
to  believe  that  a  division  of  the  symphysis  shoidd  jirecede  all  aj)i)lications  of  tlie  forceps  to  a 
peiT^istently  posterior  position  of  the  face. 


THE   MECHANISM   OF  LABOR. 


467 


liead,  so  that  lu  auterior  positions  of  the  brow  the  projecting  forehead  engages 
in  tlie  auterior  groove  of  the  lateral  pelvic  wall  as  soon  as  the  brim  has  been 
passed,  and  reaches  its  deeper  part  by  the  time  the  occiput  escapes  from  the 
sacro-iliac  notch  and  enters  the  shallow  u|)per  part  of  the  posterior  groove  of 
the  opposite  pelvic  wall. 

If  the  conditions  are  so  exceptionally  favorable  as  to  permit  of  the  expul- 
sion of  an  unchanged  brow  presentation,  the  forehead  moves  forward  along 
tiie  course  of  the  anterior  groove,  while  the  occiput,  being  still  in  the  shallow 
up])er  part  of  the  posterior  groove  of  the  opposite  side,  moves  back  into  the 
liollow  of  the  sacrum  ;  the  root  of  the  nose  conies  to  the  pubic  arch,  and  the 
pntgress  of  the  anterior  portion  of  the  head  is  then  arrested,  while  the  occiput 
travels  down  along  the  jxtsterior  wall  of  the  pelvis  and  across  the  perineum. 
The  nose  and  the  chin  then  appear  beneath  the  pubic  arch,  and  the  head  in 
anterior  positions  of  the  brow  is  thus  expelled  by  extension.  External  rota- 
tion, of  course,  carries  the  occiput  to  the  side  to  which  it  was  originally 
directed. 

Posterior  Pomtions  of  (he  Brow  {that  is,  brow  O.  L.  A.  and  brow  O.  D.  A.). 
— Should  an  unchanged  posterior  position  of  the  brow  succeed  in  passing  the 
l)rim,  the  forehead  would  enter  the  posterior  groove  and  the  occiput  would 
lie  against  the  shallow  portion  of  the  anterior  groove.  If  the  case  went  on  to 
delivery,  the  rotation  of  the  forehead  along  the  posterior  groove  would  be 
similar  to  that  of  the  occiput  in  occipito-posterior  positions  of  the  vertex  ;  but 
when  the  enormous  difficulties  incident  to  the  expulsion  of  the  brow  under  the 
most  favorable  circumstances  are  increased  by  the  inherent  difficulties  always 
attached  to  rotation  in  posterior  positions,  the  sum-total  of  the  obstacle  becomes 
so  great  that  a  delivery  is  almost  unknown,  and  it  may  be  laid  down  as  a  practi- 
cal rule  that  |)osterior  positions  of  the  brow  always  become  arrested. 

Manag'eiuent  of  Brow  Presentations :  Management  at  the  Brim. — 
When  a  brow  presentation  is  detected  at  the  brim,  we  may  deal  with  it  by  any 
one  of  the  four  following  methods  :  the  case  may  be  left  to  the  care  of  nature  ; 
the  brow  may  be  converted  into  a  vertex  by  manual  flexion  ;  the  brow  may  be 
changed  into  a  face  by  manual  extension  ;  or  the  case  may  be  delivered  by 
innneiliate  version.  The  choice  between  these  methods  of  treatment  depends 
primarily  on  the  position,  but  in  posterior  positions  of  the  brow — that  is,  when 
tiic  occiput  is  anterior — the  indications  are  considerably  modified  by  the  pres- 
iiu'c  of  excessive  moulding  of  the  presenting  part. 

Anterior  Positions  of  the  Brow. — The  class  of  cases  which  should  be  left 
to  the  care  of  nature  is  extremely  limited,  and  includes  only  those  few  cases 
of  auterior  positions  of  the  brow  which,  when  detected,  are  raj)idly  changing 
into  anterior  positions  of  the  face,  and  in  which  the  conditions  of  the  case  are 
such  that,  if  the  face  becomes  established,  its  progress  is  certain  to  be  rapid 
and  easy.  Flexion  of  such  a  brow  would  jirodnce  a  j)osterior  jiosition  of  the 
vertex,  and  there  is  then  but  little  hope  of  a  spontaneous  delivery  of  the  new 
presentation,  since  the  marked  tendency  to  extension  which  always  character- 
izes uie  posterior  positions  of  the  vertex  woidd  almost  certainly  reproduce  the 


«•;■  t 


fj^T : 


mm 
1,1  •iff 


let 


:  „ 


468 


AMERICAN    TEXT- BOOK   OF   OBSTETRICS. 


i  r  n 


1  \i 


iiSiia 


/ 


brow,  while  if  an  operative  delivery  is  to  he  undertaken,  vei-sion  is  the  opera- 
tion of  election  in  posterior  positions  of  the  vertex.  It  follows  that  vei-sion 
is  the  operation  of  choice  in  anterior  positions  of  the  brow  (see  Management 
of  Face  Freseutatious  at  the  Brim,  p.  462). 

All  other  anterior  positions  of  the  brow  should  be  dealt  with  by  iinniediato 
version  as  the  o|)eration  of  choice,  the  production  of  a  vertex  by  manual  flex- 
ion being  ruled  out  for  the  following  reasons  : 

In  freeing  a  partially-engaged  brow  from  the  brim  of  the  pelvis  as  a  pre- 
liminary to  version,  it  is  essential  thai  the  first  effort  at  raising  the  head  should 
be  directed  against  the  forehead,  siiice  a  preliminary  flexion  of  the  head  re- 
places the  long  occipito-mental  diameter  by  the  shorter  occipito-frontal  diam- 
eter, and  the  subsequent  elevation  of  the  head  therefore  exposes  the  tissues  of 
the  mother  to  far  less  risk  than  would  be  involved  in  an  attempt  to  force  the 
extended  occipito-mental  diameter  bodily  upward.  Moderate  flexion  is,  more- 
over, an  important  element  to  success  in  the  subsequent  manipulations  of  the 
version,  since  its  production  minimizes  the  obstacle  offered  by  the  projecting 
sincip.it. 

When  in  anterior  positions  of  the  brow  which  ]>romise  a  difficult  delivery 
an  attempt  at  version  fails,  a  manual  extension  of  the  brow  to  an  anterior  posi- 
tion of  the  face,  to  be  followed  by  forceps,  is  the  only  alternative  to  craniotomy, 
unless  the  condition  of  the  child  warrants  a  resort  to  one  of  the  major  cutting 
operations  (see  The  I'^se  of  Forceps  to  the  Face  at  the  Brim,  p.  464). 

When  the  brow  presents  in  a  posterior  position — that  is,  with  the  occiput 
anterior  and  with  the  head  unmoidded — its  treatment  by  mainial  flexion  results 
in  the  production  of  an  anterior  position  of  the  vertex,  and  a  manual  flexion 
is  therefore  in  these  cases  the  operation  of  choice.  After  the  re-establishment 
of  flexion  the  head  should  be  held  in  position  by  the  hands  for  a  few  pains; 
but,  unless  its  engagement  occurs  promptly,  it  is  usually  best  to  resort  to  an 
imtnediate  a])plication  of  the  forceps,  since  it  may  fairly  be  presumed  that  the 
conditions  which  originally  led  to  the  loss  of  flexion  are  still  present,  and  will 
probably  reproduce  the  extension  if  the  case  is  left  to  itself.  In  this  position 
of  the  brow  a  manual  extension  is  contra-indicated,  since  it  could  only  result  in 
the  production  of  a  posterior  variety  of  the  face,  which  in  itself  is  so  danger- 
ous that  it  demands  an  immediate  version.  If,  therefore,  in  these  cases  a 
manual  flexion  is  ruled  out,  version  should  again  be  selected  as  the  o})eratioii 
of  secoiul  choice. 

When  the  brow  presents  in  a  posterior  position — that  is,  with  the  occiput 
anterior  and  with  the  head  already  much  moulded — the  oj)eration  of  manual 
restoration  of  the  vertex  must  be  ruled  out  in  the  interest  of  the  child,  for  the 
following  reasons:  Fii-st,  if  a  marked  change  of  shape  is  apparent  at  the  time 
the  presentation  is  detected,  the  restoration  of  a  vertex  presentation  by  ii 
manual  flexion  of  the  head  ))resents  great  difHculty  ;  moreover,  the  conditions 
are  so  much  altered  by  the  change  in  shape  of  the  head  that  its  re-extension 
into  a  brow  would  almost  certaiidy  occur  as  soon  as  the  pains  reappear  or  the 
forceps  is  applied.      Second,  a  vertex  delivery  involves  so  extensive  a  re- 


THE   MECHANISM   OF  LABOR. 


469 


moulding  of  the  head  to  its  original  shape  as  to  expose  the  child  to  great  risk 
of  danger  from  cerebral  hemorrhage ;  while  the  delivery  of  a  much-moulded 
brow  by  version — that  is,  by  the  extraction  of  the  after-coming  head — results 
in  but  little  change  i'l  shape,  and  is  therefore  nmch  the  safer  for  the  child. 
Version   is,  then,  the   only  operation  which  should  be  considered  in  these 


oases. 


The  operative  treatment  of  brow  presentations,  high,  may  be  summarized 
as  follows :  In  anterior  positions,  version  is  the  operation  of  choice.  In  the 
posterior  positions  of  unmoulded  brows  a  manual  flexion  to  au  anterior  posi- 
tion of  the  vertex  and  a  subsequent  application  of  forceps  to  the  head  should 
be  preferred ;  this  failing,  version  should  be  the  second  choice.*  In  the  pos- 
terior positions  of  much-moulded  heads  version  should  be  selected. 

A  high  application  of  forceps  to  the  brow  is  ordinarily  more  dangerous 
to  the  mother  than  a  craniotomy,  and  but  little  more  ho{)eful  for  the  child. 
The  abdominal  operations  would  be  indicated  only  in  the  interests  of  the 
child,  and  would  usually  be  contra-indicated  by  the  fact  that  the  vitality  of 
the  child  is  usually  considerably  lowered  by  the  time  the  ordinary  operations 
have  become  impossible. 

Management  of  Brow  Presentations  after  their  Entrance  into  the  Pelvis. — 
Since  the  brow  never  enters  the  pelvis  until  after  an  excessive  moulding 
has  been  produced,  and  since  the  adaptation  is  then  always  so  close  that  any 
alteration  of  the  presentation  is  impossible,  it  is  unnecessary  to  discuss  in  this 
connection  any  other  prol)lem  than  the  delivery  of  the  brow  as  such  excessively 
moulded  and  closely  adapted  to  the  pelvic  cavity. 

If  the  sinciput  is  anterior,  the  forceps  should  be  applied  to  the  sides  of  the 
head  with  the  concavity  of  its  pcilvic  curve  anterior,  and  the  mechanism  of  the 
natural  delivery  of  a  persistent  brow  should  be  imitated.  The  tractions  should 
be  directed  downward  and  backward  until  the  root  of  the  nose  engages  at  the 
arch,  and  their  direction  should  thou  gradually  be  moved  forward  and  upward 
until  the  occiput  sweeps  forward  over  the  perineum,  then  downward  again  to 
permit  the  emergence  of  the  face ;  but  the  chance  of  extracting  a  living 
cliild  in  this  way  is  so  small,  and  the  risk  to  the  mother's  tissues  is  so 
extremely  great,  that  the  application  is  never  permissible  unless  the  child 
is  in  fairly  good  condition.  If  its  vitality  is  already  seriously  lessened,  it 
is  probably  the  best  practice  to  deliver  by  craniotomy.  Such  cases  are, 
fortunately,  almost  never  seen  during  the  life  of  the  child,  and  perhaps 
never  at  term. 

If  the  brow  has  entered  the  pelvis  with  the  ninciput  posterior,  and  the  child 
is  still  alive,  a  very  cautious  attempt  to  promote  rotation  by  the  forceps  might 
be  justifiable ;  but  success  would  be  extremely  unlikely,  and  a  resort  to  crani- 
otomy would  almost  certainly  be  necessary.  This  condition,  however,  is  so 
extremely  rare  that  it  is  almost  unnecessary  to  refer  to  it. 

*  An  extension  to  a  face  and  a  subsequent  rotation  of  the  chin  to  the  front  are  occasionally 
possible,  but  this  operation  is  always  diflicult,  and  should  not  be  attempted  by  operators  of  small 
experience. 


!.'  M 


it  ''I 


'     I 


if 


■[  ■! 


i';  ! 


i. 


WM 


■n 


1? 


i'i     ffl^ 


'  .  VI 


■  I--    f 


470 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


4.  Pelvic  Pkesentations. 


Pelvic  presentations  are  commonly  divided  into  breech,  knee,  and  footling 
presentations ;  but  knee  and  footling  presentations  are  so  similar  in  every 
respect  to  those  of  the  whole  breech  that  it  is  convenient  to  treat  them  as  sub- 
variations. 

Frequency. — Pelvic  presentations  occur  in  about  1  in  30  labors  when  mis- 
carriages and  i)reniature  labors  are  included.  Among  laboi"s  at  term,  however, 
their  frequency  falls  to  about  1  in  60  cases.  Thus,  Pinard  found  among 
100,000  cases  3301  pelvic  i)rosentations,  but  on  excluding  the  premature  cases 
the  proportion  fell  to  1  in  62.  Among  pelvic  presentations  about  60  per  cent, 
are  presentations  of  the  breech. 

Etiology. — Pelvic  presentations  are  produced  by  the  failure  of  the  condi- 
tions which  ordinarily  ensure  the  existence  of  cephalic  presentations  (see  p. 
418).  They  are,  then,  especially  frequent  among  premature  and  macerated 
children,  when  the  liquor  aninii  is  excessive  and  when  the  uterine  and  abdom- 
inal walls  ."'.e  very  lax.  They  are  the  rule  in  hydrocephalus,  and  one  out  of 
every  four  twins  is  a  breech  child.  In  deformed  pelves,  too,  in  which  the 
head  is  unlikely  to  become  fixed  at  the  inlet  during  the  last  weeks  of  jM-eg- 
nancy,  breech  presentations  become  more  frequent.  S.  D.  A.  and  S.  L.  P. — 
that  is,  the  two  positions  in  which  the  long  diameter  of  the  breech  occupies 
the  first  oblique  diameter  of  the  inlet — are  much  more  common  than  S.  L.  A. 
and  8.  D.  P.  Knee  and  footling  presentations  are  probably  always  secondary, 
and  are  due  to  an  active  movement  of  the  fetal  limbs. 

Diagnosis. — On  ahdommal  examination  the  head  is  found  at  the  fundus 
and  its  absence  is  noted  at  the  brim;  the  heart  is  heard  above  the  umbilicus. 
On  v<f(/inal  cramination  in  presentaticns  of  the  breech  the  presenting  part  is 
at  first  high  and  is  reached  with  difficulty.  The  finger  recognizes  the  vulva 
or  the  scrotum  and  penis,  as  the  case  may  be,  the  anus,  and  the  sacral  spines. 
On  rectal  examinaticm  of  the  fetus  the  coccyx,  the  tuberosities  of  the  ilia, 
and  the  pubic  arch  are  easily  recognizable.  The  position  is  best  determined 
by  the  position  of  the  coccyx  as  ascertained  by  a  rectal  examination.  In  knee 
and  footling  cases  the  prolapsed  extremity  is  recognized  by  its  anatomical 
characters  (see  p.  415). 

Prognosis. — The  prognosis  for  the  mother  in  breech  presentations  is  only 
altered  from  the  normal  by  the  frequency  with  which  rapid  extractions  are 
necessary,  and  by  the  fact  that  in  such  extractions  there  is  a  greatly  increased 
risk  of  laceration.  The  ])rognosis  for  the  child  is  always  poor,  the  mortality 
running  as  high  as  10  per  ccht.  in  skilled  hands.  The  prognosis  for  both 
patients  is  worse  when  the  mother's  soft  parts  are  rigid — for  example,  in 
primiparse. 

Mechanism  and  Management  of  Breech  Presentations. 

Mechanism  of  Breech  Presentations. — Normal  Mechanism. — In  breech 
presentations  the  first  stage  is  ordinarily  abnormally  slow.     If  the  membranes 


'^^i^ifis 


wmm 


THE   MECHANISM   OF   LABOR. 


471 


are  intact,  the  dilutatiou  of  the  os  is  perfcvmed  by  them  as  in  head  presenta- 
tions, and  every  care  should  be  taken  to  preserve  their  integrity  until  the  os 
is  fully  dilated.  This  precaution  is  of  special  importance  in  breech  presenta- 
tions, since,  although  the  small  and  tapering  breech  is  not  ill-adapted  to  the 
dilatation  of  the  os,  the  breech,  when  considered  as  a  dilating  wedge,  labors 
under  the  disadvantage  that  its  small  size  renders  its  passage  through  the 
cervix  an  inefficient  preparation  of  the  soft  parts  for  the  passage  of  the  larger 
and  harder  head ;  extensive  lacerations  of  the  cervix  are  therefore  frequent 
whenever  the  pre[)aration  of  the  cervix  has  been  entrusted  to  the  breech. 

When  the  resistance  of  the  cervix  has  been  overcome,  the  comparatively 
small  and  soft  breech  naturally  enters  the  pelvis  easily,  as  tlie  bitrochanteric 
diameter,  the  greatest  diameter  of  the  breech,  is  less  than  any  of  the  diam- 
eters of  the  brim.  The  bitrochanteric  diameter  enters  in  one  or  the  other 
oblique  diameter,  and  is  then  crowded 
downward  into  the  pelvis  until  the  pos- 
terior hip  impinges  on  the  pelvic  Hoor, 
when,  under  the  forward  shunt  of  this 
portion  of  the  posterior  wall  of  the  pel- 
vis, the  breech  as  a  whole  bends  for- 
ward by  a  lateral  inflection  of  the  trunk 
(Fig.  273).  This  movement  engages 
the  anterior  hip  in  the  deep  portion  of 
the  anterior  groove  of  that  side  of  the 
pelvis  to  which  it  is  directed,  and  as 
the  anterior  hip  rotates  forward  the 
posterior  hip  slips  back  into  the  groove 
of  the  sacrum.     The  lateral  infiection 

becomes  well  marked,  the  anterior  buttock  appears  at  the  vulva,  and  as 
the  trunk  is  driven  more  dee[)ly  into  the  pelvis  by  the  uterine  contractions 
tiie  anterior  hip  becomes  fixed  at  the  pubic  arch,  and  the  posterior  hip  swings 
forward  until  the  posterior  buttock  and  trochanter  appear  successively  from 
under  the  fourchette. 

As  the  posterior  half  of  the  breech  emerges  the  perineum  retracts  upward 
Aug  the  child's  pelvis,  and,  all  pressure  being  thus  removed  from  the  pos- 
teupr  surface  of  the  breech,  the  inflection  is  released  and  the  trunk  of  the 
child  is  permitted  to  straighten  itself  again,  thus  releasing  the  anterior  hip 
from  its  position  of  pressure  against  the  pubic;  arch ;  the  whole  trunk  then 
moves  downward  through  the  j)elvis,  and  only  such  moderate  lateral  inflection 
as  is  necessary  to  accommodate  the  trunk  to  the  course  of  the  pelvic  bones 
still  persists.  When  the  legs  remain,  as  they  should,  in  their  normal  position 
of  flexion,  the  escape  of  the  knees  from  the  vulva  releases  the  lower  extrem- 
ities. 

At  about  the  time  the  umbilicus  appears  at  the  vulva  the  shoulders  enter 
the  brim,  their  transverse  axis  lying  in  the  oblique  diameter.  H  the  arms 
remain  in  their  normal  position — that  is,  crossed  over  the  breast — the  anterior 


Kl(i 


:7;i.--I,iitiTnl  inflection  of  tlio  truiili  dnring 
oxpnlsion  of  tlie  broei'li. 


i^E^  ^ 


\i  \i 


'■;.■  ! 


14  ill. 


:*  V:\ 


k.  ( 


a 


M 


W}i 


1  ;  -i 


i  I 


'1, 


■i     I 


472 


AMEEICAN   TEXT-BOOK   OF   OBHTETRICS. 


shoulder  rotates  to  the  arch  and  is  delayed  by  fixation  against  its  inner  surface, 
while  the  posterior  shoulder  and  elbow  i)ass  the  vidva.  The  escape  of  the 
posterior  shoulder  so  diminishes  the  size  of  that  portion  of  the  body  occupy- 
ing the  outlet  as  to  permit  the  anterior  shoulder  to  escape  from  the  arch  and 
emerge  from  beneath  it. 

The  pressure  of  the  uterus  upon  the  longer  arm  of  the  cephalic  lever  should, 
under  uorinal  conditions,  preserve  the  flexion  of  the  head.  In  this  condition 
the  chin  aod  the  face  necessarily  enter  the  pelvis  first,  the  suboccipito-frontal 
and  suboccipito-bregn)atic  diameters  occuj)ying  one  of  the  oblique  diameters 
of  the  superior  strait.  Since,  at  the  time  the  head  engages  at  the  superior 
strait,  the  sho'ilders  have  already  rotated  into  a  position  in  which  the  bis- 
acromial  diameter  occujjies  the  antero-posterior  diameter  of  the  outlet,  the  head 
approaches  the  superior  strait  in  a  transverse  diameter,  but  the  recession  of  the 
j)osterior  portion  of  the  lateral  wall  of  the  pelvis  at  the  brim,  as  it  approaches 
the  sacro-iliac  notch,  causes  the  face  and  the  forehead,  the  first  portion  of  the 
head  entering  the  pelvis,  to  swing  backward  into  a  posterior  position.  The 
after-coming  head  thus  normally  enters  in  an  occipito-anterior  position. 

As  the  head  eutei"s  the  excavation  the  sinciput  is  so  much  lower  in  the 
pelvis  than  the  occipital  end  of  the  head  that  it  swings  along  the  course  of 
the  posterior  groove  until  it  slips  into  the  median  line  upon  the  pelvic  floor, 
the  occiput  which  is  still  exposed  to  the  smooth  bony  surface  of  the  brim  at 
the  same  time  rotating  to  the  median  line  in  front.  The  face  appears  followed 
by  the  forehead  at  the  vulva,  the  perineum  retracts  over  the  bregmatic  region, 
and  the  head  is  born,  still  in  a  state  of  flexion. 

Afmormal  Mechanwn  of  Breech  Presentations. — The  frequent  occurrence 
of  abnormalities  in  breech  presentations  is  to  be  accounted  for  by  the  ease 
with  which  the  legs,  the  arms,  and  the  head  may  become  extended  l)y  friction 
against  the  pelvic  wall.  The  descent  of  the  legs  and  the  arms  should  normally 
be  accomplished  jxw!  passu  with  that  of  the  body  through  the  transmission  of 
the  uterine  force  to  their  uj)per  surfaces  by  the  liquor  amnii ;  but  in  a  large  pro- 
portion of  cjises  the  cervix  has  still  sufficient  resiliency  to  contract  tightly  upon 
the  fetal  trunk  after  the  legs  have  passed  the  cervix.  The  upper  surface  of  the 
legs  is  then  cut  off  from  the  pressure  of  the  liquor  amnii,  while  their  descent 
is  still  opposed  by  an  undiminished  friction  against  the  pelvic  walls ;  agaH, 
they  may  be  detained  by  being  themselves  caught  in  the  grasp  of  the  cervix, 
while  the  body  continues  to  descend  ;  or,  finally,  they  may  have  been  placed  in 
an  extended  position  by  the  action  of  their  intrinsic  muscles.  As  a  result,  it 
not  infrequently  occurs  that  the  legs  become  extended  against  the  body  during 
the  descent  of  the  breech.  Under  these  circumstances  it  occasionally  hapj)ens 
that  the  legs  are  sufficiently  closely  applied  to  the  child  to  act  as  rigid  splints 
to  its  trunk,  thus  causing  arrest  by  preventing  the  lateral  inflection  necessary 
to  the  passage  of  the  trunk.  An  arrest  due  to  this  cause  usually  necessitates  a 
resort  to  operative  interference. 

The  re-contraction  of  the  cervix  upon  the  body  may  also  result  in  an  exten- 
sion of  the  arms  upwai'd  during  the  descent  of  the  shoulders,  until  they  lie  along 


SR 


THE  MECHANISM   OF  LABOR. 


473 


the  sides  of  the  head.  The  shoulders  then  enter  the  pelvis  normally,  but 
their  further  progress  is  arrested  by  the  fact  that,  unless  the  child  be  small  or 
llio  pelvis  be  uiuisually  ample,  the  head  and  the  arms  form  too  bulky  a  mass 
10  enter  the  i)elvis  together  easily,  and  the  interference  of  the  obstetrician  is 
;igain  required.  Even  though  the  legs  and  the  arms  maintain  their  normal 
relations  to  the  trunk,  the  passage  of  the  head  may  be  arrested  by  extension. 
Under  normal  circumstances  the  sinciput  is  driven  into  the  pelvis,  because  the 
pressure  of  the  liquor  amuii  upon  the  forehead  is  usually  sufficient  to  overcome 
the  resistance  of  the  face  against  the  pelvic  walls,  and  there  is  nothing,  there- 
litre,  to  disturb  the  original  relation  of  flexion  of  the  head  upon  the  chest ; 
l)iit  if  the  attendant  is  injudicious  enough  to  make  traction,  or  if  the  already 
delivered  portion  of  the  trunk  is  unsupported,  its  weight,  under  the  influence 
of  gravity,  is  transmitted  to  the  head  through  the  occipito-atlantoid  articulation, 
and  a  traction  is  thus  initiated  which  is  exerted  solely  against  the  occipital  end  of 
the  head.  The  result  is  an  abnormally  rapid  descent  of  the  occiput.  If  this 
descent  occurs  before  the  head  enters  the  superior  strait,  it  may  cause  sufficient 
extension  to  result  in  the  entrance  of  the  occipito-mental  or  the  occipito-frontal 
diameter  into  the  superior  strait,  and  thus  produce  an  arrest  of  the  head  in  this 
])oi'tion  of  the  pelvis.  If  the  influence  of  gravity  only  becomes  active  after 
the  entrance  of  the  forehead  into  the  pelvis,  no  more  than  a  partial  extension 
is  likely  to  result,  but  this  partial  extension  brings  the  occiput  into  the  deeper 
portion  of  the  anterior  groove  of  one  lateral  wall,  while  the  sinciput  rests  in 
the  posterior  groove  of  the  opposite  wall.  Rotation  of  the  forehead  forward 
is  thus  prevented,  and  there  results  a  dead-lock  which  can  only  be  broken  up 
when  a  rapid  descent  of  the  forehead — that  is,  the  restoration  of  flexion — is 
secured  by  operative  influence. 

Still  another  abnormality  occasionally  occurs.  When  the  child  is  small  or 
the  pelvis  is  exceptionally  ample — in  other  words,  when  the  adaptation  between 
the  child  and  the  pelvis  is  abnormally  easy — the  shoulders  may  enter  the  brim 
in  the  transverse  diameter.  If  the  back  of  the  child  is  anterior,  this  produces 
no  modification  of  the  mechanism ;  the  shoulders  become  oblique,  and  finally 
antero-posterior,  during  their  passage  through  the  lower  part  of  the  pelvis,  the 
head  enters  with  the  sinciput  posterior,  and  the  birth  goes  on  normally.  If, 
however,  the  shoulders  enter  the  superior  strait  transversely  in  a  posterior 
position  of  the  breech,  the  face  and  the  forehead  usually  become  engaged  in  the 
anterior  portion  of  the  pelvis  before  rotation  of  the  shoulders  can  occur.  If, 
under  these  circumstances,  the  flexion  of  the  head  is  thoroughly  well  marked, 
the  forehead  passes  along  down  the  course  of  the  anterior  groove,  the  face 
appears  under  the  arch  while  the  neck  retracts  the  perineum,  and,  if  the  pains 
are  of  tiiC  very  best,  the  forehead  may  be  urged  down  uuder  the  arch  and  the 
head  be  born  in  flexion. 

The  successful  conduct  of  this  form  of  mechanism  by  the  forces  of  nature 
is,  however,  rare.  It  often  happens  that  the  projecting  chin,  the  mouth,  or  the 
nose  catches  upon  the  upper  border  of  the  pubic  bones.  The  sincipital  end  of 
tlie  head  is  then  delayed,  exteusiou  results,  the  head  jams  across  the  brim  by 


m 


i 


474 


AMERICAN   TKXT-ROOK   OF   OBSTETRICS. 


$-- 


'  'il 


,1  >\-h\ 


the  occipito-meutal  or  tlie  occMpito-fVontal  diameter,  and  an  absolute  arre  t 
usually  follows.  Delivery  by  the  efforts  of  nature  then  almost  never  oecurs, 
and  is  only  possible  when  the  adaptation  is  so  easy  that  the  uterus  is  able  to 
drive  the  occiput  through  the  brim,  while  the  chin  slips  upward  and  forward 
over  the  horizontal  ranuis  of  the  pubes  in  order  to  make  room  for  it.  If  this 
happy  release  of  the  chin  happens,  complete  extension  follows,  the  occiput 
appears  under  the  fburchette,  and  the  head  is  born  in  extension.  This  move- 
ment of  extension  is,  however,  usually  accomplished  only  by  traction  on  the 
body  or  by  the  application  of  the  forceps ;  even  then  it  is  likely  to  involve  so 
much  delay  that  the  preservation  of  the  life  of  the  child  is  unlikely. 

Management  of  Breech  Presentations. — Nothing  more  thoroughly  tests 
the  skill  and  judgment  of  the  obstetrician  than  his  management  of  a  breech 
presentation.  Upon  the  one  hand,  it  is  of  the  first  importance  that  he  should 
remain  inactive  so  long  as  the  natural  processes  are  progressing  satisfactorily. 
Upon  the  other  hand,  he  must  be  prompt  to  foresee  the  appearance  of  danger 
to  the  child,  and  to  interfere  as  soon  as  this  danger  is  manifest.  He  cannot 
be  warned  too  strongly  to  avoid  premature  interference,  since  the  use  of  trac- 
tion instantly  disarranges  the  delicate  balance  by  which  the  normal  attitude  of 
the  child  is  maintained.  As  before  stated,  the  maintenance  of  flexion  in  natu- 
ral breech  labor  is  due  to  the  facts  that  the  legs,  arms,  and  forehead  are  driven 
down  by  the  action  of  the  intra-uterine-fiuid  pressure  upon  their  upper  sur- 
faces, and  that  this  pressure  is  more  than  sufficient  to  overcome  the  friction  of 
the  pelvic  walls  against  the  lower  surfaces  of  these  parts ;  but  when  traction 
is  made  upon  the  breech,  the  additional  force  thus  supplied  is  distributed  to 
the  members  only  through  the  knees,  the  shoulders,  and  the  occipito-atlantoid 
articulation  respectively,  while  the  very  fact  of  its  application  —that  is,  the 
promotion  of  a  more  rapid  descent — increases  the  force  of  friction  exerted 
against  the  feet,  the  hands,  and  the  forehead.  Traction  is  then  almost  invari- 
ably followed  by  extension  of  the  legs,  the  arms,  and  the  head,  with  all  its 
inherent  difficulties. 

When,  however,  interference  is  demanded,  speed  in  extracting  the  arms 
and  head  is  essential.  After  the  scapula)  appear  five  minutes  is  an  average 
time,  within  which  the  mouth  should  be  brought  to  the  vulva. 

He  who  interferes  in  a  breech  delivery  should  feel  that  unless  unusual  good 
fortune  attends  his  effi)rts  he  is  likely  to  be  confronted  by  the  necessity  of  a 
manual  delivery  of  each  and  every  portion  of  the  child's  anatomy  as  these  por- 
tions successively  approach  the  pelvis.  ICven  in  the  most  skilled  hands  this 
process  is  attended  by  much  more  danger  to  the  child  than  is  involved  in  a 
natural  delivery. 

Since  natural  delivery  is  ordinarily  possible  only  when  complete  flexion 
is  maintained,  since  a  single  traction  is  likely  to  produce  extension,  and  since, 
■when  extension  has  once  occurred,  delivery  is  ordinarily  possible  only  by  the 
immetliate  adoption  and  subsequent  prosecution  of  an  operative  extraction,  it 
becomes  evident  how  important  it  is  that  the  obstetrician  should  remain  abso- 
lutely inactive  unless  there  arise  circumstances  which  show  him  that  nature  is 


THE   MECHANISM   OF  LABOR. 


475 


likely  to  fail — that  is,  that  the  best  chances  for  the  child  have  been  lost,  and 
that  the  second  best  must  be  taken  ;  for  if  it  be  true,  upon  the  one  hand,  that 
a  prompt  natural  delivery  is  i«afer  for  both  mother  and  child  than  the  best 
operative  interference,  it  is  equally  true,  upon  the  other  hand,  that  when 
nature  fails  in  promptness  the  only  hope  for  the  child  and  the  best  prospect 
for  the  mother  is  to  be  secured  by  the  immediate  performance  of  an  o|K'rative 
delivery. 

Management  of  Nonnal  Breech  Labor. — In  breech  labor  the  obstetrician's 
duty,  so  long  as  progress  is  normally  rapid,  is  reduced  to  the  following  details  : 

It  is  wise  never  to  <!onduct  a  breech  labor  without  one  skilled  assistant,  if 
such  a  person  can  be  obtained.  This  assistant  should  give  the  ether  if  this  is 
required,  and  should  be  ready  to  apply  suprapubic  pressure  to  the  head  if  a 
rapid  extraction  becomes  necessary  When  delivery  is  imminent  the  woman 
should  be  placed  in  the  lithotomy  position,  since  there  is  never  any  certainty 
that  interference  may  not  become  necessary  at  any  moment.  It  is  also  well  to 
put  the  patient  slightly  under  the  influence  of  ether  as  soon  as  the  delivery  is 
thought  to  be  near  at  hand,  since,  if  interference  is  indicated,  it  is  rendered 
greatly  easier  by  anesthesia,  and  because  a  jiartial  anesthesia  can  be  raised  to 
the  surgical  degree  with  much  less  loss  of  time  than  is  necessary  to  produce 
unconsciousness  in  a  totally  unetherized  patient. 

From  the  time  the  breech  enters  the  |)elvis  the  fetal  heart  should  care- 
fully be  watched,  since  there  is  always  danger  of  compression  of  the  cord,  and 
for  this  reason  any  irregularity  of  the  fetal  heart  is  sufficient  cause  for  inter- 
ference. As  soon  as  the  cord  can  be  reached  its  pulsations  will  keep  the 
obstetrician  informed  of  the  condition  of  the  child. 

As  soon  as  the  buttocks  emerge  from  the  vulva  they  should  be  wrapped  in 
a  warm  sterilized  cloth  ;*  the  attendant  should  do  his  utmost  to  relieve  the 
perineum  from  undue  strain  by  pressing  the  hips  and  the  pelvis  of  the  child 
into  close  contact  witii  the  arch ;  and  even  after  the  delivery  of  the  hips  he 
should  continue  to  support  the  breech  in  an  elevated  ])osition  for  the  same  rea- 
son. When  the  knees  appear  he  should  reduce  the  bulk  of  the  })resenting  part 
by  f!>}xing  out  the  legs.  As  soon  as  the  umbilicus  is  within  reach  of  the  finger 
he  should  gently  draw  down  a  loop  of  the  cord,  to  avoid  the  danger  of  undue 
tension  upon  the  cord  or  up(m  the  umbilicus  during  the  subsequent  descent 
of  the  body.  The  hips  and  the  body  should  still  be  held  constantly  forward 
toward  the  mother's  abdomen,  in  the  curve  of  Cams,  in  order  that  the  rota- 
tion and  expulsion  of  the  head  may  not  be  interfered  with  by  the  weight  of 
tli(!  body;  but  no  traction  should  be  made  during  this  process.  As  the 
elbows  appear  the  forearms  should  be  drawn  out,  and  if  the  fetal  body  is 
sufficiently  elevated  the  head  should  follow  without  delay. f 

Rapid  Extraction  of  the  Breech  when  Arrested  High. — When  a  breech  is 
arrested  at  the  superior  strait  until  the  signs  of  exhaustion  of  one  or  the  other 

*  Wirm  in  order  to  lessen  the  danger  of  a  jjremature  resi)iration,  sterile  on  account  of  its 
contact  with  the  vnlva. 

t  For  the  procedure  of  extracting  tlie  Ijcad  and  arms  low,  see  page  480. 


I' )' 


■X 


t>b. 


AMERICAN   TKXT-liOOK   OF   OBSTETRICS, 


patient  appear,  or  when  a  rapi^l  delivery  becomes  necessary  by  reason  of  some 
condition  which  threatens  tlio  life  of  mother  or  child,  five  methods  of  securiiiir 
descent  are  applicable :  Traction  may  be  made  npon  the  anterior  j;roin  with 
the  finycr,  the  JilUt,  or  i\\i  blunt  hook ;  forceps  may  be  applied  to  the  breech  ; 
or  the  hand  may  be  inserted  into  the  uterns,  and  be  made  to  briiKj  down  a  f(y 
for  use  as  a  handle  by  v^jiich  to  make  traction. 

Of  these  metliods,  the  use  of  finj^er  in  the  groin  is  always  preferable  when 
its  employment  is  possible,  but  in  high  arrest  of  tiie  breech  the  finger  seldom 
has  sufficient  power  to  secure  descent ;  and  if  the  breech  is  but  slightly 
engaged  in  the  brim  at  the  time  interference  becomes  necessary,  the  introduc- 
tion of  the  hand  to  bringdown  a  leg  is  ordinarily  the  metiiod  which  should  be 
chosen  when  the  finger  in  the  groin  fails.  If  the  breech  is  already  so  far 
engaged  as  to  render  this  maneuvre  ditficult  or  dangerous,  the  cautious 
employment  of  the  blunt  hook  or  the  fillet  is  permissible.  An  ojierator  of 
practised  skill  may  succeed  by  the  forceps,  but  the  application  of  this  instru- 
ment to  the  breech  at  the  superior  strait  is  not  to  be  recommendeil  to  begin- 
ners. 

llie  Use  of  the  Fim/er. — In  applying  this  metluKl  the  half  hand  should  be 
passed  into  the  vagina,  the  forefinger  be  hooked  into  the  groin  in  any  manner 

convenient  to  the  operator,  and  traction 
be  made  downward  and   backward  in 
the  axis  of  the  superior  strait.     Care 
should  be  taken  to  direct  the  line  of 
traction  rather  toward  that  side  of  the 
pelvis  to  which  the  back  of  the  child 
is  directed,  in  order  to  lessen  the  dan- 
ger of  snapping  the  femur  (Fig.  274). 
The  Blunt   Hook.— Yioth  the  fillet 
and  the  blunt  hook  can  usually  be  ap- 
plied to  the  groin,  without  s|)ecial  diffi- 
culty, in  any  jjortion  of  the  pelvis,  and 
both  furnish  fairly  effective  means  of 
traction ;    both   instruments,    however, 
labor  under  the  disadvantage  of  subjecting  the  tissues  of  the  child  to  great  risk 
of  injury,  the  blunt  hook,  when  skilfully  used,  being  perhaps  the  less  daneri   - 
ous.    The  hook  should  be  passed,  under  the  guidance  of  the  finger,  betwo- 
anterior  hip  of  the  child  and  the  pubic  bones  until  it  can  be  so  rotated  tl.>.    its 
point  passes  between  the  child's  thigh  and  alxlomen.     The  finger  should  tin  ■ 
be  passed  between  the  thighs  and  be  brought  into  contact  with  the  point  of  the 
hook,  which  should  then  be  settled  downward  by  gentle  traction  until  its  curve 
fits  snugly  into  the  flexure  of  the  groin.     The  shank  of  the  hook  should  then 
be  grasped  by  the  hand  to  which  the  finger  belongs  (Fig.  275),  and  traction 
should  be  made  with  the  other  hand,  the  finger  lying  in  contact  with  the 


^'  ^"^SC'f ' 


Fio.  'J:4.- 


-Proper  (A)  imd  improper  (B) directions 
of  traction  upon  the  thigh.* 


*  Though  represented  with  tlie  fillet,  this  Figure  illustrates  equally  the  manner  of  employ- 
ing the  fillet,  the  blunt  hook,  or  the  finger. 


THE  MV.VHANISM   OF   LAIiOR. 


477 


point  of  tlie  hook  tlirotiglioiit  tho  cxtniction,  in  ordor  to  protect  the  soft  pnrtH 
from  injury  as  f'nr  as  |>ossil)l»'.  The  liiit>  of  traction  .should  iw  dirertcd  toward 
(he  side  on  which  the  sacrum  lies,  in  onler  to  avoid  fnicture  of  the  thigh. 


■■\tl 


Fui.  27.').— Mf  thod  of  gruHpIng  the  blunt  hook. 


The  Fillet. — The  fillet  may  be  made  of  a  i>iece  of  broad  tape,  preferably 
linen  on  account  of  its  greater  strength,  or  of  a  wide  .strip  torn  from  a  silk 
handkerchief;  the  best  fillet  known,  however,  is  that  made  by  pa.ssing  a  stout 
cord  through  a  piece  of  rubber  tubing  about  three-eighths  of  an  inch  in 
diameter.  The  fillet  may  occasionally  be  passed  through  the  groin  by  the  un- 
aided fingers,  but  in  high  arrest  it  is  seldom  possible  to  succeed  in  adjusting  it 
l)y  this  method.  Several  instruments  have  been  devised  for  the  special  j)urpose 
of  placing  the  fillet,  but  their  place  can  be  filled  equally  well  by  a  piece  of 
string  and  a  large  English  webbing  catheter.  The  disinfected  catheter  should 
he  threaded  with  a  double  looj)  of  disinfected  string  or  of  narrow  bobbin,  and 
with  its  stilette,  should  then  be  bent  to  the  shape  of  the  blunt  hook  (Fig.  276). 
The  catheter  shoidd  be  pas.sed  into  the 
groin  in  the  manner  directed  for  the  use 
of  the  blunt  hook,  and  the  finger  should 
dnvw  down  the  projecting  loop  of  string 
until  the  end  of  the  fillet  can  be  passed 
through  it,  when,  by  the  removal  of 
the  catheter,  the  fillet  is  jjlaced  in  posi- 
tion in  the  groin.  The  .same  precaution 
as  to  the  direction  of  the  line  of  trac- 
tion must  be  observed  with  the  fillet  as 
that  recommended  for  the  blunt  hook 
and  the  finger. 

The  Use  of  Forceps. — If  the  forcej^s 
is  used  in  high  arrest  of  the  breech,  its 
application  is  similar  to  that  which  is  to  be  described  under  low  arrest  (p. 
478     although  it  is  much  more  difficult. 

The  Extraction  of  a  Leg. — In  the  introduction  of  the  hand  into  the  uterus 
to  bring  down  a  leg,  the  breech  should  be  pres.sed  back  gently  through  the 
brim  before  any  attempt  is  made  to  pass  the  hand.  The  utmo.st  gentleness 
sh'  'Id  be  observetl  throughout  this  maneuvre,  and  undue  ten.sion  on  the  utero- 
vaginal attachments  should  be  avoided  by  a  careful  maintenance  of  counter- 


FiG.  276.— t'sc  of  the  cfttheter  as  a  porte-fiUet. 


(      * 


-lA, 


^i.-:!- 


s 


;i 


mi 


■II 


478 


AMFJilCAN    THXT-BOOK   OF    OBSTETRICS. 


prt'ssiiro  against  the  fiiiuliis  with  the  other  liand.  The  operator  should  always 
be  careful  to  ascertain  the  position  of  the  cord,  to  avoid  the  production  of  an 
uiHiecessary  prolapse.  If  the  foot  is  within  reach,  it  should  be  seized  and 
gently  drawn  out  fnMn  the  os.  He  should  seize  the  anterior  leg  whenovcr 
that  is  accessible,  as  the  line  of  traction  on  the  anterior  leg  can  be  kept  nearly 
in  the  axis  of  the  inlet,  while  a  pull  on  the  rear  leg  brings  the  anterior  but- 
tock to  a  sitting  position  on  the  brim,  and  the  traction  in  a  line  running  from 
the  child's  hip,  located  near  the  mother's  i)romontory  through  the  vulva.  If 
the  legs  are  extended  across  the  chest,  two  fingers  should  be  placed  along  the 
crest  of  the  tibia,  and  be  used  to  so  flex  the  leg  tiiat  the  foot  passes  down 
the  median  line  of  the  child's  abdomen  until  it  reaches  a  position  in  whitii 
it  «ui  be  seized  and  withdrawn. 

When  the  foot  appears  at  the  vulva,  the  h'g  should  be  wrapped  in  a  towel 
which  has  been  dipped  in  a  warm  solution  of  corrosive  sublimate,  and  traction 
should  be  made  upon  it  in  a  line  which  shoidd  at  first  be  directed  as  far  back- 
ward as  the  perineum  allows,  in  order  to  pull,  so  far  as  possible,  in  the  axis  of 
the  superior  strait.  As  the  breech  descends  the  line  of  traction  should  swing 
fi)rward,  until,  when  the  hips  clear  the  vulva,  it  is  directed  nearly  vertically 
upward,  the  woman  being  in  the  lithotomy  position.  As  soon  as  the  knee  is 
well  outside  the  vulva  the  grasp  should  be  shifted  to  the  thigh,  as  any  pro- 
longed traction  on  the  lower  leg  is  apt  to  overstrain  the  ligaments  of  the 
knee-joint.  If  there  is  any  difficulty  in  bringing  the  breech  to  the  vulva,  its 
delivery  may  be  assisted  by  hooking  the  forefinger  into  the  other  groin  as  soon 
as  it  is  within  reach  ;  as  the  breech  distends  the  perineum  it  should  be  drawn 
well  forward,  and  every  effort  sliould  be  made  to  prevent  a  laceration  precisely 
as  is  done  in  the  delivery  of  the  fore-coming  head. 

When  the  second  knee  appears  at  the  vulva,  it  should  be  drawn  outward 
along  the  side  of  the  child  and  toward  its  back,  until  the  fingers  can  reach  the 
leg  and  release  the  foot  by  flexion  of  the  leg  ui)on  the  thigh  ;  but  all  pressure 
upon  the  shaft  of  the  fenuu*  nnist  carefully  be  avoided,  since  fracture  of  the 
fenuir  during  this  process  is  always  easy.  Care  should  be  taken  to  bend  the 
knee  only  in  the  natural  direction. 

littpid  Extraction  of  the  Breech  leliea  Arrexfed  Low. — Low  arrest  of  the 
breech  can  usually  be  overcome  by  the  use  of  the  Ji)i(/er  in  the  groin,  which 
method  should  always  be  the  first  tried,  li  this  method  fails,  the  use  of  the 
Jiflety  or,  better,  the  hliail  hook,  is  decidedly  less  dangerous  to  the  child  in  low 
than  in  high  arrest,  the  method  of  applying  them  being  exactly  the  same;  the 
Joreepx  is  here,  however,  easy  and  is  almost  invariably  eflicient;  moreover,  if 
due  care  is  exercised,  this  instrument  is  fiir  less  likely  to  injure  the  child  than 
is  the  blunt  hook. 

Applk'dtio)!  of  the  Forcej)^  to  the  Jireedt  Lojr, — If  the  breech  lies  in  an 
antero-posterior  or  obli(pie  position,  the  tip  of  one  blade  of  the  forceps 
should  lie  against  the  upper  sacral  vertebne,  while  that  of  its  fellow  should  bo 
pressed  into  the  flexor  surlace  of  the  most  easily  accessible  thigh  (Fig.  277). 
If  the   position  of   the   hii)s  is  transverse,  each    tip  of  the   forceps  should 


THE  MECIIAyLSM    OF    I.AJiOR. 


479 


of  tlio 

wlik'h 

of  tlio 

ill  low 

110 ;  the 

)V('r,  if 

tiiaii 

ill  iiii 

uild  1)0 

277). 
slioukl 


impinge  upon  a    foimir  just  above   or    Itovond    the    trocliaiitor,    whicii    then 
furnishes  a  firm  hold  for  the  blades  (Fig.  27<S). 

In  making  the  application  the  forceps  shonld  be  placed  in  an  ai>proxi- 
inately  correct  position  upon  the  breech,  locked,  and  held  lightly  in  this  posi- 
tion. A  hand  should  then  be  passed  into  the  vagina  until  the  tinger-tips  can 
touch  the  exact  spots  at  whicli  t!ie  tips  of  the  blades  should  lie;  an  accurate 
adjustnieut  is  then  easily  attained  by  direct  movements  of  the  tijis  of  the  blades 
with  the  internal  fingers.  The  small  size  of  the  tapering  breech,  iu  comparison 
with  the  diameters  of  any 
pelvis  through  wiiich  a 
living  child  can  be  ex- 
tracteil,  renders  it  easy  to 
obtain  an  accuracy  in  the 
adjustment  of  the  forceps 
that  is  impossible  of  at- 
tainment when  the  forccjis 
is  used  upon  the  head.  It 
is  this  fact  which  renders 
the  forceps  valnai)le  in 
this  connection,  since  the 
avoidance  of  injury  to  the 
child  and  the  attainment 
of  a  secure  grasp  of  the 
breocli  are  to  be  eH'ected 
only  by  the  adjustment 
of  the  tips  to  exactly  the 
points  to  which  they  were 
directed,  and  the  utmost 
care  nuist  be  observed  in 
verifving  the  position  of 
the  forceps  before  any 
traction  is  made.  When 
the  operator  is  sure  that 

the     instrument     is    satis-  Fm.  JT-.-Forcops  applied  to  IV;.  OT,-lM,r..,.ps,.pplu..l  t,. 

lilCtOI'ilv    in    Ilosition     the     ""     "I'liilUL'     piisiUuii    nl     the      u    tnuisvcrso    positldU    ot    lliL- 
,         111         111  I      bret'uh.  Ijri'i'cli 

liaiulles  should  he  grasped 

sufliciently  tight  to  ensure  a  firm   pressure,   which  shonld  then   be  maintained 

without  intermission  until  after  the  (k.'livery  of  the  child. 

The  ordinary  forceps  is  better  adapted  to  this  application  than  any  special 
forms  which  have  yet  been  devised.  When  the  instrunient  is  used  u|)oii  the 
high  lireeeh  the  advantages  of  axis-traction  are  perhaps  more  t'ully  apparent 
than  in  juiy  other  obstetric  operation. 

l\(ipi(l  Krfrdcfinn  of  the  Tridili. — As  soon  as  the  legs  and  the  jielvis  of  the 
child  have  cleared  the  vulva,  they  should  be  grasped  (througli  a  warm  as(>ptic 
towel)  in  the  manner  shown  in  Figure  279,  in  which  each  thigh  is  grasped  by 


V.I 


[ 

U  .1' 


'  '1' : 


!  'i  I 


■!-:g: 


,'■   1    * 


i'^'^i 


480 


AMERICAN    TEXT- HOOK   OF   OBSTETRICS. 


V'i 


\i 


the  fingers  of  one  hand,  the  thumbs  of  the  operator  lying  along  the  sacrum  ; 

this  grasp  should  he  maintained  tliroughout  the  extraction,  no  other  grasp 

being  so  secure,  and  any  pressure  upon 
the  crests  of  the  ilium  or  upon  the  ab- 
domen of  the  child  being  dangerous  to 
its  bones  and  abdominal  viscera.  The 
line  of  traction  should  be  directed  as 
far  backward  as  the  perineum  allows, 
in  order  to  facilitate  the  passage  of  the 
shoulders  through  the  superior  strait, 
and  the  back  of  the  child  should  bo 
kept  steadily  directed  upward — that  is. 
toward  the  anterior  portion  of  tiic 
mother's  jwlvis — to  secure  an  anterior 
position  of  the  occiput  for  the  after- 
coming  head.  When  the  umbilicus  a])- 
pears  at  the  vulva  a  loop  of  the  cord 
should  be  drawn  downward,  as  is  done 
during  the  normal  delivery  of  the  breech. 
liaijid  Extmdlon  of  the  AftiT-cominf/ 

Fio.  279.-Method  of  RraspinR  the  thighs  during       lJ^.^^^l  ^,„,^   AnilS.—H,  bv   any   chaUCC, 
tht!  extraction  of  the  breech.  .  . 

either  arm  remains  flexed  upon  the  in- 
fant's chest,  it  may  easily  be  drawn  out  when  the  elbow  appears  at  the  vulva ; 
but  in  the  great  majority  of  cases  both  arms  will  be  extended  beside  the  head, 
and  their  extraction  is  then  more  difficult.  The  method  that  should  be  chosen 
for  their  release  must  depend  upon  the  point  of  the  pelvis  at  which  the  shoul- 
ders become  arrested. 

Low  Arrest  of  the  Arms  and  the  Head. — I.i  easy  extractions  it  is  very  often 
possible  to  bring  the  shoulders  into  sight  outside  the  vulva  by  simple  traction 
upon  the  thighs.  In  such  cases  it  is  frequently  possible  to  extract  the  after- 
coming  head  and  arms  by  the  very  easy  and  simple  numeuvre  known  as 
DetH'titer'i^  method.  In  this  procedure  the  body  of  the  child  is  dropped  down- 
ward as  soon  as  the  points  of  the  shoulders  are  in  sight ;  the  feet  are  grasped 
with  one  hand,  the  Hngers  of  the  other  hand  being  pressed  upon  the  upper  sur- 
face of  the  shoulders,  and  the  child  is  drawn  vertically  downward  toward  the 
floor,  the  mother  being  in  the  lithotomy  positicm.  Under  this  traction  the 
occiput  appears  at  the  vulva,  and  the  forehead  and  face  follow  coincidently 
with  the  arms.  The  mechanism  by  which  this  somewhat  surprising  dtilivery 
is  accomplished  is  as  follows :  The  method  is  applicable  only  when  the  pelvii' 
space  permits  the  head  and  the  arms  to  enter  the  brim  togeti)er,  and  both  arc 
then  contained  in  the  excavation  when  the  shoulders  are  at  the  vulva.  The 
arms  are  tiien  in  contact  with  the  elastic  sacro-sciatic  ligaments,  which  stretch 
before  them  and  permit  them  to  lie  by  the  side  of  the  head.  The  chin  is 
arrested  by  the  pelvic  floor;  the  head  extends,  and  thus  brings  the  occiput  to 
the  vulva.     The  head  is  then  delivered  in  extension,  and  the  arms  follow 


)    via 


^s^rn^ 


THE    MECHANISM   OF  LABOR. 


481 


(Fig.  280).  The  original  advocates  of  this  method  claimed  that  it  rarely  if 
ever  tears  tho  perineum,  and  the  writer's  experience  with  it  certainly  supports 
this  claim. 

When  t;,e  conditions  permit  the  head  and  the  arms  to  enter  the  pelvis 
together — that  is,  when  the  shoulders  can  be  brought  to  the  vulva  by  traction 
upon  tl'.e  thighs — Deven- 
tor's  method,  though  not 
the  most  powerful,  is  cer- 
tainly by  far  the  most 
rapid  and  easy  of  all  the 
inaneuvres  for  the  release 
of  the  head  and  the  arms, 
and  it  should  always  be 
given  a  trial.  It  is  nec- 
essarily inapplicable  when 
the  head  and  the  arms 
are  arrested  at  the  sui)erior  strait.  Trac- 
tion then  only  increases  the  difflcidty. 

If  the  shoulders  appear  at  the  vulva, 
but  Deventer's  method  fails,  the  liiothod 
known  as   combined  traction   on  the  face 
and  the  shoiddcrn  should   be  tried.     Two 
fingers  slu)uld  be  passed  along  the  upper 
surface  of  the  most  easily  accessible  arm 
until  their  tips    rest  in  the  bend   of  the 
child's  elbow.     The  elbow  should  then  be 
urged  backward  and  toward  the    median 
line  by  the  fingers,  and  be  swept   across 
the  child's  face  to  the  vulva,  at  which  the 
elbow,  forearm,  and    hand  apjiear  in  the 
order  named.     This  process   should  then 
be  repeated  with  the  other  arm.     Pressure 
upon  the  shaft  of  the  humerus  should  carefully  be  avoided,  since  it  is  certain 
to  snap  the  bone.     The  child  is  then  laid  astride  of  one  of  the  operator's  fore- 
arms, and  the  hand  belonging  to  this  forearm  is  passed  into  the  vagina  until 
its  first  and  second  fingers  lie  upon  the  canine  fossie  of  the  child.     The  other 
liand  is  hooked  over  the  shoulders,  the  nock  being  between  its  first  and  second 
fingers,  with  the  finger-tips  upon  the  supraclavicular  region  (Fig.  281).     The 
iiand  that  is  hooked  about  the  shoulders  is  then  used  to  make  traction  upon  the 
ciiild,  while  the  internal  hand  exerts  itself  to  preserve  the  flexion  of  the  head. 
The  direction  of  the  first  tractions  should  be  in  the  line  of  the  axis  of  that 
part  of  the  pelvis  in  which  the  child  lies,  and  as  the  head  emerges  the  line 
of  traction  should  sweep  fi»rwar(l  in  the  curve  of  Cams  until,  at  tlie  end  of  the 
extraction,  the  body  of  the  child  rests  upon  the  other  forearm  and  along  the 
abdomen  of  the  mother  (Fig.    282).     When  the  mouth  appears  at  the  vulva 
ai 


Fio.  280.— Deventer's  iiicthnd  of  extraction 
of  the  urter-eoiiiiuK  head  iinU  arms. 


\V' 


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I.'  .i 


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V:i: 


I"  i 

I  i  ^ 


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i  ';M.    ■(!  '■  re 


^,i 


;  I 


482  AMElilCAN   TEXT-BOOK   OF   OBSTETRICS. 

and  tlie  moiitli  and  pharynx  have  been  cleared  out,  all  hurry  ceases,  and  tin- 


Fk;.  ;!81.— Delivery  of  the  ufter-coiiiiii}?  liead  liy  coinlnned  triictiou  on  the  lieud  niid  shoulders. 

operator's  efforts  should  be  direc^^'Hl  to  the  preservation  of  the  perineum.    But 

little  traction  should  now  be 
used,  and  the  hand  that  was 
apj)lied  to  the  face  should  be 
used  to  shell  out  the  head 
by  })rcssure  on  the  forehead 
through  the  perineum,  or,  if 
necessary,  by  passing  two  fin- 
gers into  the  rectum. 

Il'uih  Anrd  of  the  Art)}>< 
and  Head. — When  the  adap- 
tation between  the  head  and 
the  pelvis  is  not  sufficiently 
easy  to  permit  the  simulta- 
neous entrance  of  the  head 
and  the  arms  into  the  pelvis, 
the  arrest  of  the  shoulders  at 
tlie  superior  strait  may  be 
known  by  the  fact  that  the 
child  ceases  to  make  progress, 
-  ^.m.     ^^  under   tractions   of  ordinai'v 

-s/s^    _^^^  strength,   at   about  the   time 

'      when  the  tips  of  the  scapula' 

Fi(i.  282.— riisitioti  n(  tl't'  cliiM  Itnnii'diiili'ly  after  the  eseupe  ,  ,  a       1  • 

of  the  unereoiuiii),'  heud  from  the  vuivu.  ap})ear  at  the  vulva.     At  tlllS 


THE   MECHANISM   OF  LABOR. 


483 


])oint  of  the  extraction  it  is  therefore  important  to  watch  for  a  marked  increase 
of  resistance,  and  when  this  is  observed  the  tractions  shouhl  immediately  be 
intermitted,  since  their  continuance  only  serves  to  lock  the  head  and  the  arms 
t-ccurely  in  the  brim,  thus  rendering  the  subsequent  maneuvres  for  their  release 
more  difficult. 

The  body  of  the  child,  in  such  an  event,  should  be  pressed  slightly  upward, 
and  be  rotated  until  t!ie  back  is  directed  to  one  or  the  other  side  of  the 
mother's  pelvis.  The  hips  should  then  be  elevated  gently  toward  the  mother's 
abdomen  and  toward  the  side  to  which  the  back  of  the  child  is  directed, 
moderate  traction  being  exerted  upon  them  at  the  same  time.  The  object  of 
tills  maneuvre  is  twofold:  first,  tiiat  space  may  be  afforded  for  the  passage 
of  the  hand  into  the  vulva  alcmg  the  abdomen  of  the  child ;  secondly,  that  the 
jiostcrior  shoulder,  which  is  usually  the  most  accessible,  may  be  brought  as 
deeply  into  the  pelvis  as  possible. 

The  hand  of  the  operator  that  naturally  faces  the  abdomen  of  the  child 
should  then  be  passed  rapidly  into  the  vulva,  with  its  palm  flat  against  the 
abdomen  and  chest,  until  two  fingers  can  be  passed  up  along  the  arm  of 
tlie  child  and  their  tips  placed  in  jwsition  in  the  bend  of  the  elljow.  No 
pressure  upon  the  arm  should  be  made  until  this  position  is  reached,  but  when 
it  is  attained  the  elbow  should  be  drawn  down  across  the  child's  face  until 
the  forearm  and  liand  are  within  easy  reach  and  can  be  brought  to  the  vulva. 

If  the  hand  passed  along  the  abdomen  fails  to  reach  the  elbow,  the  latter 
may  sometimes  be  found  by  seizing  the  feet  in  tliat  hand  and  drawing  them 
gently  upward  and  to  the  opposite  side,  so  that  the  hand  which  before  held 
the  feet  can  be  passed  along  the  back  of  the  child  close  under  the  pubic  arch 
to  the  back  of  the  posterior  shoulder,  and  thence  along  the  arm  to  the  elbow, 
which,  however,  must,  as  before,  be  brought  downward  a(!ross  the  child's  face. 

The  hips  of  the  child  should  then  '■  swept  downward  and  traction  be  made 
upon  the  thighs,  in  the  hope  that  tlie  pelvic  space  may  permit  the  entrance  of 
tiie  head  with  the  remaining  arm  ;  if  this  does  not  occur,  the  body  of  the 
child  should  again  be  pressed  backward  into  the  pelvis,  and  the  child  be  so 
rotated  that  the  arm  which  was  anterior  becomes  posterioi-,  wiien  it  should  be 
released  by  the  same  method  that  was  used  in  tlie  extraction  of  the  first  arm. 
During  this  rotation  the  back  of  the  child  should  sweep  across  the  front  of  the 
mother's  pelvis.  This  rotation  may  be  effected  either  by  grasping  and  turning 
the  thorax  with  both  hands  or  by  drawing  the  already  cxtraifted  arm  Ibrward 
along  the  side  of  the  pelvis,  between  the  labium  and  the  back  of  the  child. 

In  rotating  the  child  it  must  always  be  remembered  that  the  articulations 
of  the  neck  are  so  arranged  that  if  the  point  of  tlie  chin  be  carried  beyond 
tlie  point  of  the  shoulder  a  dislocation  of  the  atlas  upon  the  axis  is  the  result. 
l''or  this  reason  the  thorax  should  be  ])uslie(l  strongly  upward  whenever  an 
attempt  at  rotation  is  made,  in  order  to  free  the  head  iVom  the  superior  strait ; 
and  the  hands  of  tiic  assistant  should  wateli  the  heatl  from  above,  that  he  may 
warn  the  operator  if  it  fails  to  follow  the  shouhlers.  In  the  extraction  of  the 
Jiead  from  the  superior  strait  the  method  of  combined  traction  upou  face  and 


!ililfcili-i 


rP 

'i 


r 


[if 
iiil 


Ms   f 


W4 


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i  '  t 


M-i 


!i  :■ 


f:  ! 


■      I 


484 


A  ME  RICA. Y    TKXT-nOOK    OF   OliSTETIilVS. 


shoulders  is  usually  tlio  host,  hut  it  should  then  he  reinforced  hy  suprapuhic 
pressure  applied  in  the  axis  of"  the  brim  hy  the  hands  of  an  assistant. 

iJiJfictilt  Ki'trdction  of  Hie  Hend  and  the  Anns, — Arrcd  of  <m  Arm  behind 
the  Occiput. — It  sometimes  happens  that  the  head  rotates  with  the  shoulders, 
but  the  arm  is  detained  behind  the  pubes  by  friction  against  its  walls.  In 
such  a  case  the  arm  crosses  the  nape  of  the  neck  and,  if  traction  is  made, 
becomes  jammed  between  the  occiput  and  the  symphysis.  If  this  accident  is 
discovered  before  traction  has  been  made,  })rompt  rotation  in  the  reverse  din.'c- 
tion  may  unlock  the  arm,  and  in  this  case  this  reversed  rotation  should  Im; 
continued  until  the  arm  becomes  posterior — that  is,  throutih  180°  ;  l)ut  unless 
the  first  attempt  unlocks  the  jam,  the  child  will  probably  be  lost,  and  it  is  then, 
perhaps,  best  to  make  direct  traction  upon  the  arm  at  the  risk  of  fracturing 
the  humerus,  after  forewarning  those  present  that  this  must  be  the  result,  and 
that  it  is  done  in  the  interests  of  the  child. 

Closure  of  a  Constriction-rin(/,  or  of  (oi  Imperfectly  dilated  Os,  about  the 
Neck. — The  stricture  of  the  canal  formed  by  either  of  these  conditions  may 
embarrass  the  release  of  the  arms,  but  it  does  not  otherwise  affect  the  above- 
descril)ed  maneuvre,  except  that  any  abrupt  or  too  forcible  movements  of  the 
hand  while  within  the  uterus  are  even  more  dangerous  in  these  cases  than  in 
others.  The  extraction  of  the  head  from  the  constricting  band  is,  however, 
often  a  matter  of  great  difficulty.  Any  attempt  to  overcome  this  obstruction 
by  force  exposes  the  mother  to  the  most  imminent  danger  of  rupture  of  the 
uterus ;  and  though  steady  traction  upon  the  mouth  and  the  shoulders  slioidd 
be  given  a  fair  trial,  and  may  effect  dilatation  in  time  to  save  the  child,  it  is  in 
these  cases  that  the  application  of  forceps  to  the  after-coming  head  is  most 
often  indicated.  There  can  be  no  doubt  of  the  truth  of  Lusk's  observation, 
that  "  the  forceps  will  sometimes  bring  the  head  rapidly  through  the  cervix 
when  traction  upon  the  feet  only  serves  to  drag  the  uterus  to  the  vulva."  Care 
siiould  be  taken,  however,  that  this  rapidity  be  not  so  great  as  in  itself  to  cause 
a  serious  laceration. 

Arrest  of  the  Head  at  the  Superior  Strait  bi/  reason  of  an  Unusual  Size  of 
the  Head. — Most  (Jerman  and  American  obstetricians  believe  that  the  use  of 
(combined  traction  upon  the  face  and  the  shoulders  is  the  best  method  to  adopt 
in  arrest  of  the  after-coming  head  at  any  })oint  in  the  pelvis,  and  it  should 
certaiidy  be  the  first  methotl  tried  in  any  given  case;  but  as  cases  frecpiently 
occur  in  which  the  head  can  be  delivered  with  far  greater  ease  by  a  rapid  alter- 
nation between  two  or  more  methods  than  by  the  continued  use  of  any  one 
alone,  it  is  for  this  reason,  if  for  no  other,  well  to  be  familiar  with  all  the 
methods  which  have  been  foiuid  of  value. 

The  Prague  Method. — This  maneuvre  is  often  of  service  in  effecting  the 
engagement  of  the  head  and  its  initial  descent  into  the  superior  strait.  This  is 
especially  true  in  certain  forms  of  contracted  pelvis  atul  with  operators  whose 
nuiscular  strength  is  inade((uate  to  the  really  severe  strain  which  is  sometimes 
imposed  upon  the  internal  hand  in  the  use  of  the  combined  method  at  tiie 
brim,  but  it  is  usually  inferior  to  the  combined  method  after  the  greatest  diam- 


THE   .VKC/fAXISAf    OF    LAliOH. 


485 


eter  of  the  head  has  ])as.sc(l  the  superinf  .strait.  \A\w  all  iu(!th(Hls  of  inaiiiial 
extraction,  it  is  greatly  increased  in  value  by  the  application  of  proper  supra- 
pubic pressure  by  an  assistant. 

In  executing  the  Prague  method  the  feet  are  seized  by  one  hand  and  the 
body  is  drawn  as  far  downward  as  the  perineum  allows;  the  other  hand  is 


Kiu.  283.— Delivery  of  the  nftor-comiiit;  IumkI  by  floxioii  thnmtili  si'i/.iiri' (if  lower  jaw,  and  extrusion  by 

means  of  pressure  in  axis  of  lirini. 

then  hooked  over  the  shoulders,  and  traction  is  made  by  both  hands  simul- 
taneously (Fig.  '284).  As  the  head  enters  the  excavation  the  body  is  swung 
rapiiUy  upward,  aiul  the  remainder  of  the  delivery  is  acc()m{)li«hed  by  upward 


Fici.  28^1.— I'nifjiie  nietlioil  of  extrac  tint;  tlie  aftereoniiufjliead,  superior  strait. 

traction  on  the  feet,  while  the  hand  upon  the  neck  promotes  flexion  by  retard- 
ing the  descent  of  the  occiput  (Fig.  285).  The  chief  disadvantage  of  the 
Prague  method  lies  in  the  fact  that  all  the  force  exerted  by  the  operator  is 
expended  ui)ou  the  child's  neck,  and  that  the  amount  of  force  that  can  .safely 
be  applied  is  therefore  less  than  in  the  combined  method. 


1-<- 


K: : 


r-f~f. : 


tflMlL-  -t^'i-,- 


■1'i 


i  !  ;: 


/'       .i: 


r  t 


;:f 


486 


AMKRIVAX    TILXT-liOOK    OF   OUST  FT  UK'S. 


I    \ 


n. . 


Arvci^t  from  Ktioisian  of  the  Haul, — This  condition  is  rare  unless  in  iin- 
H'opcrly  conducted  extractions,  l)ut  if,  l)V  any  eiunisiuess  on  the  part  of  the 

operator,  tiie  ahdonien  of  tlie  child  has 
been  directed  to  the  front  durinjj  the 
liberation  of  the  anus,  and  the  chin  is 
therefore  arrested  at  the  symphysis,  the 
Prague  method  should  be  used  through- 
out. In  this  case  the  direction  of  the 
first  traction  should  be  nearly  horizontal 
(Fig.  286),  and  as  the  occiput  descends 
the  l)ody  of  the  child  should  be  raised 
until,  when  the  head  emerges  from  the 
vulvji,  the  line  of  traction  is  nearly 
parallel  with  the  mother's  abdomen.* 

ForcepH  to  the  After-coming  Head  at 
the  Superior  Strait. — The  use  of  the 
forceps  is  generally  believed  to  be  the 
most  powerful  and  certain  means  of 
overcoming  difficult  cases  of  high  arrest 
of  the  after-coming  head.  This  one- 
ration  is,  however,  often  difficult,  and 
the  time  occupied  in  the  application  of 
the  forceps  may  be  of  vital  importance 
to  the  child.  Moreover,  there  are  but 
few  cases  in  whicih  a  skilled  operator, 
aided  by  efficient  suprapubic  pressure, 
fails  to  deliver  by  manual  extraction  ;  but  as  such  cases  do  occasionally  occur, 
the  forceps  shou hi  always  be  at  hand  before  the  delivery  is  attempted.     If 


Fiti.  i;K),— I'niKUO  iiii'lliiMl  of  oxtnictiiin  tliu  aftor- 
I'oniiiif;  lu'iid,  iiifiTior  strait. 


I'Ki.  '.'SO.— Ivxtracliiiii  nf  arti'i-ccjiiiintr  lu'a<l,  cliiti  arrosti'(l  at  syiii]iliysls. 

forceps  be  used,  the  body  should  be  raised  to  ;i  nearly  vertical  position,  and  the 

*  If  forceps  is  necessary,  the  instruinent  sliuuld  be  aiiplieil  under  the  eliikl'H  body,  and  should 
extract  by  the  same  mechanism. 


\  ;i^ 


THE   MECHANISM    OF   LABOR. 


487 


forcei).s  sliould  be  passctl  into  phu'o  upon  th(!  sides  of  tlio  liead,  beneath  the 
abdomen  of  the  cliild.     An  axis-traction  model  siiould  be  preferred, 

Avresl  of  the  Hmd  at  the  Inferior  Strait  or  on  tlic  I'crincam. — Cases  lit 
which  manual  extraction  by  the  combined  method  fails  to  overcome  a  low 
arrest  are  extremely  rare,  but  if  forceps  be  required  the  application  and  extrac- 
tion are  always  easy. 

Arrent  of  the  Head  due  to  Contraction  of  the  Pelvii^. — ^n  t  onlinary  form 
((f  contraction  the  arrest  is  always  at  the  brim,  and  after  J  .  j.ad  has  passed 
tlie  superior  strait  the  subsecpient  delivery  is  easy. 

A  breech  presentation  should  never  be  allowed  to  persist  as  such  in  ajmto- 
minor  pelviti,  but  if  it  has  not  been  corrected  the  inevitable  arrest  of  the  head 
at  the  superior  strait  should  be  met  by  extreme  flexion  and  by  the  application 
of  forceps,  followed  by  craniotomy  if  not  proni|)tly  successful. 

In  aUjfat  pelves,  and  in  Hat  pelves  oidy,  the  head  enters  the  superior  strait 
ill  the  transverse  diameter,  and  the  passaji;e  of  the  strait  is  most  easily  eflf'ected 
in  a  somewhat  extended  position,  in  which  the  biparietal  diameter  is  received 
by  one  of  the  sacro-iliac  notches,  while  the  lesser  bimastoid  diameter  is 
opposed  to  the  contracted  conjugate :  if,  then,  the  hand,  when  it  is  passed  into 
the  vagina  for  combined  traction,  finds  the  head  transverse,  it  should  allow 
extension  to  go  on  until  the  face  begins  to  approach  the  side  wall  of  the  pelvis 
or  until  the  greatest  diameter  of  the  head  has  passed  the  superior  strait;  when 
this  has  occurred  flexion  should  promptly  be  restored,  and  rotation  and  de- 
livery will  then  rapidly  follow. 

In  simple  Jfat  pelves  the  application  of  forceps  to  the  after-coming  head  is 
rarely  successful  after  manual  extraction  has  failed,  but  in  pelves  of  the  _7en- 
erallif-contracted  flat  type,  if  the  transverse  diameter  is  markedly  dimiiushed, 
tiie  mechanism  approaches  that  of  a  normal  or  justo-ininor  pelvis,  and  if  the 
breech  presents  and  efforts  at  manual  extraction  of  the  head  fail,  the  apj)li- 
cation  of  the  forceps  may  be  tried. 

5.  FooTi,iX(;  PRr:sKXTATioNs. 

Mechanism  and  Management. — The  mechanism  of  footling  presentations 
is  in  no  way  different  from  tluit  of  presentations  of  the  whole  breech.  The 
treatment  varies  only  in  that  in  a  rapid  extraction  there  can  be  no  question 
as  to  the  choice  of  oj)eration. 

6.  Thaxsversk  Prkskxtatioxs. 

Under  transverse  presentations  are  included  presentations  of  any  portion 
of  (lie  trunk  ;  but  as  all  transverse  presentations  soon  change  to  ])resentations 
of  the  shoulder,  it  is  only  necessary  to  speak  of  the  latter. 

Freqaenetj. — Transverse  presentations  occur  in  from  1  in  150  to  1  in  800 
of  all  cases  of  labor.  Thus,  Spicgclbcrg  made  the  proportion  1  in  180; 
Churchill,  1  in  2o2 ;  and  the  (Juy's  Hospital  Reports,  1  in  297  (or  .32  per 
cent,  out  of  22,980  cases  of  labor).     The  positions  are  of  but  little  importance. 

Etiolocjy. — Transverse  and  breech  presentations  are  protluced  by  the  same 


i 


/I 


a 


'I:!  : 


«  m, 


•v'.'i  irfi  I  Ml 

^]ii\m  11! 


:^*^ 


y 


488 


AMERIVAN    TEXT-BOOK   OF   OJJSTETJiJCS. 


causes  (see  p.  470),  but  in  transverse  presentations  tl»e  influenee  of  pelvic  de- 
formities is  sonu'wiiat  more  important,  since,  if  the  head  cannot  enter  the 
brim,  it  may  slip  to  one  side  and  permit  the  shoulder  to  c  iter  even  after  labor 
is  well  under  way. 

J>ia(/uoKis, — On  (thdomhml  examination  the  longest  diameter  of  the  uterus 
is  transverse;  the  head  is  found  in  one  flaid\,  and  the  breeeh  in  the  other.  On 
vaf/inal  iwaminatiun  the  finger  may  be  able  to  recognize  the  clavicle  and  the 
spinous  process  of  the  scapula,  and  to  ascttrtain  that  there  is  but  one  liiiil) 
attached  to  the  presenting  part,  but  the  vaginal  diagnosis  is  ai)t  to  be  obscure 
unless  an  arm  is  prolapsed. 

Proynosi)t. — As  the  termination  of  a  transverse  presentation  by  natural 
labor  is  extremely  rare,  the  prognosis  for  both  mother  and  child  is  necessarily 
that  of  the  operation  undertaken.  AVhen  the  abnormality  is  detected  and 
treated  early,  the  prognosis  for  both  patients  should  be  fairly  gt)od,  but  it 
becomes  worse  in  j)roj)ortion  to  the  length  of  time  during  which  the  case  is 
allowed  to  go  on  untreated. 

Mechanism  and  Management  of  Transverse  Presentations. 

Mechanism  of  Transverse  Presentations. — Since  natural  delivery  so 
rarely  occurs  in  transverse  j)resentations,  the  later  stages  of  the  mechanism  by 
which  it  is  effected  are  of  small  practical  importance ;  but,  notwithstanding 
the  rarity  of  its  completion,  its  earlier  stages  are  rendered  not  unimportant 
by  the  fact  that  success  in  the  delivery  of  impacted  shoulders  rests  upon  a 
thorough  comprehension  of  the  processes  by  which  the  imj)action  waseilected, 
this  being,  in  fact,  the  first  stage  of  the  mechanism  of  natural  delivery  in 
transverse  presentations.  The  jirocc^s  is  commonly  known  as  the  "  spontaneous 
evolution  of  tlie  fetus."  Any  part  of  the  trunk  may  present  at  the  beginning 
of  labor;  but  as  the  fetus  is  crowded  down  into  the  brim,  the  shoulder  inev- 
itably enters  deepest  in  persi.stent  transverse  piesentations,  and,  .since  the  shoul- 
der always  becomes  anterior  early  in  labor,  it  is  only  uece.s.sary  to  describe  the 
anterior  form. 

In  the  anterior  form  the  supraclavicular  region  corresponds,  at  the  time  of 
the  entrance  of  the  shoulder,  with  the  anterior  end  of  one  oblique  diameter  at 
the  brim,  the  lower  portion  of  the  thorax  lying  at  the  posterior  end  of  tlio 
same  oblique  diameter.  The  full  width  of  the  shoulder  enters  tin;  pelvis,  and 
this  portion  of  the  child  is  then  fixed  in  position  by  contact  of  the  neck  with 
the  horizontal  ramus  of  the  pubes.  Under  the  influence  of  the  driving  power 
of  the  uterus  above,  the  lower  portion  of  the  thorax  is  forced  more  and  more 
deeply  into  the  posterior  half  of  the  pelvis  by  a  lateral  inflection  of  the  body 
of  the  child  upon  it.self.  The  trunk  then  dips  into  the  excavation,  the  true 
ribs,  false  ribs,  abdomen,  and  ]>elvis  of  the  fetus  entering  in  the  order  named 
(Fig.  287).  If  the  child  is  sufficiently  flexible  and  if  the  uterus  is  sufficiently 
])owerful  to  complete  the  delivery,  this  process  of  lateral  inflection  of  the  trunlc 
goes  on  until  the  pelvis  of  the  child  appears  at  the  vulva,  and  with  its  expul- 
sion the  case  is  converted  by  spontaneous  evolution  iiito  a  presentation,  or 


TlIK   MJJCJiAAJ^M    OF  LABOR. 


489 


ri'her  an  expulsion,  of  the  breieli,  in  which,  however,  one  tiliouldcr  is  already 
witliin  the  pelvis  anil  (»ne  arm  is  already  delivered. 

A  second  and  very  nuich  more  rare  lorni  of  tielivery  in  ju'rsistent  trans- 
verse presentations  is  seen  oidy  with  immature  fetuses,  and  it  can  seldom  occur 
unless  maceration  is  far  advanced.  In  it  the  prolapswl  shoulder  is  driven 
forward  throuffh  the  pelvi-,  the  head  of  the  child  beinj;  crowded  into  the  pel- 
vis with  the  body  (Fig.  :i88).    The  alioulder  is  the  leading  point,  uud  it  should 

A 


Fi(i.  'J87.— Spontuni'ous  evolution,  first  form  of  nicclinnism. 

rotate  to  the  arch,  but  when  this  process  is  possible  the  body  is  always  so 
small  and  soft  that  the  mechanism  is  usually  but  little  marked. 

Management  of  Transverse  Presentations. — The  prognosis  of  sponta- 
neous evolution  is  so  bad  for  botli  child  and  mother  that  transverse  presenta- 
tions should  never  be  left  to  nature,  and  the  question  of  the  treatment  is  sim- 
j)ly  the  question  of  the  choice  of  the  operation  to  be  adopteil.  Three  opera- 
tions are  applicable  to  the  treatment  of  transverse  presentations  in  its  various 
stages — the  several  savxaiwa  oi'  version,  decapitation, 'a\v\  exenteration,  the  choice 
between  them  depending  upon  the  stage  of  labor  at  which  the  presentation  is 
detected. 

Version. — If  the  presentation  is  detected  before  any  portion  of  the  trunk  is 
deeply  engaged,  and  while  the  membranes  are  still  unruptured,  one  or  the 
other  of  the  external  ver.sionx  should  be  chosen.  If  the  abdomen  or  the  hip 
presents,  pelvic  version  will  usually  be  the  easiest,  and  for  this  reason  should 
generally  be  preferred  ;  if  the  conditions  are  such  as  to  render  cephalic  version 
easy  and  if  the  pelvis  is  normal,  cephalic  version  should  be  ])erformetl. 

If  the  shoulder  ])resents,  cephalic  version  should  be  chosen,  except  in  a  flat 
pelvis,  where  the  shape  of  the  inlet  makes  a  breech  presentation  the  presenta- 


\l^ 


im  I 


.  m 


{r^ 


]  % 


... .  I  d, 


v--^ 


W^y: 


490 


AMj:iil('A\    TEXT-BOOK   OF   OliSTFTltlCS. 


)  ,  .  1      i\ 


tloii  of  clioiff.  In  such  oases  an  oxternal  ju'lvic  version  would  naturally  ht 
chosen.  It,  at  the  time  an  (tperation  is  undertaken,  the  shoulder  has  alread) 
entered  the  pelvis,  but  the  conditions  of  the  case  are  still  such  us  to  permit  of 
version,  a  bipolar,  C(ji/i(di<',  or  peteic  version  should  he  performed. 

If,  at  the  time  when   interference  is  decided  upon,  the   membranes   arc 
already  ruptured,  and  especially  if  the  shoidder  is  already  well  crowded  into 

the  pelvis,  the  external  and  bipolar 
methods  will  usually  he  impitssible,  and 
internal  podali(!  version  must  be  chosen. 
Infer  mil  Podalic  Vernion  in  Tr(in,s- 
rerne  I'resenf((tion,s.  —  This  operation 
ditl'ers  from  internal  version  in  head 
presentations  oidy  in  the  choice  and 
method  of  introducing;  the  hand,  in  the 


Kio.  'J88.-Sp(intaiico\is  ovdlutloii.sot'diid  and  riirc  Fkj.  2R0.— Krozi'u  suction  of  shoulder  prcscii- 

formofnu'clianisiii,  known  lis  l)irtli  \vitl\d(>iil)k' body       tiitkm  (Cliiara):  tlie  distortion  and  tlii'  ulont;a- 
(one-sixtli  natural  size,  ri'drawn  from  Kiistnor).  tion  of  the  nci'k  are  noteworthy. 

frequent   occurrence  of  a  prolapsed  arm,  and  lU  the  method  of  raising  an 
impacted  shoulder. 

In  raisinj;  the  shoulder  it  is  necessary  to  remember  the  mechanism  o^'  the 
method  by  which  nature  deals  with  a  neglected  transverse  presentation — that 
oi'  spontaneous  evolution.  In  this  process,  as  has  been  said,  the  trunk  enters 
the  pelvis  at  the  brim  in  an  oblitpie  diameter,  bnt  as  it  is  forced  farther  down 
the  shoulder  rotates  to  the  front  and  becomes  fixed  there,  while  the  thorax 
and  the  abdomen  are  crowded  into  the  posterior  portion  of  the  pelvis  by 
flexion  upon  themselves  (Fig.  287).  Now,  so  long  as  the  j)osition  is  still 
ol)li(pie,  and  if  flexion  of  the  trunk  has  not  begun,  the  presenting  part  may 
easily  l)e  raised  by  pressure  upon  the  shoulder  in  the  axis  of  the  superior 
strait ;  but  so  soon  as  the  shoulder  has  rotated  to  the  front  antl  the  thorax  has 
entered  the  ju'lvis,  it  is  essential  that  the  process  of  relieving  the  impaction 
should  begin  by  the  return  of  tiie  part  which  entered  last — that  is,  of  that 
portion  of  the  thorax  and  the  abdomen  still  lying  opposite  the  sacro-iliat; 
synchondrosis.  No  j)ressure  must  be  exerted  upon  the  shoulder  itself  until 
the  trunk  again  occupies  an  oblitpie  position.  It  will  be  seen  that  the  process 
of  unlocking  the  impaction  is  by  a  direct  reversal  of  the  mechanism  of  spon- 


?ii; 


fmmmmmm 


Tin:   MKCIIAXISM   OF   LAIiOIi. 


491 


tiiiit'du.s  evolution.     Of  course,  (liiriiij>;  tliis  wliole   process  tlio  most  careful 
vdiiiiter-pressure  must  be  maintaiued  at  the  fundus. 

In  simple  eases  a  prolapsed  arm  may  he  used  as  a  convenient  handle  hy 
wiiieh  to  jtush  up  the  shoulder,  and  in  all  cases  it  is  w'll  to  he^in  the  operu- 


A'<  ;;.'('/(■  'oot. 


JVt,ir  foot 
U/t 


Fig.  290.— nlrcrt  nirtlnxl  of  si'lzinp  a  fciot  in  vit- 
aion  fiir  ♦.^llIl^svL•rsl■  iiri'Sfiitations. 


Fi(i.  '201.— Oircct  ini'tlKiri  of  soizini;  a  fmit  in  vor- 
.siun  I'cir  transviT.si'  priseiitations. 


tion  by  noosing  a  fillet  around  the  prolapsed  wrist.  This  Hllet  answers  a 
double  purpo.se:  First,  it  may  be  used  to  draw  the  arm  out  of  the  way  of  the 
operating  liand ;  second,  during;  the  |)rocess  of  extraction  slight  tractions  oa 
the  fillet  will  prevent  the  extension  of  that  . 

arm,  thus  greatly  facilitating  the  delivery  ; 
but  care  nuist  be  taken  to  remove  the  noose 
as  soon  as  possible,  for  cases  arc  on  record  in 
which  sloughing  of  a  member  has  followed 
the  too  prolonged  or  violent  u.se  of  a  fillet. 

In  the  .search  for  u  fi)()t  two  methods  may 
be  u.sed  :  The  hand  that  corresponds  with  the 
position — that  i.s,  left  position,  left  hand — 
may  be  passed  along  the  back  and  over  the 
buttocks  to  the  thigh  and  leg  (Fig.  292), 
or  the  hand  may  be  pa.-^sed  across  the  ab- 
domen and  directly  to  the  feet  (Figs.  290, 
291).  The  first,  which  is  the  surer  way, 
should,  as  a  rule,  be  preferred,  but  the  latter 
method  is  often  the  easier,  especially  iu  ab- 
domino-antorior  positions.  Much  has  been 
writt(!n  on  the  advantage  to  be  gained  by  se- 
lecting the  superior  foot  in  version  for  transverse  presentation;  but  as  this  view 
has  never  obtained  much  credence  outside  of  England,  and  as  Galabin,  one  of  the 
latest  British  authorities,  not  only  di-sajiproves  of  this  practice,  but  gives  a  very 
convincing  mechanical  proof  of  the  fallacy  of  the  theory  which  prompted  it, 


Fiii.  L".i'.'.— ^f(■tlllMl  (if  rcacliina  tlu'  fnDt 
by  lirst  passuij,'  llio  liaiid  ainuiiil  the 
breech. 


^ !  i 


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AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


the  subject  need  only  be  mentioiicil  here.  Unless  special  care  be  taken  to 
select  the  superior  foot,  the  lower  foot  is  almost  inv'arial)ly  seized. 

Treatment  of  Neglected  Transverse  Presentations. — Wiien  ;.  transverse  pres- 
entation has  been  so  lonjf  neglected  that  the  release  of  the  shoulder  is  thoiiglit 
to  involve  more  danger  to  the  mother  tiian  it  wotdd  be  justifiable  to  incur  in 
the  interests  of  the  child,  or  wlien  the  child  is  already  moribund  or  dead,  one 
or  the  other  of  the  appropriate  destructive  operations  must  be  undertaken. 

If  the  neck  is  at  this  time  within  reach,  devapUation  should  be  selected. 
If  the  process  of  spontaneous  evolution  has  gone  so  far  that  it  would  be  ditti- 
cult  or  impossible  to  apply  the  decapitator  to  the  neck,  an  c.venter<dion  should 
be  chosen,  and  after  the  abdomen  and  the  thorax  have  been  emptied  of  their 
contents  the  operator  must  use  Ills  judgment  as  to  whether  it  is  safer  to  break 
the  vertebral  cohunn  and  extract  the  child  still  doubled  up  ujwn  itself,  or  to 
draw  the  fetal  pelvis  into  that  of  the  mother  by  traction  with  the  fingers  from 
within  its  cavity. 

7.    PUOLAPSKI)    EXTUKMITIES. 

Presentation  of  the  Head  and  a  Hand. — When  a  hand  ])rolapses  and 
enters  the  pelvis  with  the  head,  it  is  most  commonly  placed  at  one  end  of  the 
bitemporal  diameter.  Its  presence  then  generally  results  in  delay  through  the 
increased  size  of  the  presenting  part,  and  it  may  occasionally  interfere  with 
rotation.  If  the  hand  is  placed  against  the  occipital  end  of  the  head,  its 
presence  may  delay  the  descent  of  the  occij)ut  and  thus  produce  extension  at 
the  brim.  Tliis  abnormality  usually  causes  a  delay  sufficient  to  induce 
exhaustion  on  the  part  of  one  or  the  other  patient,  and  thus  indicates  opera- 
tive interference  ;  but  if  such  an  indication  does  not  arise,  the  ultimate  result 
in  most  cases  is  that  the  head  sli{)s  by  the  prolapsed  arm,  after  a  greater  or 
longer  period  of  delay,  and  is  thus  eventually  born  by  a  natural  labor. 

Pro(/nosis. — If  the  ])resentation  is  detected  early,  the  prognosis  is  little  dif- 
ferent from  that  of  normal  labor,  and  even  when  detected  after  a  moderately 
ong  second  stage  it  is  influenced  by  the  treatment,  and  should  never  be  grave. 

Treatment. — An  attempt  should  be  made  to  push  back  the  prolapsed  hand 
with  the  fingers,  and,  if  extension  has  occurred,  to  restore  flexion  by  pressure 
upon  the  forehead  with  the  hand.  Should  this  effort  fail,  an  operative  delivery 
nuist  be  resorted  to,  the  choice  of  operation  dej)ending  upon  the  position  of 
the  head.  If  good  flexion  is  present,  the  forceps  should  be  applied,  but  care 
must  be  taken  to  introduce  the  blade  between  the  hand  and  the  head,  and 
great  care  will  be  necessary  to  avoid  fracture  of  the  fingers,  the  hand,  or  the 
wrist.  If  the  application  fails  to  do  injury,  the  prognosis  of  the  operation  is 
good,  since  the  tractile  force  is  applied  to  the  head  while  the  hand  is  still  ex- 
posed to  friction  against  the  pelvis;  the  head  thus  always  slijvs  past  the  hand. 
When  marked  extension  is  present,  if  manual  flexion  fails  or  if  tlie  head  is 
already  much  moulded  toward  ihe  configuration  of  a  brow,  internal  })odalic 
version  should  be  performed. 

Presentation  of  a  hand  and  a  foot  is  decidedly  more  rare  than  the 
above  ;  its  j)roguosis  and  treatment  are,  however,  similar. 


DYSTOCIA. 


IV.   l^YS'roCIA 


4Ji;i 


1.  Anomalies  in  the  Forces  op  Labor.* 

In  a  noi'inal  labor  the  active  forces  of"  expulsion  (the  uterine  and  alxloruinal 
muscles)  and  the  passive  forces  of  resistance  (the  fetus,  the  pelvis,  and  the 
iiiatcrnal  sort  structtu'cs)  are  so  nicely  balanced  that  the  expulsive  forces  are 
just  sufficiently  resisted  to  ensure  a  slow  and  gradual  i)assage  of  the  fetus 
along  the  birth-canal.  Tlie  walls  of  the  birth-canal  and  the  structures  around 
(he  vulvar  orifice  are  by  this  arrangement  slowly  and  gradually  dilated,  and 
are  not  rudely  torn  apart,  as  they  would  be  by  a  more  rapid  expulsion  of  the 
Ictus.  This  balance  between  the  powers  of  labor,  however,  is  easily  disturbed. 
There  may  be  anomalies  by  deficiency  and  ;'nomalies  by  excess  in  the  com- 
ponent parts  of  the  forces  of  expulsion  and  in  all  the  sources  of  resistance. 
Tluis  the  uterine  muscle  may  be  too  weak  or  too  strong  compared  with  the 
resistance  it  must  overcome;  and  so  also  with  the  action  of  the  abdominal 
muscles.  The  resistance  furnished  by  the  pelvis,  the  soft  structures,  and  the 
fetus  may  be  excessive  or  deficient. 

1.  Dkfu'IEXt  Power  of  tiik  Uterine  Muscle;  Inertia  Uteri. 

In  this  condition  tlie  uterine  muscle  is  unable  to  overcome  the  normal 
resistance  offered  by  the  weight  of  the  fetal  body,  by  the  friction  of  the  pelvic 
walls,  and  by  that  of  the  undilated  maternal  soft  structures.  Inertia  uteri  is 
inan'.f'ested  in  the  vast  majority  of  cases  during  the  first  stage  of  labor.  The 
weakened  uterine  force  therefore  is  almost  always  neutralized  by  the  obstruc- 
tion of  an  undilated  cervix.  There  is  scarcely  another  condition  in  obstetric 
practice  that  can  be  traced  to  such  a  variety  of  causes  or  that  deujands  so  many 
different  [)lans  of  treatment. 

I'Jtiolof/}/. — Deficient  jiower  of  the  uterine  muscle  in  labor  may  be  due  to  a 
defect  of  the  muscle  it  If,  to  some  anomaly  of  innervation,  or  to  a  mechanical 
interfereuce  with  the  full  and  effective  action  of  the  muscle.  Examples  of  the 
first-named  ca' .-c  lu.iy  be  found  in  imperfect  development  of  the  womb  or  in 
anomalies  of  dec  liijincnt,  as  in  ufcrus  hicornls.  The  uterine  muscle  maybe 
exhausted  by  rapitdy-succecding  pregnancies.  It  may  be  over-distended  by 
twins  or  by  hydramnios,  thus  losing  the  power  gained  by  cohesion  of  muscular 
bundles.  The  uterus  may  be  weakened  by  some  cause — as  an  adynamic  fever 
or  a  wasting  disease — that  weakens  the  whole  organism,  but  it  does  not  neces- 
sarily follow  that  uterine  weakness  always  accompanies  a  reduction  of  body- 
strength.  The  writer  has  seen  women  in  the  last  stages  of  phiuisis  or  in  the 
midst  of  an  attack  of  typhoid  fever  or  pneumonia  exhibit  a  uterine  power  in 
labor  above  the  noruu\l.  The  uterus  may  be  weakened  by  profuse  hemorrhage, 
as  in  placenta  pra^via.  It  may  be  rendered  incapable  of  exerting  normal  lorce 
in  dry  lalH»rs.  The  li(|Uor  anuiii  iiaviug  drained  off  comjdetely  (>arly  in  the 
first  stage,  the  uterus  retracts  upon  the  child's  body,  thus  being  subjected  in 

*  Tlie  miperior  fijjurus  (  '  )  uci'iirring  thi'oiinhinit  liic  text  of  this  iU'ti(Je  refer  to  tiiu  bibliog- 
riniiiy  Kiven  on  pngt'  ST'J. 


/ 


I ;,       •»  -^ 


'I 


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\  ; 


i 


cei'tain  regions  to  sevciv  and  long-continued  pressure,  and  becoming  in  those 
spots  anemic  and  fViaMe,  while  in  the  areas  free  from  the  pressure  of  th( 
child's  body  the  uterine  wall  becomes  congested,  swollen,  and  edematoir-. 
Above  all,  the  uterine  :,iiiscle  may  become  fatigued.  This  is  the  commonest 
cause  t)f  uterine  inertia.  It  is  seen  oftenest  in  primiparje,  in  whom  inertia 
is  more  than  twice  as  common  as  in  multiparte  on  account  of  the  diffi- 
culty of  dilating  the  rigid  cervical  tissues.  Inertia  may  appear  in  con- 
sequence of  any  serious  obstruction  in  labor.  At  first  the  ))ains  are  feeble, 
infrequent,  and  inefficient,  but  as  labor  continues  the  uterine  contractions 
gather  force.  The  inertia  from  this  cause  is  bkcly  to  be  only  temporary, 
seen  at  intervals  between  periods  of  stormy  uterine  action  or  of  long-contimicd 
tonic  spasms,  until  finally  exhaustion  of  the  whole  organism  threatens  the 
patient's  life  or  the  uterus  ruptures. 

It  has  been  asserted  that  an  anomaly  of  innervation  in  the  anatomical 
sense,  a  deficient  supply  of  the  terminal  nerves  in  the  individual  nniscK'-cells, 
is  a  cause  of  uterine  inertia,  but  it  is  not  yet  clearly  demonstrated  to  bo 
so.  An  inhibitory  nervous  impulse  to  the  uterine  nnisde,  on  the  contrary, 
is  a  frequent  cause  of  uterine  inaction.  It  is  the  result  of  some  emotion 
or  of  excessive  pain.  That  the  "  doctor  has  frightened  the  pains  away"  on 
his  first  arrival  has  become  proverbial  in  tiie  lying-in  I'oom.  The  presence 
of  any  one  who  is  a  cause  of  embarrassment  or  is  disagreeable  to  the  patient 
may  have  the  same  effiL>et.  In  hyperesthetic  women  the  uterine  contractions 
may  be  so  exquisitely  jiainful  that  their  first  onset  is  followed  by  an  inhibitory 
impulse  which  cuts  them  short  almost  inunediately.  Every  clinical  observer  has 
seen  the  phenomenon  of  rajiidly-recurring,  very  painful  uterine  contractions, 
which  are,  however,  of  short  duration,  and  wiiich  secure  no  a])preeiable  dilata- 
tion of  the  cervical  canal.  A  woman  may  be  tortured  thus  for  hours  in  the 
early  part  of  the  first  stage  of  labor,  when  this  inliibitory  nervous  impulse  is 
commonly  observed.  With  the  continuance  of  labor  the  individual  becomes 
more  or  less  indiffi'rent  to  her  surroundings  or  more  iinired  to  suffering,  and 
the  inhibitory  nerves,  probably  derived  from  the  spinal  cord,  apparently  lose 
the  power  of  responding  to  the  stimulus  of  pain. 

Among  the  mechanical  causes  of  incnicient  uterine  action  during  labor  are 
fibroid  tumors  of  the  uterine  walls,  displacements  of  the  womb,  old  peritoneal 
adhesions,  and  fresh  outbreaks  of  periuterine*  inflanunation. 

J)l(i(/)i()sis. — The  n'cognition  of  uterine  inertia  should  always  be  easy.  The 
contractions  of  the  muscle  are  of  short  dni'ation  and  are  separated  usually  by 
long  intervals,  and  by  palpation  the  observer  may  convince  himself  that  tluy 
are  feeble.  The  uterus  during  the  [laiii  does  not  assume  that  intensely  hard 
consisteiKy  which  normal  vigorous  action  of  the  muscle  in  labor  oct  ;isions. 
Tlie  ])atient's  expression,  action,  and  demeanor  point  to  deficient  force  during 
the  ])ains.  The  woman  is  more  placid,  the  fa<'e  is  less  contorted,  and  there  is 
less  outcry  during  the  contractions  than  in  tiie  normal  ])arturient  patient,  except 
in  those  cases  'm  which  excessive  pain  inhibits  ut(>rine  !;"ti()n.  In  these  cases, 
however,  abdominal  palpation  and  the  short  duration   of  the  jiains  are  sr.f- 


U 


Tlic 

y  '•}• 

tlicy 
iiu'd 

idllS. 

iriiii; 

IV  is 
;•'('))( 
uses, 

si:!- 


DYSTOCIA. 


495 


ilcicntly  plain  signs  of  the  inertia.  Finally,  labor  is  delayed.  During  the 
lirrit  stage  dilatation  is  slow  or  does  not  progress  at  all,  and  in  the  second  stage 
the  presenting  part  does  not  advance.  One  fatal  error  in  the  diagnosis  of 
inertia  uteri  should  be  avoided  :  the  physician  shoidd  be  sure  that  labor  is  not 
(lelaved  by  some  obstruction.  It  lias  happened  in  a  careless  and  superficial 
cxiiniinatiou  that  the  observer  has  taken  the  distended  and  thinned  lower 
uterine  segment  for  an  inert  womb.  En  such  a  case  the  measures  adopted 
to  stimulate  the  supposedly  inactive  uterine  muscle  to  overcome  an  obstacle 
lliat  is  insui)crablo  might  easily  be  interrupted  by  rupture  of  the  womb.  A 
methodical  and  careful  examination  will  guard  one  from  this  error.  The 
source  of  obstruction  will  be  discovered.  The  firmly,  jierhaps  tctanically, 
contracted  upper  uterine  segment  may  be  contrasted  with  the  inactive  lower 
segment  by  palpation  of  the  whole  anterior  surface  of  the  womb.  The  con- 
tra(^ti()n-ring  should  be  visible,  and  the  whole  uterus  stands  out  with  unusual 
prominence,  from  the  anteversion  that  always  accompanies  prolonged  and 
powerful  uterine  contraction. 

Treatment. — From  the  diversity  in  the  causes  of  inertia  uteri  it  follows  that 
no  single  plan  of  treatment  can  be  depended  upon.  If  uterine  action  is  inhib- 
ited by  emotion,  the  cause  of  nervous  disturbance  should,  if  possible,  be 
removed.  An  objectionable  person  should  leave  the  room.  If  excessive 
pain  prevents  effective  contractions,  an  analgesic  should  be  admim'stered. 
Nothing  is  better  for  this  pur])()se  than  chloral  administered  in  15-grain 
doses,  repeated,  if  necessary,  twice  at  intervals  of  fifteen  minutes.  A  quarter 
of  a  grain  of  morphia  hypodermatically  comes  next  in  order  of  efficiency.  If 
the  uterine  nuisde  is  simjily  apathetic,  it  can  be  aroused  by  some  direct  irri- 
tant. The  insertion  of  a  bougie  as  for  the  induction  of  labor  answers  the 
purpose  well.  A  more  effective  but  more  troublesome  measure  is  the  dilata- 
tion of  the  cervical  canal  by  Barnes's  bags.  These  not  only  irritate  the  ute- 
rine muscle  and  thus  bring  on  strong  contractions,  but  they  also  artificially 
dilate  the  cervical  canal,  and  thus  relieve  the  uterine  nniscle  of  a  great  part  of 
its  task  in  the  first  stage  of  labor.  If  tlie  head  should  be  well  engaged  in  the 
pelvis,  however,  the  insertion  of  the  bags  is  difficult  and  they  are  likely  to 
cause  malpositions  of  the  head.  In  such  cases,  if  the  os  is  dilated  to  the  size 
of  a  silver  dollar,  nothing  is  so  effective  as  the  application  of  forceps — not  with 
the  idea  of  dragging  the  head  through  the  luidilatiMl  cervical  canal,  but  to  ])ull 
the  head  at  intervals  iirudy  down  upon  the  cervix.  Tiie  impact  of  the  head 
upon  the  cervix  acts  as  a  powerful  rcHex  irritant,  and  will  excite  as  strong 
contractions  as  any  direct  irritant  can  do.  Not  only  so,  but  the  ])ull  of  the 
head  upon  the  cervix  will  gradually  dilate  the  canal  as  effectually  as  coidd 
strong  propulsion  from  above.  As  soon  as  effective  ])ains  arc  established  and 
the  dilatation  of  the  cervical  ci'ual  ])rogresses  satisfactorily  the  forceps  should 
be  removed. 

Inertia  uteri  so  profiuind  as  to  (lcii;:>ud  the  somewhat  radical  measures  just 
described  is,  fortunately,  rare.  More  commoidy  the  pliysician  sees  the  minor 
grades,  in  which  there  is  simply  a  ilagging  of  uterine  eiTort  during  the  first 


■U* 


4''t^-i 


AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 

stage,  ef^pecially  in  priniiparje,  accompanied  by  every  evidence  of  temporary 
physical  and  mental  exhaustion.  After  a  period  of  rest  effective  contractions 
will  reappear,  even  if  nothing  whatever  is  done  to  aid  the  patient.  The  more 
complete  the  rest,  the  more  vigorous  will  be  the  uterine  action  when  it  is 
resumed,  and  for  this  reason  the  administration  of  chloral  and  opium  is  often 
followed  after  a  time  by  a  satisfactory  progress  in  labor.  But  these  drugs 
necessarily  retard  the  termination  of  labor  by  the  time  of  rest  they  secure. 
It  is  ordinarily  desirable,  therefore,  to  resort  to  drugs  of  a  stimulant  character 
that  shall  at  once  revive  the  flagging  uterus  and  so  hasten  the  delivery.  ^Nfanv 
medicaments  have  been  recommended  for  this  purpose,  but,  of  them  all,  alco- 
hol, quinin,  and  ergot  alone  deserve  consideration.  The  last  was  employed 
extensively  at  one  time,  but  clinical  experience  forbids  its  use  to-day.  The 
contractions  of  the  womb  induced  by  ergot  are  likely  to  become  tetanic.  The 
uninterrupted  contractions  interfere  with  the  fetal  circulation ;  they  niav 
cause  fatal  intra-uterine  asphyxia,  and  they  often  produce  such  exaggerated 
blood-presssure  and  stagnation  of  the  current  in  the  fetal  body  as  to  in^luco 
extravasations  in  important  viscera,  especially  the  brain.  Further,  the  cir- 
cular fibres  of  the  cervix  come  under  the  influence  of  the  drug,  and  by  their 
firm  contraction  neutralize  the  contraction  of  the  longitudinal  fibres  of  the 
uterine  body,  and  thus  retard  labor  almost  indefinitely ;  and,  worst  of  all, 
should  there  be  some  obstruction  to  the  descent  of  the  child  in  the  maternal 
pelvis  or  in  the  fetal  body,  the  administration  of  ergot  predisposes  to  rupture 
of  the  uterus.  For  these  sufficient  reasons  this  drug  as  a  stinndant  to  the 
uterine  muscle  in  the  first  and  second  stages  of  labor  should  be  banished  from 
the  obstetrician's  pharmacopeia,  except  in  the  single  instance  of  the  birth  of 
the  second  of  twins  (see  p.  509).  Owing  to  the  recommendations  of  Albert  H. 
Smith  and  of  Fordyce  Barker,  quinin  has  had,  and  still  has,  a  great  reputa- 
tion as  a  stimulant  to  the  uterus  in  labor.  The  writer's  experience  with  the 
drug,  however,  does  not  permit  him  to  subscribe  to  a  belief  in  its  efficacy  as  a 
uterine  stitnulaiit  in  labor.  Quinin  has  the  positive  disadvantage,  moreover, 
that  it  will  occasionally  in  certain  susceptible  individuals  produce  a  violent 
post-partum  hemorrhage.  In  the  minor  grade  of  inertia  under  description,  so 
often  seen  in  j)rimipara',  and  almost  always  the  result  of  exhaustion,  the  writer 
has  found  nothing  so  useful  as  alcohol,  in  the  shape  of  a  wineglassful  of  sherry, 
taken  slowly  with  a  cracker,  and  given  with  the  positive  assurance  that  it  will 
bring  back  the  pains  and  hasten  the  conclusion  of  labor,  for  the  patient  needs 
moral  and  mental  supjutrt  as  nnich  as  she  requires  a  physical  and  muscular 
stimulus. 

An  impression  prevails  among  general  physicians  that  inertia  uteri  in  the 
first  stage  of  labor,  before  rupture  of  tlie  meinl)ranes,  may  safely  be  disre- 
ganled.  In  a  n\easure  this  view  is  correct.  Tiie  writer  has  seen  in  a  number 
of  instances  a  partial  dilatation  of  the  os  and  then  an  entire  cessation  of  ute- 
rine contractions  for  many  hours  and  even  for  days.  In  one  case  the  cervical 
canal  was  sufficiently  dilated  to  receive  foin-  fingers,  and  it  remained  so  for 
more  than  a  week,  the  patient  all  tli(>  while  going  about  on  her  feet  in  per- 


itsmmmmum' 


f 


DYSTOCTA. 


497 


feet  comfort,  without  a  single  painful  contraction  of  the  womb.  But  should 
inefficient  uterine  contractions  be  accompanied  by  much  pain,  as  happens  in 
some  cases  of  inertia,  the  long-continued  first  stage  should  not  be  regarded 
with  indifference.  The  patient  will  in  time  show  the  irritant  and  depressant 
iU'eots  of  long-continued  suffering  in  an  elevated  temjierature,  an  accelerated 
]nilse,  and  a  lessened  resisting  power  of  body-cells,  the  last  playing  an  import- 
ant r/)le  in  the  predisposition  to  sepsis  after  labor.  Another  consequence  of 
delayed,  painful  labor  may  be  seen  in  a  sensitive,  nervous  individual,  who  is 
thrown  into  a  state  of  excitement — who  from  gloomy  foreboilings  of  harm  to 
herself  and  to  her  infltnt  passes  into  an  almost  maniacal  condition  of  terror 
and  dread. 

It  should  be  a  rule  of  practice,  therefore,  to  watch  carefully  all  cases  of 
inertia  uteri,  and  to  interfere  as  soon  as  the  patient's  mental  condition  or  her 
jMilse,  tem])erature,  and  general  vigor  are  demonstrably  affected  by  the  delay 
in  labor. 

2.  Excessive  Po^\'Eu  in  the  Expulsive  F(jrces  of  Lahor. 

An  actual  excess  of  power  in  the  expulsive  forces  (the  uterine  and  abdom- 
inal muscles)  in  labor  sufficiently  great  to  expel  the  fetus  })recipitately  is 
extremely  rare.  A  relative  ex'cess  is  not  uncommon.  The  child's  body  may 
be  so  small,  the  pelvis  so  abnormally  large,  the  maternal  soft  parts  so  relaxed, 
that  the  ordinary  power  exerted  by  the  uterine  and  abdominal  nuiscles  is  far  in 
excess  of  that  required  to  overcome  the  weak  resistance  offered,  and  the  child 
is  fairly  shot  out  of  the  birth-canal.  The  rapid  delivery  may  cause  serious 
residts  to  both  mother  and  child.  In  the  woman  the  structures  on  the 
])elvic  floor  may  be  lacerated  severely  ;  the  sudden  evacuation  of  the  womb 
])ro(lis])oses  to  hemorrhage  from  inertia ;  the  placetita  may  be  detached  pre- 
maturely ;  and  the  sudden  evacuation  of  the  abdominal  cavity  predisposes 
to  dangerous  syncope.  For  the  child  the  chief  danger  is  the  possibility  of 
unexpected  delivery  of  the  mother  in  tiie  erect  posture.  The  umbilical  cord 
may  rupture,  and  the  chikl,  falling  to  the  ground,  may  be  injured  fatally. 
I'rccipitate  and  unexpected  labors  occur  mrst  frequently  when  women  are 
seated  U2)on  the  water-closet.  The  child  i'  evacuated  into  the  waste-pipe  or 
<lown  a  well,  and  may  be  destroyed.  Some  astonishing  examples  of  infantile 
vitality,  however,  are  furnished  by  such  cases.  In  one  instance  a  woman  was 
unexpectedly  delivered  while  seated  upon  the  conimtM'e  in  a  railway  train 
moving  at  the  rate  of  thirty  miles  an  hour.  As  soon  as  she  could  connnuni- 
cate  the  startling  intelligence  to  the  conductor  tlu'  train  was  ])acked  until, 
several  miles  from  the  place  wIkm'c  it  was  stopjxd,  the  infant  was  found  u])on 
the  railway  ties  alive  and  well  I*  In  another  ease,  under  the  writer's  obser- 
vation, a  young  woman  purposely  discharged  her  fetus  at  term  into  the  well 
of  a  privy  twelve  ieet  deep.  Three  bricks  were  thrown  or  fell  (k)wn  the  well 
after  the  child  and  lay  across  it*  body.     Eight  hours  after  its  birth  the  infant 

*  Professor  AVillijim  Osier  told  t'lo  writir  nf  \\\\>  renmrkiible  nceurrence.     It  liappened 
on  llie  (amulian  I'acilic  Huilroad. 
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was  fished  out  of  the  bed  of  niaiitire  in  wliicli  it  was  iinniersed  to  the  neck, 
unharniod  and  in  good  condition. 

Unfortunately,  the  i)hysician  is  usually  not  at  hand  to  prevent  a  precip- 
itate delivery  and  to  avert  its  consequences.  Shoidd  he  find  an  infant  descend- 
ing the  birth-canal  with  a  rapidity  dangerous  to  itself  and  to  its  mother,  he 
can  easily  retard  its  progress  by  pressure  with  his  hand  against  the  presenting 
part. 

3.    DEF()R>riTIES   OF   THE    PELVIS. 

Comprehensive  and  satisfactory  knowledge  of  deformities  in  the  female 
pelvis  has  been  gained  only  in  the  latter  half  of  the  present  century,  since 
the  appearance  of  Miciiaelis'  work  in  1851.'  Until  the  announcement  bv 
Arantius  in  the  last  quarter  of  the  sixteenth  century  that  a  contracted  pelvis 
is  a  serious  obstacle  in  labor,  the  prevailing  belief  had  been  that  difficult 
labors  from  mechanical  obstruction  by  the  maternal  bones  were  due  to  a  failure 
on  the  part  of  the  pelvis  to  expand  sufficiently  for  tiie  passage  of  the  child. 
This  idea  continued  in  force  for  a  number  of  years  after  Arantius'  time. 
According  to  Litzmann,  Heinrich  von  Dcventer  (LGol-1 724)  should  be  re- 
garded as  the  real  founder  of  our  knowledge  of  the  pelvis  and  of  its  anomalies. 
He  described  the  inclination  of  the  pelvis,  the  axis  of  the  pelvic  inlet,  the 
contracted  pelvis,  and  the  flat  pelvis.  Pierre  Dionis  was  the  first  to  point  out 
(1718)  the  relationship  between  rachitis  in  childhood  and  a  deformed  ])elvis 
in  the  adult.  William  Smellie's  contributions  to  the  study  of  the  female 
pelvis  were  remarkably  full  and  clear,  when  one  considers  how  little  was 
known  before  his  time.  His  description  of  the  rachitic  pelvis,  his  reflections 
on  its  cause,  and  his  accounts  of  illustrative  cases  may  be  read  with  profit 
to-day.  Roederer,  Stern,  Cooper,  Vaughan,  Denman,  Haudelocque,  and  1'  re- 
mery  added  nuich  to  the  stock  of  knowledge  during  the  latter  half  of  the 
eighteenth  century.  The  men  of  the  present  century  to  whom  we  owe  most 
of  our  present  information  about  the  pelvis  and  pelvimetry  are  Naegele,  Kilian, 
Rokitansky,  Michaelis,  Robert,  Litzmann,  Xeugebauer,  and  many  others  to 
whom  reference  will  be  made  in  the  sections  devoted  to  the  particular  varieties 
of  deformed  jielvis.- 

Frequency  of  Deformed  Pelves. — It  is  difficult  to  estimate  the  frequency 
in  America  of  ])elvcs  sufficiently  deformed  to  influence  decidedly  the  course 
of  labor.  Statistics  from  our  lying-in  hospitals  affi)rd  little  aid  to  a  correct 
conclusion,  because  the  inmates  are  chiefly  European  immigrants  and  negresses. 
In  the  Boston  Lying-in  Hospital,  however,  deformed  pelves  wen-  foiuid  in 
2  per  cent,  of  native-born  and  in  0  per  cent,  of  foreign-born  women  (Rey- 
nolds).' The  writer's  experience  in  private  and  consulting  practice  convinces 
him  that  deformed  pelves  are  by  no  means  rare  among  native-born  women  in 
the  densely-popidated  centres  of  the  Eastern  States.  Xo  general  practitioner, 
in  a  large  city  at  least,  can  hope  to  avoid  such  I'ases,  and  it  is  likely  that  each 
year  will  affitrd  him  one  or  more  striking  exap.ple.s.  It  follows  that  an  ability 
t(»  recognize  deformities  of  the  female  pelvis  is  a  necessary  c(piipment  for  every 


DYSTOCIA. 


409 


practitioner  of  medicine  \vlio  may  be  called  upon  to  attend  women  in  confinc- 
iiicnt,  and  that  a  knowledge  of"  pelvimetry  i.s  as  essential  to  the  intelligent 
and  successful  practice  of  obstetrics  as  are  jjcrcussion  and  auscultation  to 
till'  practice  of  medicine.  European  statistics  bearing  on  the  frequency  of 
contracted  pelves  give  the  following  results:  Michaelis  found  in  1000  partu- 
rient women  131  contracted  pelves;  Litzmann,  149.  Winckel  found  in  Ros- 
tock 0  per  cent.,  in  Dresden  2.8  per  cent.,  and  in  Munich  9.5  per  cent,  of  con- 
tracted pelves  among  pregnant  and  parturient  women.  Winckel  believes  that 
10  to  15  per  cent,  of  childbearing  women  have  cojitracted  pelves,  but  that  in 
only  5  per  cent,  is  the  obstruction  serious  enough  to  be  noticed.  Kaltenbach 
puts  the  frcHpiency  of  contracted  pelvis  at  14  to  20  per  cent.  In  Marburg  it 
was  found  to  be  20.3  per  cent.,  in  Dottingen  22  per  cent.,  in  Prague  IG  per 
cent.     Schauta  estimates  it  at  20  per  cent. 

Classification  of  Anomalies  in  the  Female  Pelvis. — All  classifications 
are  merely  a  convenience  for  the  teacher  and  .student.  It  is  rarely  possible  to 
draw  sharply-defined  lines  between  varying  manifestations  of  a  condition. 
The  majority  of  German  authors  follow  Ijitzmann's  classification  of  abnormal- 
ities of  the  female  pelvis,  by  which  they  are  broadly  divided  into  those  of  size 
and  those  of  shape.  Modern  French  authors  ado})t  the  still  less  satisfactory 
division  of  over-size,  under-size,  and  anomalies  of  inclination.  The  writer 
linds  Schauta's  classification  the  most  convenient,  and  therefore  utilizes  it, 
with  some  slight  modification.* 


ANOMALIES    f)F   THE    PELVIS   TJIE    RESILT   OF    FAULTY    DEVELOPMENT. 

Simple  flat ; 

Generally  equally-contracted  ( justo-minor) ; 

Generally  contracted  flat  (non-rachitic) ; 

Narrow  funnel-shaped,  fetal  or  undeveloped; 

Imperfect  devehtptnent  of  one  sacral  ala  (Naegele  pelvis) ; 

Imperfect  development  of  both  sacral  aUe  (Robert  pelvis) ; 

Generally  cijually-eidarged  ( jnsto-major) ; 

Split  pelvis. 

ANOMALIES   DUE  TO   DISEASE  OF   THE   PELVIC   I50NE.S. 
Rachitis  ; 
Osteomalacia ; 
New  growths ; 
Fractures ; 
Atrophy,  caries,  and  necrosis. 

ANOMALIES    IN    THE    ( 'ON JUNCTIONS    OF   THE    PELVIC    HONES. 

Abnormally  firm  union  (syiU)stosis),  which  is  apt  to  be  found  in  elderly 
juMuiiparje,  particularly  at  the  sacro-coccygeal  joint: 
Of  symphysis  ; 

Of  (lue  or  both  sacro-iliac  synchondroses; 
Of  sacrum  with  coccvx. 


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Abnormally  loose  union  or  separation  of  the  joints : 
llelaxation  and  rupture ; 
Luxation  of  the  coccyx. 

AXOMALIIvS   DIK  TO    DISEASE  OF  THE  SUPERIMPOSED  SKELETON. 
Spondylolisthesis ; 
Kyphosis ; 
Scoliosis; 
Kyplio-scoliosis ; 
Lordosis. 

ANOMALIES  DUE  TO   DISEASE   OF  SUBJACENT  SKELETON. 
Coxalgia ; 

Luxation  of  one  femur ; 
Luxation  of  both  femora  ; 
Unilateral  or  bilateral  club-foot ; 
Absence  or  bowing  of  one  or  of  both  lower  extremities. 

Diagnosis  of  Pelvic  Anomalies :  Pelvimetry. — Deformities  of  the 
female  pelvis  may  be  detected  by  the  history  of  the  patient,  by  her  a])pear- 
ance,  by  ])alpation  of  the  exterior  and  interior  of  the  pelvis,  and  by  external 
and  internal  measurements  of  those  pelvic  diameters  that  are  accessible,  or  of 


Fi(i.  293— Modem  c  iiiibiiiation  t>{  Hiui- 
(li'l(ii'iiiii.''s  mill  (isimiiUT:-  iu'lvimL'tiT. 


Fit!.  201.— Osinnik'r's 
pclviniL'tLT. 


Fig.  2'j:i.— Martin'.s 
pt'lvimetor. 


salient  points  on  the  woman's  body  corresponding  as  nearly  as  po.ssibIe  with 
the  internal  measurements  desired  ;  the  relations  between  the  two  la.st  haviiiiz; 
been  a.scertained  l)y  many  observations  on  dead  and  living  bodies.    For  taking 


DYSTOCIA. 


601 


])elvic  measurements  the  examiner's  fingers,  a  tape  measure,  and  a  modified 
mathematician's  callipers — a  pelvimeter — are  usually  employed.  Baudeloctpie 
(1775)  was  the  first  to  devise  the  pelvimeter  in  ordinary  use.  He  laid  the 
luundations  of  pelvimetry,  and  his  instrument  and  methods  are  in  use  at  the 
present  time  (Figs.  293-25)6).  It  is  convenient  to  describe  the  measurements 
ot'  the  diameters  of  the  pelvic  iidet,  pelvic  cavity,  and  pelvic  outlet  separately. 
3feasai'ctnent  of  the  Antero-posterior  Diameter  of  the  Superior  Strait. — 
This  measurement,  the  most  important  in  ihe  pelvis,  cannot  be  taken 
directly.  It  must  be  estimated  by  several  plans.  Baudelocfjue  was  the  first 
to  point  out  the  relation  between  the  measurement  from  the  depression  under 
tlie  last  spinous  process  of  the  lumbar  vertebrte  to  the  upper  edge  of  the  sym- 
physis pubis,  and  the  true  conjugate  diameter  of  the  pelvic  inlet.     To  this 

external  measurement  the  name  "ex- 
ternal conjugate"  was  given,  but  it  is 
often  called  "  the  diameter  of  Baude- 
locque  "  (Fig.  208).  Its  discoverer  be- 
lieved the  relation  between  the  external 
and  internal  diameters  to  be  constant — 
that  the  one  exceeded  the  other  by  8  to 
8^  centimeters — but  in  this  he  was  mis- 


Fia.  'JlU'i.— Harris-Dickinson  yiortiiljle  polvlmetLT.  Fig.  2U7.— Measuring  oxtermil  conjugate. 

taken.  The  line  of  the  e\ternal  diameter  does  not  usually  coincide  with  the 
line  of  the  internal,  an<l  the  thickness  of  bones  and  superimposed  structures 
differs,  of  course,  in  each  individual.  In  30  cases  in  which  Litzmann  had 
an  opportunity  to  compare  the  measurement  of  the  external  conjugate  taken 
during  life  with  the  actual  measurement  of  the  true  conjugate  taken  after 
death,  there  was  an  average  difterencc  of  9.5  centimeters,  but  the  maxinuini 
dilTerence  was  12.5  centimeters  and  the  minimum  7  centimeters — a  variation 
of  5.5  centimeters  in  this  small  nund)er  of  cases.  Michaelis  found  a  ditterence 
of  0.6  to  3.2  centimeters,  and  Schroeder  11  to  3  centimeters  between  the 
external  conjugate  of  the  living  body  and  that  of  the  dried  specimen.     The 


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measureiiK'nt  of  the  oxtcrnal  coiijiigato,  thoreforo,  is  not  to  be  reliod  upon  in 
making  an  cstiniatt'  of  the  size  of  tiie  true  conjugate.  It  sini|>ly  serves  to 
indicate  the  i)rohal)ility  or  tlie  improbability  of  pelvic  contraction.  An  exter- 
nal conjugate  of  IG  centimeters  or  under  means  certainly  an  antero-jiosteriorlv 
contracted  pelvis ;  between  10  and  19  centimeters  the  ])elvic  inlet  will  be  con- 
traetetl  in  more  than  half  tlie  cases;  between  19  and  21.6  centimeters  there 


Fig.  2US.— MonsurltiK  the  I'xtoriml  cdiijugnto  (liametcr  uikiii  the  living  fcmiile. 

will  be  but  10  per  cent,  of  contracted  pelves;  and  above  21.5  centimeters  it  is 
almost  certain  that  the  conjugate  diameter  of  the  pelvic  inlet  is  not  contracted  at 
all.  The  external  conjugate  cannot  be  measured  accurately  without  some  prac- 
tice. The  begiimer  in  pelvimetry  will  do  well  to  remend)er  the  ftdlowing  rules: 
Have  the  patient  dressed  for  bed.  Place  her  upon  her  side,  with  the  thighs 
slightly  flexed  and  the  clothing  rolled  well  up  out  of  the  way,  the  lower  part 
of  the  body  being  covered  with  a  sheet.  The  examiner  stands  at  the  patient's 
back,  facing  her  head.  The  de])ression  below  the  last  spinous  process  of  the 
lumbar  vertebrie  is  found  l)y  rubbing  a  finger-tip  over  the  lumbar  spines  from 
above  downward  until  the  finger  sinks  into  the  depression  sought  and  feels  no 
more  prominent  spinous  processes  below.*  The  knob  at  the  end  of  one 
branch  of  the  ])elvinieter  is   placed   firndy  in   this  depression,  and   is  held 

*  Micliaelis  preferred  the  nicisurenieiit  from  the  tip  of  the  hist  liinibar  spinous  process, 
instead  of  from  the  depression  l)eh)\v  it. 


DYSTOCIA. 


503 


tlicre  with  ono  hand  wliilc  the  fingers  of  the  other  hand  find  a  pouit  on  the 
.>;viiij)hy.si.s  pnhis  about  \  of  an  inch  lx'h)\v  its  nppor  eilgo,  on  wliich  j)oint  tiie 
other  l)ranfh  of  the  ju'lvinu'ter  is  firmly  set;  tlic  pelvimeter  having  heen  so 
placed  that  the  indicator  is  turned  toward  the  examiner,  the  measurement  is 
thcrefijrc  easily  read  off  as  soon  as  the  pelvimeter  is  in  proper  position.  It 
i-  (tn  the  average,  in  well-built  women,  20\  centimeters. 

The  best  means  for  determining  the  length  of  the  antero-posterior  diameter 
of  the  pelvic  inlet  are  the  measurement  taken  from  the  lower  edge  of  tiie 
symphysis  pubis  to  the  promontory  of  the  sacrum,  the  diagonal  conjugate 
diameter,  and  the  distance  between  the  upper  outer  surface  of  the  symphysis 
jiubis  and  the  pronjontory  of  the  sacrum.  The  diagonal  conjugate  diameter  is 
one  side  of  a  triangle  the  other  two  sides  of  which  arc  the  height  of  the  sym- 
pliysis  and  the  true  conjugate.  The  distance  between  the  outer  ujiper  surface 
of  the  symphysis  and  the  promontory  of  the  sacrum  differs  from  the  true  con- 
jugate by  the  thickness  of  the  upper  portion  of  the  .symphysis.  SnicUie  was 
accustomed  to  estimate  rougidy  the  length  of  the  true  conjugate  by  a  digital 


Fi(i.  2li'J.— Stfin's  iiistniiiR'nt  Inr  diivct  iiR'asuri'inoiit  of  tlic  ciPiijuKatt.'. 

examination,  basing  his  estimate  on  the  ease  with  which  the  ])romontory  could 
be  reached.  In  the  latter  pai't  of  the  eighteenth  century  .lohnson  '"  proposed  fi»r 
estimating  the  size  of  the  pelvic  inlet  a  method  which  consisted  in  inserting 
the  fingers  of  one  hand  in  the  mouth  of  the  wond)  and  then  spreading  them 
between  the  pntmontory  and  the  sacrum.  A  few  yeai-s  later  the  elder  Steiu 
devised  a  graduated  rod  for  measuring  the  distance  between  the  lower  edge  of 
the  symphysis  pubis  and  the  division  between  the  second  and  third  sacral 
vcrtebric.  This  distance  he  believed  to  be  \  to  1  inch  greater  than  the  true 
conjugate.  Stein  later  constructed  the  instrument  fi»r  the  direct  measurement 
of  the  conjugate  shown  in  Figure  299.  Many  instruments  have  since  been 
constructed  on  this  principle,  but  they  are  impracticable  in  the  living  female, 
fi)r  obvious  reas'  .is.  I>audelocqu(!  was  the  first  to  propose  the  measurement 
of  the  diagona'  conjugate  and  the  subtraction  from  it  of  an  average  figure 
(i  inch)  to  dett'rniine  the  length  of  the  true  conjugate.  His  method,  exactly 
as  he  described  it,  is  still  in  use,  with  the  exception  that  two  fingers  instead  of 
one  are  emjdoyod  in  measuring  the  distance  between  the  symphysis  and  tlie 
promontory.  To  measure  the  diagonal  conjugate  correctly  the  examiner  must 
have  the  skill  that  comes  of  practice,  and  he  must  conduct  his  examination  in 


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a  careful  anU  methodical  manner.  The  patient  is  put  in  the  lithotomy  posi- 
tion and  is  brought  to  the  edge  of  the 
table  or  bed  on  which  she  lies,  so  that 
the  buttocks  project  well  over  it.  The 
examiner  cleanses  \\\i.  lefl  hand  and 
anoints  the  first  two  fingers  with  an 
unguent ;  he  then  inserts  these  fingers, 
held  stiffly  extendetl,  inward  and  up- 
ward till  the  tip  of  the  second  finger 
finds  and  rests  upon  the  promotory 
of  the  sacrum.  Care  must  be  exor- 
cised not  to  take  the  last  lumbar  for 
the  first  sacral  vertebra  or  vice  verad, 
nor  the  second  for  the  first  sacral 
vertebra  —  mistakes  easily  nuide  in 
cases  of  so-called  "double  promon- 
tory." Witii  the  tip  of  the  second 
finger  resting  firndy  in  place  u[)(>n 
the  middle  line  of  the  promontory  the 
radial  side  of  the  hand  is  elevated 
until  upon  it  is  plainly  felt  the  im- 
press of  the  arcuate  ligament  under  the  lower  alge  of  the  symphysis.  With 
a  finger-nail  of  the  otlier  hand  a  mark  is  made  upon  this  point  of  the  examin- 
ing hand,  whicii  is  tiien  withdrawn 
(Fig.  ,'}n(i).  Tiie  listance  between 
this  mark  and  tiie  tip  of  the  middle 
finger  held  extendetl  is  taken  by  a 


l''iii.  :!iMi.- 


-Mfiisurinn  the  iliau 
iliaiiiLtor. 


iiiiil  ciinjiignte 


/./ 


Kin.  I'lOl— KlTcot  nf  ilitrcrciil  Incliimtlmis  of 
the  imliis  upiiii  the  ri'liilioiisliiii  ln'twci'ii  tho 
trui'   1111(1    tin-   iliiiK'ciiinl    ('(injuKuti.'   illiimcttT 

(Kilirlllnlltlll'SSllinnes). 


Fio.  ;«)2.— EflVct  of  different  thlekiicRses  of  the  sym- 
physis upon  tlie  relationship  between  the  true  nnil  tho 
diiigonul  eotiJURUte  diameter  (Uibemont-UessaiKncs). 


pelvimeter.     This  distance  is  the  diagonal  conjugate.     By  the  observation  of 


DYSTOCIA. 


505 


many  subjects,  alive  and  dead,  an  agreement  has  been  reached  that  1 J  centi- 
meters should  be  subtracted  from  the 
diagonal  conjugate  to  obtain  the  true 
conjugate  diameter.  But  the  acceptance 
of  this  average  difference  depends  upon  a 
normal  height  of  the  symphysis,  4  centi- 


Fi(i.  303— Effect  of  (liffiTcnt  hctpthts  of  the 
promontory  upon  tlio  relntionship  iK'tweon  the 
(rue  nnil  the  dingoiml  conjugiito  (Kibemont-Des- 
sniKnes), 


Fio.  304.— Kffect  of  different  heights  of  tlie 
symphysis  upon  the  relationship  between  the  true 
nnd  tlie  ilingonal  conjugate  diameter  (Kibeinont- 
Dessaigncs). 


motors,  a  normal  angle  between  the  axis  of  the  pubis  and  the  true  con- 
jugate, 105°,  a  normal  thickness  of  the  symphysis,  and  a  normal  height  of 
the  promontory  (Figs.  301-.'i05). 
Those  factors,  however,  are  not 
constant,  and  if  they  vary  much 
from  the  normal  the  most  skilful 
and  most  experienced  obstetrician 
may  be  misled  wofully  in  his 
estimation  of  the  true  conjtigate. 
The  writer  has  had  under  his  care 
a  rachitic  dwarf  in  whom  there 
was  more  than  3  contimotors'  dif- 
ference between  the  diagonal  and 
true  conjugates,  and  Pershing 
found  among  90  pelves  in  the 
miisoiuns  of  Philadelphia  a  dif- 
ference varying  from  0.8  centi- 
meter to  3.6  centimeters.  It  is 
declared  that  these  soiu'ces  of 
error  may  be  eliminato<l  by  the 
following  corrections  :  For  every 
degree  of  increase  in  the  conjugato-syniphyseal  angle  add  half  the  niunber  of 
millimeters  to  the  sum  to  be  subtracted  from  the  diagonal  conjugate,  and  vice 


Fiii.  30.').— Effect  of  the  lessoned  slant  outward  of  the 
syniiiliysis  in  a  nu'lUtic  pelvis  upon  tlie  relationship 
between  the  true  and  the  conjugate  diameter  (K  boniont- 
Dessttignes). 


f 


II 


Iffii 

|lliB 

'  mammml^^ms 

'■  I 

'IIBH 

'HH 

IflKHH 

tf  Si 


\  'my, 


0()«) 


AMEltlCAX    TEXT-BOOK    OF   OBSTETlilCS. 


i( 


revHti  ;  also,  for  evorv  O.o  centimeter  increase  in  tlie  height  of  tlie  svinphysis 
over  tlie  normal  add  0.3  centimeter  to  the  snn»  to  be  suhtractetl  from  the 
diagonal  conjugate,  and  vice  rcrml.  While  these  rules  are  admirable  for  tin 
study  of  the  dried  specimen  in  a  museum,  they  are  not  easily  applied  to  tiic 
living  ])regnant  female.  The  height  of  the  symphysis  can  be  measured  in  the 
living  subject,  but  an  allowance  for  variations  in  this  respect  eliminates  error 
in  only  a  small  proportion  of  cases.  The  variations  in  the  angle  of  the  syni- 
l>hysis,  a  much  more  important  source  of  error,  can  only  be  surmised.  The 
writer  much  prefers  the  measurement  between  the  upper  outer  edge  of  tin; 
synij)hysis  pubis  and  the  promontory  of  the  sacrum  for  the  estimation  of  the 
true  conjugate,  having  demonstrated  its  superior  accuracy  in  practice.*  For 
taking  this  measurement  the  patient  is  put  in  the  dorsal  position,  with  the 


Fk;.  aiJii.  — Hirst's  ju'lvimctiT:  a,  fur  monsiirintr  tlie  tnio  cimjiiKiiti'  iilus  the  tliicknoss  of  the  symphysis; 
n,  witli  extra  tip  iidileil  for  iiieasiiriiit;  the  tliiciciiess  of  tlie  syinphysis. 

buttocks  projecting  beyond  the  edge  of  the  table  or  bed  on  which  she  lies. 
A  mark  with  the  point  of  a  lead  pencil  is  made  on  the  skin  over  the  sym- 
physis pubis,  about  J  of  an  inch  below  the  upper  edge.  The  two  fingers  of 
the  left  hand  are  inserted  in  the  vagina  as  in  measuring  the  diagonal  conju- 
gate. The  tip  of  the  middle  finger,  having  found  the  middle  line  of  the 
promontory,  is  moved  a  little  to  the  patient's  right,  and  tip  B  of  the  pelvi- 
meter, shown  in  Figure  30(5,  is  made  to  take  its  place.  While  the  examining 
physician  holds  the  shaft  of  the  pelvimeter  firndy  in  place  an  assistant  adjusts 
tip  A  of  the  movable  bar  over  the  mark  made  on  the  symphysis.  This  bar  is 
then  screwed  tight,  the  whole  pelvimeter  is  removed,  and  the  distance  between 
the  t'ps  is  found  by  a  tape  measure.  This  distance  is  the  conjugate  plus  the 
'hickness  of  the  symphysis  (Fig.  307).     The  latter  the  writer  has  found  to  be 


DYSTOCIA. 


607 


ijiliysis 


2   IK'S. 

sv  ni- 


l's 0 


['OlljU 

)1"  til 


bol 


VI- 


tiniiig 
llj  lists 


IP 


tl 
I  to  be 


Fl<i.  307 


MousuriiiK'  tlu'  truo  (•()Ilju^'Htt'  [ilus  the  tliick- 
iK'ss  of  tho  symphysis. 


1  centimeter  in  twenty-six  dried  jwlves,  IJ  centimeters  in  nine,  1^  centi- 
meters in  thirteen,  IJ  centimeters  in  tour,  and  2  centimeters  in  tliree  sjieei- 
iiiens,  one  a  high-grade  rachitic 
l)elvis,  another  of  the  masculine 
type,  and  the  third  a  justo-majo- 
pelvis.  The  thickness  of  the  sym- 
physis is  measured  as  shown  in 
Figure  30H.  In  living  subjects  the 
index  finger  of  the  left  hand  must 
find  the  inner  surface  of  the  sym- 
physis pubis,  and  follow  it  up  to 
within  about  |  of  an  inch  of  the 
top,  where  it  bulges  to  its  full 
thickness.  On  this  point  one  tip 
of  the  pelvimeter  is  placed,  and 
it  is  then  held  in  position  between 
the  ends  of  the  first  and  second  fin- 
gers ;  the  other  tip  of  the  instru- 
ment is  adjusted  over  the  mark 
made  on  the  skin  externally  :  the  distance  is  read  off  from  the  indicator  pro- 
vided for  the  purpose.  It  is  not  necessary  to  make  an  allowance  for  the  thick- 
ness of  the  tissues  over  the  sym- 
physis, for  this  is  included  in  both 
measurements,  and  on  subtracting 
one  from  the  other  tlu^  necessary 
correction  i'  of  course  made.  The 
tissues  over  the  inner  surface  of 
the  symphysis  can  usually  be  so 
compressed  by  the  kiKtb  of  tiie 
pelvimeter  as  to  be  practically 
eliminated.  If  this  is  impossil)lc, 
as  may  happen  in  some  primiparie, 
a  small  allowance  may  be  made 
for  these  tissues — say,  at  the  most 
0.5  centimeter.  In  taking  this 
measurement  it  may  be  necessary 
to  anesthetize  the  j)atient ;  and  this 
is  well  worth  while  if  a  decision 
between  some  of  the  more  serious  obstetrical  operations  is  to  be  based,  as  it 
must  be,  upon  an  accurate  estimation  of  the  true  conjugate.* 

Mmmrement   of  the   Traimrrw   Diainchr   of  the   Sujivrlor   Stndt. — The 

*  Wi'llcnliortrh  was  tlie  lirst  to  pini>loy  this  jirinciplo  in  jielvinictry.  Ilis  polviiiictrr  was 
imjtrovi'il  npim  by  Van  IIiiovcl,  ami  in  ri'cont  tinius  iiy  Skiilscli  ami  t)y  niilliti  i  Dniiscln-  iiuili- 
clnixchf  WocliciiKrhrift,  No.  18,  1S!K);  Aiiiiriritii  Joiinial  nf  ObnMriri',  IHW ;  Miiller's  Ilundbuch 
der  CicbitrtMil/<;  vol.  ii.  pp.  2')'),  'J(>0,  'JGl). 


Flo,  ;j(JS.— MeiisurinB  the  thli'kni.'ss  of  thu  sympliysis. 


!IM' 


L  - 
4 


'^ 


i  i  f 


mmmm 


%9 


508 


AMERICAN   TEXT-BOOK  OF   OBSTETRICS. 


transverse  diameter  of  the  pelvic  inlet  cannot  be  nieasnred  directly,  nor  can 
it  be  estimated  accurately.  Fortunately,  this  is  not  necessary.  It  answers 
the  I'equirements  of  practice  to  determine  whether  there  is  a  diminution  of 
this  measurement,  without  determining  the  exact  degree  of  lateral  contraction. 
To  do  this  the  following  measurements  are  relied  u^wn  :  The  di.'-tance  between 
the  anterior  suj>erior  spinous  processes  of  the  iliac  bones,  which  in  well-formed 
women  is  26  centimeters ;  the  distance  between  the  crests  of  the  iliac  bones, 
29  centimetei*s  ;  the  distance  between  the  tr()chantei*s,  31  centimeters;  the  dis- 
tance between  the  posterior  superior  spinous  processes  of  the  iliac  bones,  9.8 
centimeters ;  the  distance  between  the  subpubic  ligament  and  the  upper  ante- 
rior angle  of  the  great  sacro-sciatic  notch,  which,  according  to  Lohlein,  is  2  cen- 
timeters less  than  the  transverse  diameter  of  the  inlet ;  finally,  an  estimation 
of  the  width  of  the  pelvic  inlet  by  a  vaginal  examination.  In  taking  the 
external  measurements  the  woman  is  placed  upon  her  back.  The  salient  points 
are  easily  found  except  in  the  case  of  the  iliac  crests.     They  are  discovered  by 


^ ■";,.^«'j 


Fio.  3()9.— Skutsch's  method  of  measuring  the  conjugate  diameter. 

moving  the  knobs  of  the  pelvimeter  evenly  along  the  crests  of  the  ilia  until  the  two 
opposite  points  most  widely  separated  from  each  other  are  foiuid.  If  the  crests 
are  no  farther,  or  even  less,  separated  from  each  other  than  the  spines,  points 
5  centimeters  back  of  the  latter  are  arbitrarily  selected  as  the  sites  of  the 
crests.  The  posterior  superior  spinous  processes  are  t)ften  marked  by  distinct 
dimples  on  tiie  woman's  back.  The  internal  measurement  of  Lohlein  is  made 
by  the  fingers  in  the  vagina.  If  all  these  measurements  are  much  less  than 
normal,  a  lateral  contraction  of  the  pelvis  may  be  assumed,  and  the  degree  of 
contraction  is  roughly  estimated  by  the  amount  of  decrease  in  the  measure- 
ments, although  the  relations  between  these  measurements  and  the  distance 
sought  is  very  variable.  The  efforts  of  Skutsch  and  of  others  before  him 
accurately  to  measure  the  transverse  diameter  of  the  pelvic  inlet  by  combined 
internal  and  external  measurements  camiot  be  said  to  have  vet  been  crowned 
by  success.  The  softness  of  the  tissues  externally  permits  the  external  knob 
of  the  pelvimeter  to  sink  into  the  flesh  to  a  varying  degree,  and  the  same  is 
true  of  the  structures  within  the  pelvis.     It  is  difficult  also  to  keep  the  pel- 


DYSTOCIA. 


nm 


vimeter  in  the  same  straight  line  when  the  internal  knob  is  changed  from  one 
siilc  to  the  other  (Figs.  309,  310).  Moreover,  better  results  in  practice  luay 
be  obtainetl  by  an  estimate  formal  by  a  vaginal  and  a  combinetl  examination, 
under  anesthesia  if  necessary,  of  the  relative  size  of  the  transverse  diameter 
of  the  pelvic  inlet  and  the  antero-posterior  diameter  of  the  child's  head. 

Measurement  of  the  oblique  diameters  of  the  pelvic  inlet  is  rc<|uired  only  in 
obliquely-contracted  pelves.  It  will  be  referred  to  in  the  description  of  these 
pelves. 

The  Measurement  of  the  Capacity  of  the  Pelvic  Cavity. — The  capacity  of 
the  pelvic  cavity  must  be  estimated  by  vaginal  examination.     There  is  no 

plan  by  which  accurate  meas- 
urements can  be  made.     It  Is 
sufficient  to  estimate  the  size 
and  the  shape  of  the  pelvic 
canal  by  palpating  the  lateral 
•;•.       walls  of  the  pelvis ;  by  dcter- 
//       mining  the  curve,  perpendicu- 
\l       larly  and  laterally,  of  the  sa- 
:•      crura ;   by  noting  the  height 
;/•■       of  the   sacro-sciatic   notches, 


Kio,  310.— Skutsc'li's  inothoil  of  iiicnsurint,'  the  trans- 
verse diiimeter  of  the  jielvie  inlet. 


Fig.  ol!.— Munsnrcment  of  the  nntero-iKistcrior 
diumeler  of  the  pelvic  outlet. 


the  approximation  of  the  tuljcrositics  of  the  ischia,  the  depth  of  the  pelvis, 
and  the  direction  of  its  canal ;  by  detecting,  pt)ssibly,  the  presence  of  an  exos- 
tosis, an  osteosarcoma,  an  abnormally-projecting  spinous  process,  an  old  frac- 
ture, or  asymmetry  of  the  pelvic  walls  from  any  cause. 

Measurement  of  the  Transverse  Diameter  of  the  Pelvic  Outlet. — The  atitoro- 
posterior  diameter  of  the  inferior  strait  is  enlarged  during  labor  by  the 
displacement  backward  of  the  coccyx.  The  transverse  diameter  between  the 
tul>erosities  of  the  ischiatic  bones  is  constant,  and  if  there  is  contraction  of  the 
outlet  the  greatest  resistance  to  the  escape  of  the  fetus  is  furnished  by  these 
firm  bony  eminences.  The  transverse  diameter  of  the  pelvic  outlet  can  be 
measured  directly  with  ease.  The  woman  is  placctl  in  the  dorsal  pt^ition 
with  thighs  and  legs  flexed.     The  distance  between  the  tuberosities  of  the 


jcdttM*><'4^' 


ii' 


dim 


!■(■    1 


f# 


51 0 


AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 


iscliia  is  mcasuretl  with  a  ix-'lvinicter,  or  the  examining  physician  places  his 
thumbs  squarely  on  the  tuberosities,  and  an  assistant  measures  the  (listaiu-e 
between  the  physician's  thiuiib-nails. 

If  it  should  be  tlesire<l  to  measure  the  antero-poaterinr  diameter  of  the  pelvic 
outlet,  this  may  be  done  as  shown  in  Figure  311,  1.5  centimeters  being  sub- 
tractetl  for  the  thickness  of  bone  and  superimposed  structures. 

4.  Description  of  the  Several  Varietie.s  of  Abnormalities  in 

THE  Female  Pelvis. 

The  simple  flat  pelvis  (Fig.  31 2)  is  the  earliest  recognized  form  of  contracted 
pelvis — the  peliu)i  j)l(()ia  of  Deventer,  who  did  not,  however,  make  a  distinction 
between  the  simple  flat  and  the  rachitic  flat  i)clvis.  It  is  doubtful,  indeed,  if 
ho  knew  the  difference  between  the  two.  lictschler  was  the  first  to  point  out 
the  distinctive  features  of  this  form  of  pelvis.  In  I^urope  it  is  the  commonest 
variety  of  deformed  pelvis.  Schroedcr  states  that  it  is  seen  more  frequently 
than  all  the  other  forms  put  together.  In  America  it  is  also  eonmion,  but  the 
equally  general ly-contractetl  pelvis  is  encountered  here  as  often  or  perhaps 
oftcncr.  Out  of  a  series  of  316  pelves  in  women  of  American  birth  the 
writer  has  found  eighteen  (a  percentage  (»f  5.6)  with  the  measurements  charac- 
teristic to  some  degree  of  a  simple  flat  pelvis. 

Cha)'acteri,stic)<. — In  the  simple  flat  jielvis  the  sacrum  is  small  and  is  pressetl 
downward  and  forward  between  the  iliac  bones,  but  is  not  rotated  foi  ivard 
on  its  transverse  axis.  The  antero-posterior  diameter  is  contracted,  therefore, 
throughout  the  whole  of  the  pelvic  canal.  The  contraction,  however,  is  not 
often  great.  It  is  scarcely  ever  below  8,  and  is  usually  not  under  9.5, 
centimeters.* 

The  transverse  diameter  is  as  great  as,  or  jiossibly  greater  than,  that  of  the 
normal  pelvis.  Occasionally,  however,  in  pelves  aj)proaching  the  type  of  the 
generally-contracted  flat  pelvis  the  transverse  diameter  may  be  found  some- 
what diminished.  There  is  in  those  pelves  quite  frequently  a  double  promon- 
tory formed  by  the  abnormal  jirojection  of  the  cartilaginous  junction  between 
the  first  and  second  sacral  vertebric.  The  line  drawn  between  the  lower  prom- 
ontory, or  the  second  sacral  vertebra;,  and  the  symphysis  is  often  as  small  as,  or 
smaller  than,  the  true  conjugate.f 

Kiiologij. — The  simple  flat  pelvis  has  been  as(Tibe<I  to  heredity,  to  an 
arrested  rachitis,  to  overwork  before  puberty  (especially  the  carrying  of  heavy 
weights),  to  premature  attempts  to  walk  or  to  sit  up,  and  to  the  weight  of  a 
heavy  trunk  upon  a  j>elvis  ill  fitted  to  bear  it  on  account  of  weakness  of  its 
ligaments.     It  is  probable  that  in  the  majority  of  these  pelves  the  form  is 

*  Eiifrolken  has  descriljod  a  specirni'ii  with  a  true  conjugate  of  4.S  oentimeters,  a  diajional 
conjugate  of  7.-")  pcntiiut'tepi,  with  transverse  and  ohli(|ue  diameters  of  the  inlet  13.3  and  12.4 
centimeters  respectively.     This  specimen  is  iini(|uc. 

t  Crfde  found  in  nine  pelves  with  a  double  promontory  the  conjugate  from  the  true  prom- 
ontory longer  in  four  and  shorter  in  three  cases  than  the  conjugate  measured  from  the  false 
promontory.  In  two  cases  the  two  conjugates  were  of  equal  length  (Klin.  Vortriige  ueber 
Gebuiishiilft;  Berlin,  1853). 


DYSTOCIA. 


511 


iiilioritci  and  congenital.     It  has  been  loiuul  by  Feliling  in  a  number  of  fetuses 
and  new-born  infants. 

J)iaf/no8ix. — The  simple  flat  pelvis  is  easily  overlooked.  There  is  nothing 
in  the  patient's  appearance  or  history  to  suggest  the  deformity,  unless  she  has 
had  difticulty  in  previous  labors.  The  characteristic  signs  are  the  diminished 
antero-posterior  dianjcter,  determined  by  internal  and  external  measurements, 
and  a  transverse  diameter  as  great  as,  or  greater  than,  normal,  or  prhaps  a 
trifle  under  the  normal  nteasurement.  This  last  point  is  determined  by  meas- 
urements externally  and  by  the  internal  palpation  of  the  iielvic  canal.  In 
measuring  the  conjugate  diameter  of  this  pelvis  one  must  take  into  account 
the  lessened  inclination  of  the  sym- 
physis outward,  its  height,  some- 
what below  the  normal,  anil  the  low 
position  of  the  promontory.  Usually 
the  average  sum  of  1 1  centimeters  is 
a  suflicient  amount  to  subtract  from 


Fl(i.  31J.— Plinpk-  lliit  pi'Ivis  (mixk-l  in  Hirst 
Colk'ctioii,  liiivLTsity  nf  IViiiisylvaiiiii) ;  e.  v.,       Ku;.  313,— TIk- two  oonjuiintos  of  n  (lou))k>  proiiKintory 
85  cm. ;  tr.,  l;U  cm. ;  obi.,  I'.'l  cm.*  (Kil)cm(itit-l>cssait!iies). 

the  diagonal  conjugate.  If  there  is  a  double  promontory,  as  is  frequently  the 
case  in  this  form  of  pelvis,  the  ccmjugate  must  be  measured  from  the  promon- 
tory nearest  to  the  symphysis,  usually  the  lower  (Fig.  SVl). 

Jiijfucm'c  upon  Lahor. — From  the  failure  of  the  presenting  part  to  enter 
the  pelvis  during  the  last  weeks  of  ge.«tation  there  is  frequently  some  degree  of 
pendulous  abdomen,  especially  in  women  with  abdominal  walls  relaxed  from 
previous  pregnancies.  The  uterus  is  sometimes  broader  than  common,  and 
is  often  tiltetl  to  one  si<le.  The  pre,->enting  |>art,  if  the  head,  may  be  lo().«e 
al)ove  the  superior  strait,  resting  on  one  iliac  bone  or  on  the  symphysis,  or  it 
may  be  pressed  down  firmly  upon  the  brim  in  a  transverse  position,  to  accom- 
modate its  longest  diameter  to  the  longest  diameter  of  the  pelvic  inlet.  Mal- 
prcsentations  are  common,  as  is  also  prolapse  of  the  cord  and  of  the  extrem- 
ities. The  meml  I'anos  may  protrude  in  a  cylindrical  pouch  from  the  external 
OS  as  the  liquor  amnii  is  forced  out  of  the  uterus  without  obstruction  from 

*  Tlie  !il)l)reviii  ions  ti:  nnil  <>lil.  will  be  iiseil  throughout  to  designate  the  transverse  and 
oblique  diameters  of  the  iielvic  inlet. 


.ill 


r)i2 


AM  ERIC  AX   TEXT- BOOK   OF   OliSrETlilCS. 


\\ 


!    » 


111' 


-4    :i-  .  r<i 


the  ini|)orfbctly  engagcil  head.  From  the  same  caii.xe  an  early  rupture  of  the 
inenihranes  is  likely.  Acconling  to  Lit/inann,  natural  tbrees  end  the  labor  in 
79  \iGV  cent,  of  cases,  but  in  .50  per  cent,  the  head  is  not  fully  engaged  until 
the  OS  is  completely  dilatinl.  The  dilatation  of  the  os  proeeetls  slowly,  for  the 
head  does  not  descend  low  enough  io  press  upctn  the  cervix.  Consequently 
the  dilatation  must  be  effected  by  a  retraction  of  the  cervix  over  the  head  or 
by  the  distended  menibmnes.  Should  these  ruptiu'c,  the  os,  although  consid- 
erably dilated,  may  retract  until  the  head  at  length  descends  and  again  dilates 
it.  Alter  the  obstruction  at  the  superior  strait  is  passetl — where,  of  course,  it 
is  greatest — the  head  usually  (leswnds  the  remainder  of  the  birth-canal  with 
ease  and  rapidity,  but  labor  may  be  prolongetl  by  an  exhaustion  of  the  natural 
forces  in  the  attempt  to  secure  engagement.  The  apparent  anomalies  in  the 
niei-hanism  of  labor  characteristic  of  this  dcfornuil  pelvis  are  in  reality  the 
best  pttssible  provision  for  the  spontaneous  obviation  of  the  obstruction.  The 
transverse  position  of  the  head  at  the  inlet,  the  increased  lateral  inclination, 
and  the  imperfect  flexion  are  designed  to  accommo<late  the  size  and  the  shape 
of  the  head  to  the  unnatural  size  and  shape  of  the  pelvic  inlet.  An  explana- 
tion of  these  peculiarities  in  the  engagement  of  the  head  can  be  found  in  the 
alteretl  relation  of  expidsive  and  resistant  forces.  The  head,  forcetl  down  upon 
tlie  flattened  brim  and  free  to  move  upon  the  neck,  rotates  until  its  longest 
diameter  is  adjusted  to  the  greatest  diameter  of  the  inlet — the  transverse.  It 
seeks  the  direction  of  least  resistance,  as  any  inert  body  will  when  propelled 
through  a  contracted  canal.  But  the  transverse  position  of  the  head  alone  is 
not  sufficient  to  overcome  the  obstruction.  The  bijjarietal  diameter  of  the 
head  is  too  large  to  enter  the  conjugate  of  the  pelvis.  The  occiput,  the  bulk- 
iest portion  of  the  skull,  seeks  the  greater  space  to  one  side  of  the  promontory, 
and  is  pushed  against  the  lateral  brim  of  the  pelvis,  the  ilio-pectineal  line. 
Here  it  is  arrestetl.  Further  propulsion  of  the  head  is  secured  by  a  movement 
of  partial  extension,  which  brings  rather  the  small  bitemporal  than  the  larger 
biparietal  diameter  of  the  head  in  relation  with  the  contracted  conjugate. 
Still,  the  obstruction  may  not  be  overcome.  Both  sides  of  the  head  may  be 
unable  to  enter  the  jielvis  at  once.  One  side  is  propelled  into  the  j)elvic  canal, 
the  other  is  held  back.  That  side  which  encounters  the  most  resistance  will 
naturally  be  the  last  to  enter.  Thus  it  is  that  usually  the  anterior  parietal 
bone,  slipping  more  epsily  past  the  symphysis,  enters  first.  To  this  result 
also  the  inclination  of  the  pelvic  axis  to  the  axis  of  the  trunk  contributes. 
Owing  to  the  anterior  jiosition  of  the  whole  sacrum  and  to  the  diminished 
antero-posterior  diameter  of  the  pelvic  outlet,  on  account,  also,  of  the  transverse 
position  of  the  head  and  of  its  imperfect  flexion,  rotation  of  the  head  on  the 
floor  of  the  pelvis  occurs  late,  and  occasionally  fails  altogether,  the  head  being 
exjiellcd  froni  the  vulva  in  its  original  transverse  or  in  an  oblique  position. 

The  localized  pressure  to  which  the  maternal  structures  are  subjected 
results  sometimes  in  necrosis  of  cervical  tissue  over  the  promontory  and 
of  the  anterior  vaginal  wall  behind  the  symphysis.  On  the  child's  head  the 
caput  succedaneum  is  not  exaggerated,  because  the  head,  when  once  firmly 


DYSTfiClA. 


\\:\ 


F|. 


■prfssliiii  m  the  iniiiitiil  iMdit-  <'mis(M|  by  llii-  pressure  (il  llu;  imimniiinry  o 


iiciicc,  usually  f|uitocl(»s(>  to  tlicsiiiittal  f^iiturcl  Fii;.  WW).  Sinuctiiuos  a  suocos- 
sioii  of  tli('S(!  ilcprcssioiis  or  a  <futU'i'-.slia|)('(l  <>;roov('  uiay  lu'  noted  in  a  lino  nui- 
ning  outward  and  iorward  on  the  oiiild'.s. skull.     More  l"rc(|ii('iilly  the  course  of 


Fiii.  ;!1.'>.— Murks  iimde  liy  the  promontory  on  the  child's  hend  mid  fiiee  (Fritsch  nnd  Kii.stner). 

the  head  and  face  over  the  promontory  is  marked  by  a  red  streak  runninj;  from 
the  depression  before  noted  in  a  line  parallel  with  the  coronal  siitiu'c  toward 
the  temple  if  the  head  is  well  flexwl  after  cnjiajjjement,  or  to  the  outer  corner  of 
the  posterior  eye,  or,  in  case  of  extreme  Hexiou,  to  the  cheek  (Fig.  315,  A,  B,  c). 
33 


/ 


^6 


r'r!? 


514 


.1.1//v7.'/r.l.V    TEXT-lKiOK    OF    (Hi.STirmKS. 


I'siiallv  tlic  posterior  parietal  hone  is  tlcprossc*!  Iwlow  tlu!  anterior,  wliieli  over- 
lupH  it  at  tlie  .sagittal  suture.  The  posterior  side  of  the  skull  is  also  Hatteiieil 
t'ruiii  the  greater  and  more  prolonged  pressure  to  which  it  is  suhjeeteil.  Ordi- 
narily the  lateral  ineliuation  of  the  child's  head  is  in  a  direction  front  hefore 
backward,  so  that  the  anterior  parietal  l)one  presents  at  the  centre  of  ♦',o  supe- 
rior strait.  <  )eeasionally  this  inclination  is  so  exaggerated  that  the  ear  is  the 
])resenting  part.  Kxceptionally  the  lateral  inclination  takes  the  opposite  direc- 
tion, the  anterior  parietal  hone  catches  on  the  rim  of  the  puhic  bones,  and  the 
])osterior  parietal  bone  is  the  first  portion  of  the  child's  hea«l  to  enter  the 
pelvis.  The  i)resentatii»n  of  the  posterior  fontiuielle  occurs  even  in  normal 
])elves  as  a  rare  exception,  but  is  seen  in  about  10  per  cent,  of  co:itractc(l 
pelves  (Schauta),  and  is  the  residt  in  them  very  likely  of  firm  alMlominal 
walls  an<l  an  increased  in<-liiiatiou  of  the  pelvic  inlet  to  the  axis  of  the  trunk. 
In  these  cases  the  anterior  parietal  bone  is  pushed  under  the  posterior  at  the 
sagittal  suture.  When  the  posterior  side  of  the  head  by  descent  finds  romn 
in  the  hollow  of  the  sacrum  and  moves  backward,  the  anterior  portion  of  ilic 
skull  glides  over  the  symphysis,  and  the  sagittal  suture  UKtves  from  lis  oriijiiial 
])osition,  just  behind  the  symphysis,  toward  the  median  line  of  the  |M'lvic<.-.«nal. 
In  adtlition  to  these  anomalies  (»f  mecli;'.nism,  Hreisky  de>cri!Hs  what  he  calU 
an  "extra-median"  engagement  of  the  head  in  eases  of  flat  pelvis  in  which 
there  is  considerable  h^rdosis  of  the  lund)ar  vertebra'.  The  head  in  extreme 
flexion  is  forced  down  upon  half  of  the  pelvic  inlet,  an<l  enters  the  ])elvie  canal 
on  this  side  alone.  Directly  the  obstnu'ting  ])romontorv  and  lumbar  vertebra 
are  passed  the  head  descends  the  pelvic;  canal  with  rapidity  and  ease.  This 
mechanism  was  noted  nineteen  times  in  Hreisky's  clinic  among  2002  labors.^ 

Justo-minor  Pelvis. — In  this  ty|)e  of  contracted  pelvis  the  form  of  the  female 
])elvis  is  preserved,  but  the  size  is  diminished  ( 1*1.  2i',  Fig.  1).  Three  divisions  of 
this  pelvis  are  commonly  made:  'V\\v  jmrnilr,  in  which  the  bones  are  small  and 
slen<ler ;  the  iiuixculitic,  in  which  the  bones  are  large,  heavy,  and  thick  ;  and 
the  (Iinirf,  or  jxlrin  tiatui,  in  which  the  pelvis  is  very  dimimitive  in  size  and 
tljc  pelvic  hones  ar(>  not  joined  by  bony  union,  but  are  separated  by  cartilage 
as  in  the  infant.  The  innominat(>  bones  are  divided  inio  iheii  three  parts,  and 
the  s;H'ral  vertebra*  are  distinct  from  one  another  (1*1.  2J),  Fig.  2).  The  justo- 
minor  pelves  pass  by  insensible  gradations  into  the  simple  flat,  the  transversely- 
contracted,  and  the  generally-contracted  flat  pelves.  In  the  larger  cities  of  the 
United  States  the  justo-minor  jx'ivis  is  very  frequently  encountered.  It  is  cer- 
tainly !is  common  here  as  is  the  simple  flat  ])elvis,  and  if  one  were  to  judge 
ftiwn  lios])ital  patients,  among  whom  there  is  a  largo  |)roporti(m  of  shop- 
and  factory-girls,  this  variety  of  cimtraeted  pelvis  would  be  regarded  as  the 
commonest. 

('/Kintctcristics. — While  it  is  convenient  to  speak  of  the  justo-minor  pelvis 
jis  the  normal  female  pelvis  in  miniature,  the  description  is  not  strictly  accu- 
rate. There  are  peculiarities  due  to  an  arrest  of  ilevelopment  which  give  to 
the  e(|iially  general ly-contraoted  pelvis  some  of  the  features  of  an  infantile 
j>elvis.     The  alie  of  the  sacrum  are  narrower  than  they  .should  be  in  eompari- 


I 


DYSTOCIA. 


Platk  2fl. 


r.  V.  idici 
Tr.  (irili'ti  ' 


4  Tr.  (uutli'tl  7  em, 

Aiit,  iKiat.iiiitlt't  Ti  I'lii, 


1.  .Iiisto-iiiinor  jK'lvis  iMiittiT  Musi'uin,  CulUw  nf  I'hysicinns,  I'liiIacU>l|i)iiiiK  inlet  n  pprt'frtly  sjniiiu't- 
riciil  (ivciid,  ■_•.  Mwiirl'  pelvis.  ;;.  .lustniiiiiinr  pilvis  with  nipliiri'il  pelvic  jniiit'^,  fulldwint;  I'urci'ps  iippli- 
ciiiiiin  illirst  tullictiun,  l'iiivir>ily  ni'  rinnsylviiiiini.  I.  Narruw,  I'unMcl-slmpfil  pilvi.s  i^piiiiiini  in  tlic 
Hirst  ((illcitinii,  rniviT>ily  ni  rcunsylviiiiitn.    ■'>.  h'cttil  illclrvilnpecl  pelvis,  pinlialily  an  ,irn>lii|  divi-lnp- 

iiirnl  I'niiii  racliili>  ( Miillci'  Mii-runi,  rulli'uT  of  I'liysii-iansi.    il.  Minm-  uraclc  ..f  n,iii-.iH .  im 1  .h.-ipcil  pi'l- 

vi>  uilli  cunlriKli'il  puliie  an'li.     7.  i  ililic|iiclyccintnicti'cl  pelvis  ^^^u'gl■l('l.    ,>.  ( ililii|Mi'ly  i-uiitni(;ii|  pelvis 
iplintu'.'iaphed  Iniii  a  pla.-ler  ea>tj. 


1: 


'fi 


H  !  i» 


!  ,*! 


:•  .  '  )  ' 


n« 


DYSTOCIA. 


515 


soil  with  the  bodies  of  the  vertebrte.  The  sacrum  is  short  and  is  not  pushed 
as  far  forward  between  the  iliac  bones  as  it  usually  is;  it  shows  also  a  dimin- 
ished forward  inclination,  and  on  its  anterior  surface  a  greater  lateral,  and  a 
less  marked  perpendicular,  concavity  than  common.  The  distance  between 
tiie  posterior  superior  spinous  processes  of  the  iliac  bones  is  relatively  great, 
on  account  of  the  posterior  position  of  the  sacrum  and  its  slight  rotation 
forward.  The  conjugato-symphyseal  angle  is  greater  than  normal,  by  reason 
of  the  lessene<l  inclination  outward  of  the  symphysis  and  the  pubic  bones. 
The  promontory  la  high  and  not  prominent,  and  the  inclination  »)f  the  pelvic 
entrance  to  the  abdominal  axis  as  the  individual  stands  erect  makes  a  more 
obtuse  angle  than  it  does  in  the  normal  ptslvis.  The  bones  in  this  form  of 
contracted  pelvis  are  commonly  small  and  slender,  except  in  that  somewhat 
un\isual  variety  the  masculine  pelvis,  in  which  they  are  firm  and  thick  beyond 
the  normal.  Women  with  a  justo-minor  jielvis  are  ordinarily  of  slight  build 
and  below  the  medium  height;  but  this  pelvis  may  be  found  in  individuals 
of  ordinary  stature,  and  sometimes  actually  in  tall  women  of  large  frame. 

The  true  dwarf  pelvis  (PI.  29,  Fig.  2)  is  very  rare.  It  is  found  only  in 
women  of  dwarf  stature.  The  bones  are  slender  and  fragile,  and  the  carti- 
laginous junction  between  the  original  divisions  of  the  pelvic  bones  is  pre- 
served.    There  is  extreme  contraction  of  the  pelvic  canal. 

In  the  commoner  kinds  of  justo-minor  pelvis  the  contraction  is  not  often 
very  great.  The  conjugate  diameter  is  seldom  below  9,  and  scarcely  ever  so 
low  as  8,  centimeters.  The  pelvic  outlet  in  some  cases  is  laterally  contracted ; 
in  others  it  is  comparatively  roomy. 

Etiolofjrj. — The  justo-minor  pelvis  is  the  result  of  arrested  development ;  it 
may  be  foiuid  in  women  descended  from  a  stock  that  has  deteriorated  physically, 
or  in  women  subjected  during  childhood,  infancy,  or  intra-uterine  existen*  e  to 
unfavorable  hygienic  surroundings  or  conditions. 

Diafpioxh. — The  justo-minor  pelvis  is  easily  confused  with  a  rachitic  pelvis, 
but  the  distinction  is  readily  made  by  careful  j)elvimctrv.  All  the  measure- 
ments, while  equally  reduced,  bear  their  normal  proportion  to  one  another, 
except  in  the  case  of  the  external  conjugate  diameter,  which  is  apt  to  be  longer 
than  would  be  expected,  on  aeeoimt  of  the  posterior  position  of  the  sacrum 
antl  its  lessened  inclination  forward.  In  estimating  the  true  conjugate  diameter 
from  the  diagonal  conjugate  one  must  take  account  often  of  the  increase  in  the 
conjugato-symphyseal  angle,  and  must  remember  that  the  sum  to  be  subtracted 
from  the  diagonal  conjugate  is  not  infrequently  greater  than  common.  The 
symphysis  is  less  in  height  than  in  the  normal  pelvis,  but  the  error  of  compu- 
tation from  this  source  may  be  disregarded.  Ij()hlein  lays  special  stress  upon 
the  importance  of  measuring  the  pelvic  circumference  in  making  the  diagnosis 
of  this  form  of  contracted  pelvis.  It  is  always  far  below  the  normal,  90  cen- 
timeters. An  internal  examination  of  the  pelvic  cavity  and  inlet  should  Imj 
made  carefully,  to  determine  approximately  their  capacity,  with  a  special 
regard  to  the  approximate  length  of  the  transverse  diameters. 

Influence  on  Labor. — The  mechanism  of  labor  shows  far  fewer  anomalies 


11^ 


AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 


ill  this  than  in  any  of  the  other  forms  of  contracted  pelvis.  The  head,  from 
the  greater  resjistance  encountered,  is  strongly  flexed.  It  may  be  placed  trans- 
versely, but  is  quite  commonly  oblique,  and  may  even  be  antero-posterior  in 
position  if  there  is  a  tendency  to  lateral  contraction  of  the  pelvic  canal.  By 
the  [)erfect  flexit>n  of  the  head  the  obstruction  to  the  progress  of  labor  is  in  great 
part  obviated.  If  anything  interferes  with  this  movement  of  the  head,  as  a 
faidty  application  of  the  forceps,  engagement  and  descent  may  become  impos- 
sible. Pelvic  presentations  in  labor  are  a  great  disadvantage  by  reason  of  the 
difficulty  experiencetl  in  freeing  the  arms  and  in  bringing  the  head  last  through 
the  generally-contracted  pelvic  canal.  To  secure  its  rapiil  passage,  the  child's 
head  must  be  flexed  strongly  by  the  operator's  finger  in  its  mouth  before  an 
attempt  is  made  to  secure  engagement  in  the  superior  strait.  While  the 
woman  escapes  localized  necroses  of  the  soft  tissues  following  labor  in  the 
justo-minor  pelvis,  there  is  greater  likelihood  of  rupturing  pelvic  joints  in  this 
than  in  any  other  variety  of  contracted  pelvis,  and  there  is  also  an  extraordi- 
nary liability  to  eclampsia  (PI.  29,  Fig.  3).  Tiie  caput  succedaneum,  which  is 
very  large  on  account  of  the  early  fixation  of  the  head  and  the  long  labor,  is 
situated  directly  over  the  smaller  fontanelle.  There  is  an  overlapping  of  the 
cranial  bones  both  laterally  and  antero-posteriorly. 

The  generally-contracted,  flat,  non-rachitic  pelvis  presents  the  com- 
binetl  features  of  the  flat  and  the  generally-contracted  pelvis. 

Characteristics. — All  the  diameters  are  below  normal,  but  the  conjugate  is 
less  in  proportion  than  any  of  the  others.  This  pelvis  has  many  of  the  feat- 
ures of  a  rachitic  pelvis,  but  the  anterior  half  of  the  pelvic  circumference  is 
not  markedly  broadened  ;  indeetl,  it  is  often  the  reverse.  The  sacrum  is  small 
and  is  not  rotate<l  on  its  transverse  axis ;  it  is  placed  farther  back  between  the 
innominate  bones  than  in  the  normal  pelvis,  and  very  much  fiirther  back  than 
in  the  rachitic  pelvis.  The  promontory  is  high  and  is  not  prominent.  The 
influence  of  this  deformity  of  the  jwlvis  upon  labor  is  that  of  a  flat  pelvis,  but 
the  difficulties  are  greater  than  in  the  case  of  the  simple  flat  pelvis,  for  tliere 
is  less  compensatory  room  in  a  transverse  direction.  The  generally-contracted 
non-ra''hitic  flat  pelvis  is  comparatively  rare.  The  flattening,  according  to 
Litzmann,  is  due  to  a  shortening  of  the  innominate  bones,  especially  at  the 
ilio-pectineal  line.  In  estimating  the  true  conjugate  diameter  of  the  generally- 
contracted  flat  pelvis  it  is  safer  to  subtract  2  instead  of  If  centimeters  from 
the  diagonal  conjugate,  on  account  of  an  increase  in  the  conjugato-symphyseal 
angle,  the  result  of  the  high  position  of  the  promontory  and  the  diminished 
slant  outward  of  the  symphysis. 

Etiology. — This  generally-contracted  type  of  pelvis  is  due  to  hereditary 
influence  or  to  an  arrest  of  development  in  the  embryo,  fetus,  or  infant.  It  is 
claimetl,  however,  that  it  may  be  j)roduced  by  premature  attempts  to  walk  anil 
by  long  standing  upon  the  feet  in  very  early  life. 

Diagnosis. — The  recognition  of  a  generally-contracted  flat  pelvis  is  diffi- 
cult. The  measurements  usually  resemble  those  of  a  generally  equally-con- 
tracted pelvis,  but  the  conjugate  diameter  is  less  than  one  expects  in  that  form 


DYSTOCIA. 


517 


is  (lifti- 
lly-cf)ii- 
at  Ibriii 


of  contracted  pelvis,  and  the  mechanism  of  labor  is  that  of  a  flat  pelvis.  The 
diagnosis  can  be  made  by  finding  tlie  reduced  conjugate  diameter  and  by  the 
ease  with  which  one  can  reach  the  lateral  pelvic  wall  in  the  palpation  of  the 
interior  of  the  pelvic  canal.  A  certainty  of  diagnosis  can  be  obtained  during 
life  only  by  the  direct  measurement,  not  only  of  the  conjugate  diameter,  but 
also  of  the  transverse,  by  the  methods  of  Liihlein  and  of  Skutsch. 

The  Narrow,  Funnel-shaped  Pelvis ;  Petal  or  Undeveloped  Pelvis. — 
This  variety  of  pelvis  is  contracted  transversely  at  the  pelvic  outlet,  or  both 
in  the  transverse  and  antero-posterior  diameters,  without  abnormalities  in  the 
spinal  colura.  The  depth  of  the  pelvic  canal  is  much  increased  by  the  length 
of  the  sacrum,  of  the  symphysis,  and  of  the  lateral  pelvic  walls.  The  sacrum 
is  narrow,  has  little  perpendicular  curve,  and  is  placed  far  back  between  the 
ilia  (PI.  29,  Figs.  4,  5).  Schauta  ascribes  this  form  of  contraction  to  an  anom- 
iilv  of  development  by  which  the  pelvic  walls  are  lengthened  downward  and 
the  weight  of  the  body  is  thrown  backward  upon  the  sacrum.  It  is  said  to 
be  very  rare,  but  it  has  been  found  quite  frequently  in  those  hospitals  where 
the  outlet  of  the  pelvis  is  regularly  measured.  It  comprises  from  5  to  9  per 
cent,  of  all  contracted  pelves,  according  to  Breisky,  and  Fleischmann  found 
twenty-four  examples  in  2700  parturient  women.^  A  slight  manifestation  of 
tiie  deformity  is  often  called  a  ''masculine"  pelvis  by  reason  of  the  diminu- 
tion in  the  breadth  of  the  pubic  arch.  Tin's  degree  of  the  funnel-shaped 
pelvis  is  frequently  encountered  (PI.  29,  Fig.  6). 

Diagnosis. — The  diagnosis  of  a  narrow,  funnel-shaped  pelvis  is  made  by 
a  comparison  of  the  measurements  of  the  pelvic  inlet  with  those  of  the  outlet. 
The  former  are  found  to  be  normal  or  even  greater  than  normal,  while  the 
measurements  of  the  outlet  are  diminished.  If,  as  is  the  rule  in  extreme 
degrees  of  this  deformity,  the  inlet  and  cavity  are  contracted,  the  outlet  is  still 
smaller  in  proportion.  A  careful  palpation  of  the  pelvic  canal  is  an  important 
aid  to  a  correct  diagnosis.  The  pelvic  walls  are  felt  to  converge  as  they 
ajiproach  the  outlet ;  the  narrowness  of  the  pelvic  arch  is  appreciated,  and  the 
approximation  of  the  tuberosities  and  spines  of  the  ischiac  bones  is  noticeable. 

Influence  xqwn,  Labor. — The  peculiarities  of  mechanism  in  labor  are  mal- 
positions of  the  head  at  the  outlet  (as  backward  rotation  of  the  occiput),  ob- 
lique and  transverse  position  of  the  head,  and  imperfect  flexion.  There  is  also 
an  insufficiency  of  the  expulsive  forces,  the  greater  part  of  the  fetal  botly 
being  contained  in  the  lower  iiterine  segment,  cervix,  and  vagina,  while  the 
upper  muscular  segment  of  the  uterus  is  in  great  part  emptied  and  therefore 
powerless.  By  the  approximation  of  the  pubic  rami  the  presenting  part  is 
forced  backward,  and  serious  lacerations  of  the  perineum  are  to  be  feared. 
Tiip  pressure  of  the  head  upon  the  lower  birth-canal  may  result  in  necrosis  of 
soft  structures  or  lacerations  along  the  descending  rami  of  the  pubis  and  the 
ascending  branches  of  the  ischium.  The  tissues  over  the  projecting  spines  of 
the  ischiac  bones  are  also  the  seat  of  tears  or  of  necroses.  The  narrowing  of 
the  jiubic  arch  may  lead  to  serious  injuries  if  the  forcejis  be  applied.  The 
writer  has  seen  long  clean  cuts  in  the  anterior  vaginal  walls,  and  profuse  hem- 


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518 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


orrhage,  following  the  use  of  instruments.  In  well-niarketl  examples  of  the 
narrow,  funnel-shapetl  pelvis,  with  a  transverse  diameter  at  the  outlet  not 
much  below  3  inches,  symphysiotomy  gives  the  best  chance  of  a  successful 
termination  for  mother  and  child.  Higher  grades  of  contraction  with  a  diam- 
eter of  2  inches  and  under  demand  Cesarean  section.  In  lesser  grades  the 
woman  may  be  delivered  spontaneously  or  by  forceps. 

Obliquely-contracted  Pelvis  froza  Imperfect  Development  of  the 
Ala  on  one  Side  of  the  Sacrum  (Naegele  Pelvis). — This  pelvis  was  first 
describetl  in  1834  by  Franz  Carl  Naegele,^  but  had  been  noticed  as  early  as 
1779  without  a  full  understanding  of  its  significance  (PI.  29,  Figs.  7,  8). 

Chantderistics. — The  pelvic  inlet  has  an  oval  shape,  with  the  small  point 
of  the  oval  directed  to  the  atrophied  side  of  the  sacrum.  The  sacral  ala  is 
atrophied  or  is  absent,  not  only  in  that  portion  of  the  bone  entering  the 
sacro-iliac  joint,  but  also  in  the  transverse  process  along  its  whole  length. 
The  sacro-iliac  joint  on  this  side  is  ankylosetl  in  the  vast  majority  of  cases, 
but  not  invariably.  The  sacrum  is  narrow,  asymmetrical,  and  turned  with 
its  anterior  face  toward  the  deformed  side  of  the  pelvis.  The  promontory  is 
not  only  turned  in  this  direction,  but  is  also  pulled  over  to  the  diseased  side. 
The  innominate  bone  on  this  side  is  pushed  as  a  whole  upward,  backward,  and 
inward,  and  its  anterior  face  is  pushed  inward  and  backward.  The  tuberosity 
of  the  ischium,  as  a  necessary  consequence  of  the  displacement  of  the  innom- 
inate bone,  is  higher  than  its  fellow,  projects  into  the  pelvic  canal,  and  is  so 
turne<l  that  it  looks  rather  antero-posteriorly  than  laterally.  The  spine  of  the 
ischium  is  brought  quite  close  to  the  corresponding  edge  of  the  sacral  bone 
and  juts  prominently  forward  into  the  pelvic  canal.  The  whole  innominate 
bone  on  the  diseased  side  lacks  its  normal  curvature  at  the  ilio-pectineal  line, 
and  may  run  almost  straight  from  the  sacro-iliac  junction  to  the  symphysis 
pubis.  The  opposite  innominate  bone  has  a  greater  curvature  than  common, 
especially  in  its  anterior  half;  otherwise  it  is  practically  normal  in  structure, 
position,  and  inclination.  The  symphysis  pubis  is  pushed  toward  the  healthy 
side  of  the  pelvis,  and  its  outer  surface,  instead  of  looking  directly  forward,  is 
inclined  to  the  diseased  side.  The  pubic  arch  likewise  faces  somewhat  in  this 
direction  ;  its  aperture  is  asymmetrical  and  irregularly  contracted,  as  the  ischiac 
and  pubic  rami  on  the  diseased  side  are  pushed  inward  upon  the  pelvic  canal 
and  over  toward  the  healthy  side  (PI.  29,  Figs.  7,  8). 

Etiology. — The  cause  of  the  obliquely-contracted  pelvis  under  description 
is  an  absence  of  the  bony  nuclei  in  the  ala  or  lateral  process  on  one  side  of 
the  sacrum.  The  lateral  process  consequently  fails  to  develop,  and  the  in- 
nominate bone  is  brought  in  relation  with  the  bodies  of  the  sacral  vertebrae. 
As  a  result  there  must  be  some  distortion  of  the  innominate  bone  even  in  fetal 
and  infantile  life,  but  this  is  increased  to  an  exaggeratetl  degree  when  the  indi- 
vidual begins  to  walk.  Instead  of  receiving  the  pressure  from  the  lower 
extremity  approximately  on  the  keystone  of  an  arch,  as  does  a  normally- 
curved  innominate  bone,  the  defornial  bone  in  a  Naegele  pelvis  transmits  the 
pressure  in  almost  a  straight  line  upward  and  backward,  so  that  the  extremity 


DYSTOCIA. 


519 


of  the  posterior  arm  of  the  arch  slides  past  the  sacro-iliac  joint  instead  of 
resting  firmly  on  it  as  an  arch  does  on  its  abutments.  The  irritation  and 
strain  of  this  nnnatural  movement  bring  about  in  time  the  atrophy  and 
ankylosis  of  the  joint. 

That  the  deformity  in  this  kind  of  oblique  pelvis  does  not  follow  a  primary 
ankylosis  of  the  sacro-iliac  joint  is  proven  by  the  fact  that  the  innominate 
bone  is  pushed  backward  and  upward  on  the  sacrum — a  movement  that  would 
be  impossible  were  this  joint  first  ankylosed.  As  a  further  proof  of  primary 
lack  of  development  and  secondary  ankylosis,  there  is  no  trace  of  inflammation 
in  or  about  the  ankylosed  joint,  and  the  alse  or  transverse  processes  of  the 
sacrum  are  atrophied  or  are  absent  along  the  v/hole  length  of  the  sacrum, 
and  not  only  in  that  portion  of  it  which  enters  into  the  composition  of  the 
sacro-iliac  joint. 

Diagnosis. — The  recognition  of  an  obliquely-contracted  pelvis  from  arrested 
development  of  the  sacral  alse  may  be  very  difficult.  There  is  nothing  to  direct 
the  attention  of  the  physician  to  the  possibility  of  this  deformity.  There  is 
no  history  of  previous  disease  or  of  accident,  no  scar  of  an  old  fistula  over  the 
joint,  and  the  patient  does  not  limp.  The  diagnosis  can  be  made  only  by  a 
methodical  external  and  internal  palpation  of  the  pelvis  and  by  careful  me'^s- 
ureraents.  If  the  outspread  hands  are  laid  over  the  innominate  bones,  it  will 
be  noticed  that  the  dorsal  surfaces  are  directed  obliquely  forward  and  back- 
ward as  they  lie  upon  the  diseased  and  healthy  sides.  An  internal  palpation 
of  the  pelvis  will  detect  one  lateral  wall  much  nearer  the  metlian  line  than  the 
other,  and  the  diagonal  conjugate  will  be  found  to  run  not  antero-posteriorly 
in  direction,  but  from  before  backward  and  from  the  healthy  to  the  diseased 
side  of  the  pelvis.  There  are  a  number  of  points  from  which  measurements 
may  be  taken  that  will  show  inequalities  where  in  the  normal  pelvis  the  dis- 
tances should  be  the  same  or  should  differ  by  a  very  small  sum.  Naegele 
recommended  the  following  measurements :  (1)  The  distance  of  the  tuber 
ischii  on  one  side  from  the  posterior  superior  spinous  process  of  the  ilium  on 
the  other ;  (2)  from  the  anterior  superior  spinous  process  of  one  ilium  to  the 
posterior  superior  spinous  process  of  the  other ;  (3)  from  the  spinous  process 
of  the  last  lumbar  vertebrse  to  the  anterior  superior  spines  of  both  ilia ;  (4) 
from  the  trochanter  major  of  one  side  to  the  posterior  superior  spinous  process 
of  the  opposite  iliac  bone  ;  (5)  from  the  lower  edge  of  the  symphysis  pubis  to 
the  posterior  sujierior  spinous  processes  of  the  iliac  bones.  In  addition  to 
these  measurements,  others  of  value  have  been  suggestal  by  Michaelis  and  by 
Ritgen.  These  are  the  distances  from  the  middle  line  of  the  spinal  column  to 
the  posterior  suj)erior  spinous  processes  of  the  iliac  bones,  and  the  distance 
from  the  lower  edge  of  the  symphysis  to  the  ischiac  spines,  and  from  these 
spines  to  the  nearest  point  on  the  edges  of  the  sacrum.  In  this  latter  measure- 
ment it  will  be  found  that  the  distance  from  the  symphysis  to  the  ischiac  spine 
is  longest  on  the  diseased  and  shortest  on  the  healthy  side,  while  the  distance 
from  the  ischiac  spine  to  the  edge  of  the  sacrum  is  very  much  shorter  on  the 
diseased  than  on  the  healthy  side.     This  last,  which  is  a  very  important  meas- 


i 


AMinUCAX    TEXT-BOOK    OF    OJiSTETIilCS. 


urenient,  can  easily  be  taken  by  laying  finger-broailtlis  between  the  points  to  be 
measured. 

Infiucnce  on  Labor. — The  mechanism  of  labor  in  an  ol)li(|nely-eontraeto(l 
pelvis  is  in  the  main  that  (tf  labor  in  a  generally-eontractcHl  pelvis.  The 
shape  of  the  pelvic  entrance  and  canal  is  symmetrically  ovoid,  and  the  head  can 
enter  the  contracted  space  only  by  extreme  flexion.  There  are  none  of"  those 
anomalies  of  position,  flexion,  and  inclination  o.  the  head  which  are  seen  in 
the  flat  pelvis.  As  the  head  descends  the  birth-canal  anomalies  of  mechanism 
may  appear  resembling  those  described  in  the  narrow,  fnnnel-sha])ed  ])elvis — 
namely,  abnormal  and  imperfect  rotation  and  anomalies  of  flexion.  Depend- 
ing npon  the  degree  of  deformity,  there  is  more  or  less  interference  with  the 
progress  of  labor  to  (!ompIcte  obstruction.  The  head  can  almost  invariably 
be  found  entering  the  ])clvis  and  passing  through  the  canal  with  its  longest 
diameter  in  coincidence  with  the  longest  obliipie  diameter  of  the  pelvis,  from 
the  diseased  sacro-i Mac  joint  to  the  op])osite  ilio-pectineal  eminence. 

Prnr/noxia. — In  the  recorded  cases  the  results  of  labor  in  the  Xaegele  pelvis 
have  been  bad.  Of  28  women  reportctl  by  Lit/maiui,  twenty-two  died  in 
their  first  labor,  five  of  them  undelivered.  Three  of  these  women  died  in 
consequence  of  their  second  labor,  and  two  after  the  sixth.  Out  of  41  cases, 
six  were  delivered  spontaneously,  twelve  by  the  forceps,  fourteen  by  craniotomy, 
five  by  version  and  extraction,  four  by  premature  labor,  and  two  by  Cesarean 
section.  The  following  accidents  were  noted  in  the  course  of  labor  or  shortly 
afterward  :  Ilupture  of  the  uterus  or  vagina,  vesico-vaginal  fistula,  fracture  of 
the  horizontal  ramus  of  the  pubis,  rupture  of  the  sacro-iliac  joint  and  of  the 
syin])hysis.  In  another  series  of  cases,  28  women  furnished  42  labors  witii 
the  following  results :  twenty-one  died  as  the  result  of  the  first  labor,  three 
of  the  second,  and  one  after  the  sixth.  These  women  were  delivered  seven 
times  by  craniotomy,  once  by  Cesarean  section,  four  times  by  premature  labor. 
and  in  a  number  of  instances  by  forceps.  Out  of  41  children  in  Litzmann's 
statistics  there  were  only  ten  delivered  alive,  two  of  these  by  Cesai'can  section 
and  two  by  premature  labor.  The  six  other  living  children  were  all  born  of 
the  same  mother.* 

Treatment. — Force])s  and  version  are  not,  as  a  rule,  successful  in  the  treat- 
ment of  labor  obstructed  by  an  oblicjuely-contracted  pelvis  unless  the  degree 
of  deformity  is  slight.  The  induction  of  jH'emature  labor  and  the  perform- 
ance of  Cesarean  section  are  the  most  successful  means  of  delivery,  but  the 
former  should  be  resorted  to  only  when  the  distance  between  the  lower  edge 
of  the  symphysis  pubis  and  the  sacro-iliao  joint  of  the  healthy  side  is  not 
under  8.5  centimeters.  In  20  forcejis  operations  thirteen  women  died.  The 
proposition  of  Pinard  to  do  what  he  calls  ischio-pubiotomy  will  not  meet  with 
much  favor.  The  room  trained  bv  the  movement  outward  of  the  innominate 
bone  on  the  healthy  side,  the  other  being,  of  course,  immovable,  will  be  suf- 
ficient only  in  pelves  so  slightly  contracted  o^  to  allow  a  delivery  perhaps  by 
much  simpler  means. 

*  The  writer  is  indi'litcd  for  tiiese  statisties  to  Schauta  Hoc.  cit.). 


DYST(XIA. 


1'I.ATE  30. 


•'.   V.  ''i  1111 

v:\Wi\  II'.  iihiiii  n  I'lii. 


i.  Tr.itisviTSfly-contriictt'il  prlvis  (Unln'it  ;  iiiiulcl  in  MiittiT  MllscMini.t'iiiliK'"'"  I'liysiciiLiis,  riiiliii|rl|.liiii). 
'J.  TniMsvrrsi'lycimtniitcil  pelvis, slmwiiij,'  <-iriilniclioii  nl  iiiillct  (iiumIcI  in  llic  Hirst  Cnllci'iidii,  t'liivcrsily  <if 
I'L'iiii-ylvimiiil.  ;l.  Triilisvcrscly ciintniclcil  pelvis,  u  itii  nlpseiiee  nl'sneniiii  ( llolil).  I.  Split  pelvis  iSeliinitiil. 
f).  (ielie rally  eiilliilly-ciiiitnictecl  nieliitie  pelvis  i  Hirst  Ciilleelinii,  riiiversily  df  I'eiiiisylviiniii),  0.  lieiieriilly- 
oiinlriieleil  raeliilie  i n'l vis  i  Hirst  ('iilleetinii,  t'liivi'isity  iit'  reiiiisylvii'iiiii.  7.  'I'ypieiil  Hat  raeliilie  pelvis  >  .M lit- 
ter Miiseuiu,  Ciilletje  iif  I'tiysieiaiisi.  'I'lie  pruiiiiiiitnry  nl'  the  saeniiii  pruji'ets  sn  I'ar  Inrwanl  tluit  the  tnio 
traiisv'.Tso  diaiueter  is  hiseeled  liy  it.  s.  I'lat  raeliilie  pelvis,  with  uim^ual  ciesceut  of  lliu  itroiuulitury,  riitu- 
tion  (if  the  saeniiii,  and  lordosis  (Miitler  Mu.seiiiii,  ColleKi'  of  I'hysieiaiis). 


vj'r  ''5' 


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IF 


DYSTOCIA. 


521 


Transversely-contracted  Pelvis  the  Result  of  Imperfect  Develop- 
ment of  both  Sacral  Alse. — This  pelvis  was  first  described  in  1842  by 
Hubert,  and  is  generally  known  as  the  "Robert  i)elvis"  (PI.  30,  Fijjs.  1,2). 
It  is  the  rarest  of  all  contracted  pelves.  Schauta  was  able  to  find  but  six 
examples  recorded  in  childbearing  women.  Ferruta  has  recently  rejwrted 
another  case.'"  Herman  gives  eight  as  the  number  of  recorded  cases.  The 
anatomical  conditions  are  the  same  as  in  the  Naegele  pelvis,  except  that  both 
sides  of  the  sacrum  are  aft'ected  instead  of  one.  Other  parts  of  the  sacrum 
besides  the  alse  may  show  imperfect  development.  There  is  a  case  reportwl  in 
which  the  whole  lower  portion  of  the  bone  was  absent  (PI.  30,  Fig.  3).  The 
sacnnn  in  this  pelvis  is  extremely  narrow,  and  the  posterior  superior  spinous 
processes  of  the  iliac  bones  are  brought  close  together.  The  degree  of  con- 
traction in  the  transverse  diameter  is  so  extreme  that  natural  labor  is  out  of 
the  question.  An  asymmetry  of  the  Robert  pelvis  has  been  observed,  one 
side  showing  a  greater  degree  of  the  deformity  than  the  other,  and  thus 
approaching  the  type  of  an  obliquely-contracted  pelvis. 

The  cause  of  this  deformity  is  an  absence  of  the  bony  nuclei  in  the  sacral 
aloe  of  both  sides.  Secondarily,  as  in  the  Xaegcle  pelvis,  there  is  apt  to  be 
an  ankylosis  of  the  sacro-iliac  joints.  That  this  ankylosis  is  secondary  and 
not  primary  is  demonstrated  by  the  same  condition  which  proves  that  anky- 
losis is  not  a  primary  cause  of  the  oblique  contraction  and  ill-development  of 
one  side  in  the  Naegele  pelvis — namely,  a  displacement  of  the  ilia  on  the 
sacrum  necessarily  occurring  before  the  ankylosis. 

The  treatment  of  labor  obstructed  by  a  transversely-contracted  pelvis  of 
this  kind  simply  resolves  itself  into  the  performance  of  Cesarean  section. 

Justo-major  Pelvis. — A  generally  equally-enlarged  pelvis  nuiy  be  found 
in  women  of  gigantic  stature,  but  it  may  also  be  demonstrated  in  a  woman 
of  medium  height.  The  pelvis  of  the  Nova  Scotian  giantess  was  large  enough 
to  give  passage  to  a  child  weighing  28f  pounds.  The  largest  pelvis  that  has 
ever  come  under  the  writer's  notice  was  found  in  a  woman  somewhat  below 
the  average  height,  without  an  abnormally  great  development  of  any  other 
portion  of  her  frame. 

Diar/nosis. — The  diagnosis  of  a  justo-major  pelvis  is  made  mainly  by  exter- 
nal measurements.  If  all  of  them  are  found  far  in  excess  of  the  normal  while 
preserving  their  normal  relative  proportion,  the  diagnosis  of  a  justo-major 
pelvis  is  justifiable.  The  internal  examination,  if  considered  necessary,  will 
show  that  the  promontory  is  quite  inaccessible,  and  that  it  is  much  more  dif- 
ficult than  common  to  reach  the  lateral  pelvic  walls.  This  anomaly  of  the 
pelvis  does  not,  of  course,  obstruct  labor ;  on  the  contrary,  it  predisposes  to 
precipitate  deliver^-,  although  the  resistance  of  the  soft  parts  may  be  quite 
sufficient  to  delay  the  process  considerably,  even  though  the  pelvis  present  no 
obstacle  whatever.  During  pregnancy  it  is  noted  that  the  uterus  has  a  tend- 
ency to  sink  deep  within  the  pelvic  canal,  so  that  pressure-symptoms  of  the 
pelvic  viscera  and  blood-vessels  are  common  in  the  latter  weeks  of  gestation, 
and  these  symptoms  may  become  so  exaggerated  as  to  make  locomotion  diffi- 


kl 


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522  AMERICAN  TILXT-UOOK  OF  OliSTKTliJVii. 

cult.  In  l!il)(»r  tliorc  may  be  noted  anomalies  in  the  mechani.sm  (lo|>enileiit 
ujHtn  insiilHcient  resistance  to  tlie  enj^af^cmeiit  of  tlui  liead.  Thus  imperiecl 
flexion  at  tiie  superior  strait  may  be  observed,  and  there  may  be  a  tardv 
rotation  of  the  head  on  the  pelvic  floor. 

Split  Pelvis. — The  split  pelvis,  which  is  due  to  a  defect  in  the  develop- 
ment of  the  hnver  portion  of  the  trunk  in  front,  is  almost  invariably  associated 
with  exstrophy  of  the  bhulder.  This  pelvis  has  very  rarely  been  observed  in 
tiie  childbearinj;  woman  ;  there  are  on  record  but  seven  examples  complicating^ 
labor.  This  form  of  pelvis  presents  n<»  obstacle  in  parturition.  There  are  the 
same  peculiarities  in  labor  as  in  the  justo-major  j)elvis — namely,  a  tendency  to 
precipitate  birth,  and  anomalies  in  the  mechanism  the  result  of  imperfect 
resistance.  After  labor  it  is  almost  certain  that  there  will  be  a  prolapse  of 
the  uterus.  The  didf/iiositi  of  this  detbrmity  j)resents  no  difHcultie^,  and  no 
obstetric  treatment  is  called  for  in  labor  (PI.  30,  Fig.  4). 

The  Rachitic  Pelvis. — In  the  healthy  life  and  growth  of  bones  two 
opposed  processes  are  found  :  on  the  j)erif»hery  there  is  an  active  proliferation 
of  cells  to  form  the  bone-structure,  while  in  the  interior,  l)one-substance  is 
being  constantly  ab.sorbed  by  the  marrow.  In  rachitis  the  absorption  of  hone- 
substance  goes  on  more  rapidly  than  it  does  in  healthy  bone,  and  at  the  same 
time  there  is  in  the  perij)herv  a  very  mu«  h  more  rapid  proliferation  of  cells, 
which  do  not,  however,  develop  normal  bone-structure.  Their  growth  and 
multiplication  result  in  the  formation  of  an  osteoid  material  poor  in  lime-salts 
and  much  more  jtliable  than  healthy  bone.  The  result  of  this  pathological 
process  in  the  pelvic  bones  is  to  make  the  pelvis  more  sensitive  than  it  should 
be  to  the  mechanical  forces  that  are  brought  to  bear  upon  it. 

In  the  rachitic  pelvis  the  size  and  shape  of  the  pelvic  canal  are  modified  by 
three  factors  :  the  pressure  from  the  trunk  above  and  the  counter-pressure  from 
the  extremities  below  ;  the  pull  on  the  pelvic  bones  by  ligaments  and  muscles ; 
and  an  arrested  development  the  conseciuence  of  an  interference  with  normal 
growth  that  this  disease  occasions. 

ChavaderiMics — The  effect  upon  the  shape  and  size  of  the  pelvic  canal  of 
rachitis  in  the  pelvic  boiK's  is  not  unif()rm.  Several  varieties  of  contracted 
pelvis  may  result.  The  commonest  is  the  fiat  pelvis  with  .some  contraction  of 
all  the  diameters,  but  a  most  marked  diminution  in  the  antero-posterior 
diameter  (PI.  .'!().  Fig.  7).  There  may,  in  addition  to  this  conmion  form,  be 
found  a  simple  flat  rachitic  pelvis  without  alteration  of  the  transvcr.se  diam- 
eters, a  generally  e(pially-contractcd  rachitic  pelvis  (PI.  30,  Figs.  5,  6),  and  a 
so-called  "  pseudo-osteomalacic  "  pelvis,  in  which  the  effect  .seen  in  osteomalacia 
is  jiroduccd  by  pressure  upon  the  bones  .softened  by  rachitis.  There  are  other 
rare  forms  of  asymmetrical  development,  in  connection  usually  with  spinal 
disease  of  racihitie  origin,  that  will  be  described  elsewhere. 

CliaracteriNticfi  of  (he  Fltif,  ( h'HVi'aUii-cnntraded  Rdcliitic  Pelvis. — The 
sacrum  is  |)resscd  forward  and  downward  between  the  iliac  bones,  and  is 
rotated  on  its  transverse  axis,  mainly  by  the  pressure  of  the  trunk  upon  it, 
but  partly  by  the  pull  downward  of  the  psoas  muscles  upon  the  spinal  column 


i;  ■  i' 


DYSTOCIA. 


Plate  31. 


('.  V,  .'i  riu. 

Tr.  liiiliti  11  cm 


Tr,  l"iiil.-ti  llj  .ni. 


1.  Fliit  riichitic  pelvis,  sin  iwinu'  tititcTior  pnsitinii  df  ncctiilnila  iMillliT  Musiiiin,  ( •nlh'i.'c  i.f  riivviiiaiis, 
I'liilinK'lphiiii.  ■_'.  I'liit  railiitic  pelvis,  slmwiiiir  reltitive  iiieasiircnieiils  df  iiiiieni-pnsteiidr  ami  tniiisverse 
iliuiiieti'i-s  lit  inlet  (Miitler  Museiiiii.  Ciillei:!'  nf  riiysicMiiiisi.  :i.  Kliil  riiehitie  |ielvi<  willi  Imueil  I'eiiinni  i  Miit- 
ter  Museum.  Cullene  of  riiysieiiiiisi.  I.  l-'l.-it  racliitic  pelvis,  slinwiiit;  reliilive  iMeii-iireiiieiit-  ..f  inlet  Mini 
(unlet  ^.Miitter  Museum,  Culletie  nf  i'li.vsieiansi.    .V7.  I'seiiilo-dstenmalaeiii. 


ur.i 


Ma 


DYHTOCIA, 


o2.J 


and  the  p''ll  upward  u|K)n  the  ixjsterior  surface  of  the  saertun  by  the  ereotores 
spime  miiscli's  (PI.  30,  Fijj.  8).  Tlie  effect  of  tins  movement  would  naturally  be 
to  throw  the  tip  of  the  sacrum  and  the  coccyx  directly  backward,  so  that  the  pos- 
terior surface  of  the  sacral  bone  would  rim  an  almost  horizontal  course  lus  the 
woman  stood  upon  her  feet.  The  attachments  of  the  sacro-sciatic  ligaments 
and  muscles  to  the  lower  sacrum  and  coccyx,  however,  prevent  this  backward 
movement  of  the  bone  us  a  whole,  and,  pulling  the  lower  portion  of  the  bone 
forward,  cause  a  sharp  bend  in  it,  usually  at  the  junction  of  the  fourth  and  fifth 
sacral  vcrtebrse.  The  sacrum  is  narrowed  in  its  transverse  diameter,  and  the 
lateral  concavity  of  the  anterior  siu-fact;  is  ctJaced,  by  the  forward  movement 
of  the  bodies  of  the  vertebrte  between  the  alte.  The  anterior  surface  of  the 
sacrum,  indeed,  may  be  convex  from  side  to  side.  By  the  pull  of  the  strong 
sacro-iliac  ligaments  running  from  the  sacrum  to  the  ])osterior  superior  spinous 
processes  of  the  iliac  bones  the  latter  are  pulled  downward  and  forward  by 
the  descent  of  the  sacral  promontory,  and  are  consequently  made  to  apjjroach 
one  another  bel. !nd,  but  they  do  not  keep  pace  with  the  movements  of  the 
sacrum,  and  co:  .iccpiently  project  more  prominently  than  common  on  either 
side.  The  natural  result  of  this  movement  forward  and  inward  on  the  part 
of  the  posterior  superior  portions  of  the  ilia  would  be  to  throw  the  anterior 
half  of  the  innominate  bones  outward,  but  this  movement  is  opposed  by  their 
junction  at  the  symphysis,  and  to  a  less  degree  by  the  attachment  of  Poupart's 
ligament  to  their  anterior  superior  spinous  j>rocesses.  The  ilia,  however, 
restrained  by  a  somewhat  yielding  force,  are  thrown  to  a  certain  degree  out- 
ward and  backward,  so  that  their  upper  edges  run  almost  horizontally  outward, 
and  the  distance  between  their  anterior  spines  becomes  little  less  than,  the 
same  as,  or  even  greater  than,  the  distance  between  their  crests  (PI.  30,  Fig. 
7).  A  further  result  of  these  combinetl  forces  pulling  the  innominate  bones 
inward  and  forward  behind  and  holding  them  in  place  in  front  is  to  produce 
in  them  an  abnormal  curvature,  as  in  the  case  of  the  sacrum,  or  as  in  a  bow 
bent  between  one's  hand  and  the  ground  (PI.  31,  Figs.  3, 4).  The  point  of 
angulation  or  greatest  curvature  is  found  on  the  ilio-pectineal  line,  back  of 
the  median  transverse  line  of  the  pelvic  inlet,  near  the  sacro-iliac  joints. 
On  account  of  the  flexion  of  the  innominate  bones  the  transverse  diameter 
of  the  rachitic  pelvis  is  relatively  increased,  but  as  the  whole  pelvis  is  com- 
monly below  the  normal  in  size,  this  diameter  rarely  exceeds,  if,  indeed, 
it  equals,  the  normal  transverse  measurement.  A  further  consequence  of 
the  exaggerated  curvature  of  the  innominate  bones  is  to  throw  the  ace- 
tabula  forward,  so  that  the  counter-pressure  of  the  lower  extremities  is 
exerted  more  antero-posteriorly  than  in  the  normal  pelvis  (PI.  31,  Fig.  1). 
The  pubic  rami  and  the  symphysis  are  diminished  in  height  and  show  a 
lessened  slant  outward.  The  cartilage  at  the  junction  of  the  symphysis 
projects  inward  upon  the  pelvic  canal,  standing  out  above  the  level  of  the 
bones  to  such  a  degree  that  it  is  sometimes  a  source  of  injury  to  the  head  or  to 
the  maternal  structures.  The  force  of  resistance  at  the  symphyses  to  the  out- 
ward movement  of  the  innominate  bones  sometimes  bends  the  ends  of  the 


,  \s^A 


.11.,  i 


\i:  'm 


:¥m 


pwm 


ifpllite 


, ,    , If-  '    'i  ■'■;:. "' 


i— 


fM'   .■ 


vm 


\l 


524 


AMEIifCAX    TEXT- BOOK    OF   OJiSTETRICS. 


H 


pu])ic  bones  inward  upon  the  pelvic  pjinal,  Jijivinji;  to  the  pelvic  inlet  the  shape 
of  a  Hiiiire  S.  From  the  traction  of  tlu'  adductor  and  rotator  muscles  of 
the  thi<ih  upon  the  tidierosities  of  the  ischiac  bones  (inereased  in  rachitis  bv 
the  p(isitit)ns  of  the  acetubula  and  tlie  bowin*;"  of  the  femora),  the  latter  are 
])ulled  outward  and  forward  so  that  the  pubic  arch  is  <;reatly  widened  and 
tlie  transverse  diameter  of  the  pelvic  outlet  is  increased  (I'l.  31,  Fijj.  4).  The 
antcro-posterior  diameter  of  the  outlet  is  somewhat  diminished  by  the  excess- 
ive jierpcndicular  ciu'vatiire  of  the  sacrum,  but  lh(>  contraction  is  relativeiv 
much  less  than  in  the  conjugate  of  the  inlet.  The  whole  ])clvis  is  lilted 
forward  on  its  transverse  axis,  so  that  the  inclination  of  the  superior  strait 
is  increased  and  the  external  genitalia  are  displaced  backward. 

The  bones  of  a  rachitic  pelvis  arc  usually  slighter  and  more  brittle  than 
conunon.  They  may,  pcrhaj)s,  show  no  peculiarities  iik  structure,  or  in  rare 
cases  they  may  be  tbund  much  thicker  and  heavier  than  normal. 

In  the  generally  etpially-contractcd  rachitic  ])elvis — a  rare  +ype — is  seen 
mainly  an  arrest  of  development,  the  consequence  of  rachitis  in  very  early  lii'e, 
Avhieh  retarded  growth  without  much  atfecting  the  shape  of  the  pelvic  inlet  and 
canal,  from  the  fact  that  the  pelvis  had  not  been  subjected  to  the  pressure  of 
the  tnmk  diu'ing  the  active  stage  of  the  disease,  because  it  ran  its  course  to 
complete  recovery  before  the  child  attempted  to  sit  up  or  to  walk.  Possihiv 
also  the  disease  in  some  of  these  cases  is  not  severe  and  lasts  but  a  short  time. 
As  the  detbrmity  is  the  result  of  arrested  development,  we  find  a  transverse 
contraoiion  as  in  th(>  fetal  ill-developed  ])elvis  (PI.  .'JO,  Figs.  5,  G). 

The  ilidfpiosifi  of  the  rachitic  origin  of  this  type  of  pelvis  is  made  by  the 
relations  of  iliac  spines  to  crests,  by  the  history  of  rachitis  in  early  iid'ancy 
perhaps,  and  ]K)ssil)ly  by  the  signs  of  the  disease  in  other  portions  of  the  body. 

In  the  psci((fo-of<ti'0))i(il(ii'ic  pclris  the  rachitis  has  been  severe  in  character 
and  long  contimied.  Etforts  to  walk  have  been  made  while  the  disease  was 
in  active  progress,  and  possibly  the  weight  of  the  trindi  has  been  exaggerated 
by  attempts  to  carry  heavy  burdens.  As  a  consetpience  of  the  pressure  of  the 
trunk  and  the  countcr-])ressure  of  the  lower  extremities  the  pelvis  bends  to  an 
extreme  degree  under  the  forces  imposed  u])on  it.  The  sacrum  siidvs  far  down 
into  the  j)clvic  canal  and  is  sharply  curved  or  bent  from  above  downward  ; 
the  innominate  bones  are  bent  at  a  sharp  angle  laterally,  and  the  acetabula  are 
j)ressed  inward  upon  the  pelvic  canal.  Wh«>n  at  length  the  bone  disease  has 
riui  its  course  the  pelvis  is  firndy  set,  by  the  hardening  of  the  bones,  in  its 
unnatural  position  and  shape.  The  dilfcrential  diagnosis  between  this  ju'lvis 
and  the  true  osteomalacic  ])elvis  is  made  by  the  direction  of  the  iliac  crests,  by 
the  tb'in  constitution  of  the  boi.cs  after  the  disease  has  been  arrested,  and  by 
the  signs  ol' rachitis  in  other  portions  of  the  body.  Osteomalacia,  besides,  has 
certain  peculiarities  of  its  own  that  enable  one  to  recognize  it  without  ditlieulty 
(IM,  :M,  Fig^.  5,  (J,  7;   Pi.  ;52,  Fig.  1). 

Diaf/uosiK. — The  diagnosis  of  a  rachitic  ])elvis  is  made  by  external  and 
internal  measurements,  by  ])alpation  of  the  exterior  and  interic.  of  the  pelvis, 
by  the  woman's  history,  and  by  her  appearance.     An  individual  who  has  had 


t  the  shape 
ninsck's  df 
rachitis  hv 
I  hUtor  arc 
iileuod  and 
^4).  Tiic 
the  cxccss- 
i  rehitivcly 
is  is  tihcd 
I'l'ior  strait 

irittle  tiiaii 
or  in  rare 

)c — is  seen 

early  liic, 

e  inh't  and 

ressure  of 

s  eonrse  to 

Possihly 

short  time. 

transverse 

ade  by  tlie 

•ly  infancy 

'the  body. 

1  cliaracter 

isease  was 

iggeratcd 

lire  of  tiie 

nds  to  an 

far  down 

Dwnward  ; 

ihnhi  are 

sease  has 

les,  in   its 

lis  pelvis 

ei'csts,  by 

I,  and  by 

sides,  has 

ilifliciilty 

I'lial  and 

lie  pelvis, 

has  had 


DYSTOCIA. 


Pi  .n:  32. 


e.  V.  lioni  1st  mill  tiiiiii     4 
2il  mil',  vi'i't.  Ill  rm. 


Ti-,  IJi  iiii. 


1.  I'si'udii-iislCdinnliiciii.    'J.  Kiicliilii' lu'lvis  with  I'nntriicti'il  liiiti'i-ii-iiostcfionliiiiiiilii' llniiiiu'liiiiil  llic  |n'l- 

vie   I'll  Mill  I  M  lit  If  r    MllM'Mlll.  Cnllri^r   of  l'll\siriillis,  l'llil;|i|i'l|illill  '.      ".,    I'rilcllllnll-   lirl  1)   nl'  lilillil  h  ,  ( 'h.-i  T'lu'M- 
lirll.    1,  Uiirliilir  Iu'lvi^  with  il.Mililr  |ironiniiiiiry  i  Mullrr  Miim'Uiu.  i  'nil  rL:r  .■!'  I'li>  -iii.iii^  ■.    :•.>''   Miii  'i'  miiilrs 

uf  usll'iUMUllU'il'  Iil'lvrs.      7.   0.-|i'"lllu!lli'ill,  ^Imw  ilii;  ,  »\  linin;lriri,l  rMllU'ilrlinll  Ml  .illlirt 


/ 


DYSTOCIA. 


525 


rachitis  in  childhood  '.?,  usually  of  ^niall  stature,  with  short,  thick,  curved 
extremities,  a  low  broad  brow,  a  large  square  head,  a  flat  nose,  a  "chicken 
breast,'  and  enlarged  joints.  The  lumbar  lordosis  and  the  rotation  of  the 
sicruni  produce  a  sway-back,  most  noticeable  when  the  woman  lies  on  her 
back  upon  a  hard  surface.  When  she  stands  erect  the  pregnant  uterus  near 
term  falls  abnormally  forward  and  downward,  on  account  of  the  short  abdo- 
men and  lack  of  engagement  of  the  presenting  \vAvt  (PI.  32,  Fig.  .i).  riie  most 
characteristic  facts  in  her  history  arc  that  she  walked  first  at  three  or  four 
vcars  of  age  and  was  late  in  getting  her  teeth.  By  the  pelvimeter  the 
normal  relation  between  the  iliac  spines  and  crests  is  found  disturbed.  Tlie 
ditfcrcnce  in  distances  between  the  former  and  between  tlie  latter  is  much 
reduced.     The  posterior  superior  spinous  pmcesses  arc  apprdxiiiKUcd,  and  the 


Kk;.  :Ui;  — Afipcnr.'iiiii'  iliiriiv.:  liO'  of  tli(>  liicrh-        Fn;.  :U7. -'^K-i'lrtnn   nf  m   rncliitic  duinr  M.iliriil 
csl    ;;r.iili'   nl"  ^ll(■llili^;     iiscUiln(i>liiiiiiiiliiriii    (I'il'-  Milsiinii,   1  ni\ri>iiy  nf  IViiii^\  l\  aiii;n. 

|piii^>h  jiilili. 

depression  luider  the  last  spinous  process  of  the  lumbar  V('rtel)ra  approaches 
or  is  actually  in  the  line  drawn  between  them.  The  external  antcro-posterior 
diameter  of  Baudelocque  is  below  the  normal.  Internally,  the  diagonal  con- 
jugate is  found  considerably  reduced.  The  symphysis  has  less  of  a  slant  out- 
ward than  it  should  have,  the  promontory  is  found  low  an^i  prominent,  tli(( 
sacral  bone  is  sharply  bent  upon  itself,  and  the  pelvic  canal  is  remarkably 
shallow.  On  account  of  the  increase  in  the  conjugate-syinphyseal  angle  due 
to  the  lessened  slant  outward  of  the  symphysis,  at  least  2  centimeters  should 
be  subtracted  from  the  diagonal  conjugate.  The  difference  between  the  two 
would  be  greater  were  it  not  for  tlie  low  situation  of  the  j)romontory,  which 
compensates  to  a  certain  extent  for  the  lessened  slant  of  the  symphysis,  but 
does  not  entirely  neutrali/.e  it.     A  double  promontory  in  these  pelves  is  not 


F»>»i 


►!    J6 


^^f^ 


1     Si 


V  J?: 
:  r 


■' 


:?i'S 


f'^i 


526 


ylJ/^72/C^l.A^   TEXT-BOOK   OF   OBSTETRICS. 


uncommon  (PI.  32,  Figs.  2,  4).  If  found,  the  mtasurement  should  be  taken  from 
the  promontory  nearest  the  symphysis.  Occasionally  the  lordosis  of  the  lum- 
bar vertebra;,  the  result  of  spinal  rachitis,  is  so  great  as  to  constitute  itself  an 
obstruction  above  the  pelvic  inlet.  In  such  a  case  the  effective  conjugate  must 
be  taken  from  a  j)oint  above  the  sacrum  to  the  symphysispubis(Pl.  30,  Fig.  8). 
Injiuence  on  Labor. — The  influence  on  labor  of  a  flat  rachitic  pelvis  is  mudi 
the  same  as  the  influence  of  a  simple  flat  pelvis,  except  that  the  contraction, 
and  consequently  the  obstruction  to  labor,  is  greater  in  the  rachitic  form,  and 
that  the  promontory  of  the  sacrum  is  more  prominent  and  more  '^barplv 
defined.  The  anomalies  of  mechanism  at  the  inlet  are  the  same  in  both  forms 
of  pelvis,  but  they  are  exaggerated  in  the  flat  rachitic  pelvis.  As  soon  as  the 
obstruction  at  the  inlet  is  overcome  the  descent  of  the  head  and  its  esca]ie  is 
more  rapid  in  the  raciiitic  pelvis,  because  of  the  shallow  canal  and  the  expanded 


Fiii.  318.— I'ressuru  of  tliu  iiruinoutory  \ipon  the  hcftJ  in  a  contniotod  pelvis  (Sraellic). 

outlet.  Injuries  to  the  child's  head  and  to  tlie  maternal  tissues  from  pressure 
are  common.  In  the  former  a  sharp  indentation  may  be  seen  on  that  portion 
pressed  against  the  promontory  in  tlie  efforts  to  secure  engagement  (the  so- 
called  "  sjxKJU-shaped  "  depression,  witli  fracture  of  the  parietal  bone;  Figs. 
314,  318,  3I9j.  lA)cali/ed  Jiecroses  are  not  infrequently  seen  in  the  mater- 
nal structures  where  they  have  been  nipped  between  the  child's  head  and 
prominent  portions  of  the  ])elvic  bones — namely,  in  the  cervical  tissues  over 
the  j)romontory,  or  very  rarely  in  the  ])osterior  vaginal  vatdt,  and  in  the  ante- 
rior vaginal  wall  behind  the  symphysis  and  the  ridge  of  the  piibie  bones. 
AA'hen  the  slough  sej)arates  openings  may  be  established  between  the  birtii- 
canal  and  the  peritoneal  cavity,  the  bowel,  the  bladder,  and  a  uretcir. 

Osteomalacic  Pelvis. — Osteomalacia,  a  soft  condition   i>f  tlie  bones  in 
consequence   of    an    osteomyelitis   and    an    osteitis,    is    exceedingly    rare   in 


DYSTOCIA. 


o27 


America.  There  are  certain  jiarts  of  the  world  where  it  is  frequently  seen, 
notably  Italy,  Germany,  ami  Austria,  but  in  America  there  are  but  three 
!)!■  i'oiir  examples  on  record.  The  bones  of  the  pelvis  in  this  disease  become 
,~()  soft  that  they  yield  to  every  force  imposed  upon  them.  They  bend  before 
llio  pressure  of  the  trunk  from  above,  tlu;  extremities  from  below,  and  the 
|)iill  of  the  muscles  attached  to  the  pelvic  bones.  The  flexibility  of  the 
pi'lvis  in  extreme  cases  of  osteomalacia  can  bo  appreciated  when  it  is  stated 
that  the  superior  iliac  spines  may  be  bent  backward  until  they  touch  the  spinal 
column;  the  horizontal  rami  of  the  pubis  maybe  jjushcd  inward  imtil  they 
almost  obliterate  the  pelvic  inlet ;  and  the  tuberosities  of  the  ischium  mav  be 
approximated  until  they  nearly  close  the  pelvic  outlet.  Xot  only  are  the  pelvic 
walls  so  compressed  that  they  almost  obliterate  the  pelvic  canal,  but  tlu> 
spinal  column  also,  sinking  under  the  weight  of  the  trunk,  bends  liir  forward 


ih 


I'lu.  319.— Ovfrlapping  of  the  criiiiiul  bDiios  in  a  futile  attempt  to  engage  in  the  superior  strait  of 

a  rachitie  pelvis  (Smellie). 

and  descends  low  into  the  pelvis,  occupying  the  little  remaining  room  in  the 
inlet  and  canal,  and  becoming  itself  a  serious  obstruction  to  the  engagement  of 
the  i)resenting  part.  From  the  lateral  pressure  of  the  thigh-bones  the  ischia  and 
])iibcs  are  pushed  inward  and  backward,  making  by  the  former  movement  a 
sharp  beak-like  projection  of  the  pelvic  inlet  between  the  jjubic  rami,  and  by 
the  latter  much  diminishing  the  s-ize  of  the  pelvic  canal  (PI.  32,  Figs.  5,  (i,  7). 
Tile  sacrum  is  rotated  on  its  transverse  axis  and  is  driven  low  into  the  pidvic 
canal — an  exaggeration  of  the  nioveinont  seen  in  a  rachitic  pelvis.  The  lower 
portion  of  the  sacrum  and  the  coccyx  are  pulled  sharply  forward  by  the  mus- 
cles attached  to  them,  so  that  the  sacrum  is  bent  at  a  sharp  angle  in  its  lower 
third.  The  innominate  boucs  are  bent  laterally  at  a  jioint  slightly  anterior 
to  the  sacro-iliac  junction,  and  the  iliac  bones  may  be  folded  upon  themselves 
horizontally.     The  inclination  of  the  pelvis  as  a  whole  is  much  increased. 


t  ,i 


•i-^: 


!; 

r 


m 


\ 


AMi:ni<'A\  TEXT- nook'  or  oustktrics. 


The  (luifpi()Ni.s  may  Itc  based  ii|)(iii  tlir  flillnw  inu-  symj)tuiiis  :  Tlic  (IImmt 
bc'jrins  usually  (liirini"'  prcoiiaMcy  or  l:icl;iti<.ii.  w  itii  dull  ai'liiii;:  pain-  in  ii„. 
extroniitics,  tlii'  back,  (he  li!uil>ar  rcuion,  and  over  tlic  ante  rinr  iidrtiiai  nf  il,,. 
jK'lvis,  Every  umveineMt  incica-cs  iIksc  pains.  As  ijic  di>ea>e  pi'(ii;if>., . 
the  bones  of  the  spinal  eolunin  are  -o  iicnt  and  eoni|nvs<ed  thai  llie  Individn,, 
is  dinnni-licil  in  >talnre  to  an  exiraordinarv  decree.     She  nia\   lo>e  a>  nnicji  ,i~ 


Fli..  HJiJ.— ll:i>l  .s  (use  nl'  u^icdiimliiciii  ilmiit  iiinl  prnlilo  vii^ws  in  (lill'trfiil  |>i'rs|icctivc!. 

;.  I  and  a  half  in  hci<iht  (Fig.  320).  The  gait  of  an  osteomalacic  patient  i.> 
il:  u".  In  order  to  compensate  for  the  approximation  of  the  thighs  brought 
aUoUi  i)y  t'.ie  collapso  of  the  ]>elvis  the  imhvidual  nuist  turn  almost  through  a 
half  circle  in  order  to  bring  one  foot  in  front  of  the  other.  Upon  examination 
of  the  pelvis  tenderness  upon  presiiure  is  discovered  over  its  anterior  wall.  The 
flexibility  of  the  pelvic  bones  may  bo  denutustrateii  by  direct  pros.sure,  antl  an 


DYSTOCIA. 


Pl,ATK  33. 


I-     ill    li, 
II    III' 


III. 


I'dLlI'"'-- 


iili\li|i| 


lllllcli   :i- 


iclll  |> 
•dlliillt 
illli'll  :i 
Cltioll 
TIlc 

tul  nil 


1.  ExoRtosi's  nt  tho  sacro-iliai' juiictliiiis.    'J.  KiiDblikf  oxnstosis  on  the  promontory  (SohiuitiO.    3.  Ai'nn- 
tlicipi'lys.    t.  Kiichitic  jii'lvis  with  "Imormiil  bill  hhiiit  proji'i 


I'i'lion  of  iU'ii-pi'i'tincal  riiiliicin'cs  iMiittcr  Mu- 
lliii'linriilnniiii  Ot<'hnn.    il.  Knictuii' nl' tlic  ju'lvis  (Otto).    7. 
iri'  of  tlii^  acotabuhi  in  coiisoiiik'Iku  of  coxalnia  (Ottoi.    S.  Fracture  of  tlie  ri(,'ht  ahi  of  the  sacrum 
(Kritscli). 


'0  m 


scum,  Cnllou'c  of  rhysiciuiis,  I'liiliic   '.oliii 
Kractu 


DYSTOCIA. 


o2{) 


internal  oxaminatioii  discovers  in  the  early  stage  of  the  disease  the  peculiar 
licak-like  space  behind  the  symphysis,  and  later  the  almost  entire  obliteration 
of  the  pelvic  outlet  and  canal  by  the  sinking  in  of  the  pelvic  walls.  Jf  it  is 
possible  to  make  a  satistiictory  internal  examination  of  the  pelvis,  the  low 
po-ition  and  tiie  projection  of  the  promontory  at  once  attract  attention,  and 
tlie  sharp  angulation  on  the  anterior  face  of  the  sacrnm  can  be  felt.  On 
account  of  the  exaggerated  inclination  of  the  pelvis  it  may  be  necessary  to 
iriakc  an  examination  with  the  patient  upon  her  side.  An  osteomalacic  pelvis 
lias  been  taken  for  a  kyphotic,  a  Robert,  a  pseudo-osteomalacic,  a  cancerous,  or 
a  fractured  pelvis,  but  a  careful,  methodical  examination  of  the  patient  will 
always  lead  to  a  correct  diagnosis. 

liiffuciice  upon  Labor. — The  results  of  labor  in  osteomalacic  pelves  show 


;H. 


I' 


irt 


m\ 


fC- 


''X\i-\y 


I'm.  oL'l.— Cystic  enchondrnma  (Zweifel).       Fi(i.  S22.— Button-like  exnstdsis  on  tho  promontory  (Sphiiuta). 


that  the  obstruction  is  a  serious  one  in  spite  of  the  flexibility  of  the  pelvic 
liones,  by  rcascm  of  which  flexibility  in  some  cases  the  head  can  distend  the 
pelvic  canal  sufliciently  to  pass  through.  In  80  cases  collected  by  Lit/maun 
forty-seven  ended  fatally.  In  another  series  of  128  cases  the  labor  had  a 
spontaneous  termination  in  twenty-seven  cases,  in  four  there  was  premature 
delivery,  and  in  five  abortion  ;  four  times  the  labor  was  naturally  terminated  ; 
ill  eight  cases  version  was  ])erformed,  in  four  the  child  was  extracted  by  the 
feet,  in  twenty-five  forceps  was  employed,  in  eleven  craniotomy  was  performed, 
and  in  thirty-six  Cesarean  section  ;  rupttu'e  of  the  uterus  occurred  in  five 
women  before  any  operation  was  undertaken.  In  still  another  series  of  cases 
reported  from  ^lilan  the  flexibility  of  the  pelvis  was  so  great  that  the  child 
was  delivered  in  only  two  instances  by  Cesarean  section.     The  most  successful 


530 


AMElilVAX  TEXT-BOOK  OF  OJiSTETRIVS. 


Flo.  ;>j;!.— Exostosis  on  the  symphysis  (Sclmutn). 


treatment  in  modern  times  fur  this  obstriietion  in  labor  ninst  be  the  perlbrin- 
ance  of  Cesarean  seetion,  and  the  oi)erat<)r  should  at  the  same  time  remove 
the  ovaries,  or,  what  is  better,  do  a  eoniplete  Porro  operation.  It  is  bewjnd 
dispute  that  tlie  eessation  of  sexual  funetions  favorably  modifies  or  aetuallv 
cures  the  tliscase. 

Tumors  of  the  Pelvis. — The  commonest  ])elvie  tumors  are  bony  excros- 
cences,  usually  Ibund  over  one  of  the  pelvic  joints.  The  excrescences  are  oriji- 
inally  cartilaj^inous  projections  which  become  ossified  by  an  extension  of  bonv 
tissue  from  the  two  bones  between  wliich  they  lie.  These  exostoses  mav  be 
found  over  the  saero-iliac  joints,  over  the  symphysis  pubis,  and  over  the  prom- 
ontory of  the  sacrum  (Figs.  322,  32."i ; 
ri.33,Fijrs.l,2).  They  may  reach  t lie 
size  of  a  pigeon's  egg,  though  they  aic 
nstially  not  larger  than  a  pea  or  a  nut. 
In  the  exostoses  occupying  the  seat  of 
the  pubo-iliac  junction,  <lirectly  above 
the  acetabula,  the  bony  growth  is  iipt 
to  assume  a  sharp,  thorny  shaj)e,  i)ro- 
jecting  with  its  point  into  the  pelvic 
inlet.  Kilian  was  the  first  to  direct 
attention  to  this  fact;  he  called  a  pelvis  thus  deformed  ^' acanthopcli/s"  {V\. 
.'>3,  Fig.  3),  or  a  "yWm  npinom."  Another  possible  seat  for  a  bony  projec- 
tion is  along  the  crests  of  the  pubic  bones,  the  exostosis  taking  here  the  form 
of  a  long,  sharji  edge,  and  j)robal)ly  owing  its  origin  to  an  ossification  of  the 
attachment  of  the  iliac  fascia,  a  transformation  of  tissue  analogous  to  the  ossi- 
fication sometimes  seen  in  (Jimijernat's  ligament.  These  bony  outgrowths  con- 
stitute a  serious  form  of  obstruction  in  labor,  not  so  nuich  fron;  their  encroach- 
ment uj)on  the  room  of  the  pelvic  inlet  as  from  the  sharply-locali/od  pressure 
which  they  exercise  ujiou  the  maternal  structures  and  upon  the  fetal  head.  In 
the  four  cases  repcjrted  by  Kilian,  death,  it  was  claimed,  resulted  in  each  case 
from  a  i)erforate(l  uterus.  Other  tumors  of  the  pelvis  offering  an  obstruction 
in  labor  are  enchondromata,  fibromata,  sarcomata,  carcinomata,  and  cysts  (Fig. 
321 ;  PI.  33,  Fig.  5).  These  tumors  are  rare,  and  their  importance  as  an  obstacle 
in  labor  depends,  of  course,  upon  their  size.  Cysts  of  the  ju'lvis  are  formed 
usually  in  sarcomata  and  in  enchondromata,  or  are  hydatid  cysts.  Cancer  of 
the  pelvic  bones  is  always  a  secondary  growth  or  is  metastatic.  It  may  result 
in  a  number  of  small  tumors  in  the  bony  pelvic  walls,  or  may  take  on  the  form 
of  cancerous  infiltration  with  a  consequent  softening  of  the  bones  like  that  of 
osteomalacia.  The  treatment  of  labor  obstructed  by  tumors  of  the  pelvis  is 
ordinarily  the  performance  of  Cesarean  section.  There  is  one  case  on  record 
(Abernethy's)  in  which  the  tumor,  an  enchondroma,  was  removed  by  an  incis- 
ion in  the  j)osterior  vaginal  wall,  but  in  the  vast  majority  of  cases  these  growths 
cannot  be  reached  or  cannot  safely  be  excised.  In  49  cases  of  labor  obstructed 
by  a  pelvic  tumor  50  per  cent,  of  the  women  and  90  per  cent,  of  the  children 
lost  their  lives  (Winckel). 


DYSTOCIA. 


r>;n 


Fractures  of  the  Pelvis. — Out  of  13,200  fniotiircs  roportcd  from  nine 
lar.ii;e  hospitals  in  America  and  in  Kuropo,  but  0.8  of  one  por  cent,  were 
i'racttn'os  of  the  pelvis.  When  one  considers  that  almost  all  grave  injuries  of 
tlie  pelvis  end  fatally,  the  rarity  of  a  pelvic  deformity  dependent  upon  a 
united  fracture  of  a  pelvic  bone  in  a  woman  of  childi)earin<i:  age  may  be 
appreoiatctl.  Most  frcfjuently  the  fracture  is  found  in  the  pubes,  next  in  the 
ilium,  next  in  the  ischium,  next  in 
the  acetabulum,  and  least  frequently 
(if  all  in  the  sacriun.  The  effect  of  a 
fracture  of  the  pelvis  upon  the  shape 
anil  size  of  its  canal  depends  on  the 
situation  of  the  fracture,  and  may  be 
due  to  distortion  of  the  pelvic  walls, 
ti>  excessive  callus-formation,  or  to 
ossification  of  the  pelvic  joints  near- 
est the  seat  of  fracture.  In  a  fracture 
of  the  acetabulum  the  result  of  hip- 
joint  disease  the  head  of  the  fenuu" 
may  project  into  the  pelvic  canal  (PI. 
.'{;},  Fig.  7).  Fracture  of  the  pubes 
results  in  an  irregular  distortion  of 
the  pelvic  inlet,  most  marked,  of 
course,  on  the  injured  side  (PI.  33, 
Fig.    6).     A    fracture   of  the  upper 

portion  of  the   sacrum    mav  residt    in       Fk;.  ;i24.-Trnn8Vfrsi' fracture  nC  thf  sacrum  with 
,,,.,.         1    ,.      *  .  /T-i.  .siioiidylolisthctic  (lefiiruiitv  iNcUKcbaiRT). 

a   spondylolistlietic   deiormity    (r  ig. 

324).  Fracture  of  the  lower  portion  of  the  sacrinn  is  followed  by  a  dislo- 
cation of  the  lower  fragment  inward.  In  a  case  seen  by  the  writer  the  lower 
half  of  the  sacral  bone  was  turned  in  at  right  angles  to  the  rest  of  the  bone  by 
the  pull  of  the  pelvic  muscles  attached  to  it.  A  fracture  of  the  sacral  aKT  may 
cause  an  oblique  contraction  of  the  jielvic  inlet  like  that  of  the  Xaegele  pelvis 
Pi.  33,  Fig.  8).  Neugebauer"  reported  an  extraordinary  case  of  bilateral 
fracture  of  the  pubic  rami  in  which  there  was  union  with  callus-formation  on 
one  side  and  an  ununited  fracture  on  the  other,  the  fragments  moving  on  one 
another  2  or  3  centimeters  when  the  woman  walked. 

Caries  and  Necrosis. — The  only  effect  of  this  disease  of  the  pelvic  bones 
is  the  production,  in  rare  cases  of  tid)erculosis  of  a  sacro-iliac  joint,  of  an 
oblique  contraction  of  the  jielvis.  When  the  sacro-iliac  joint  is  affected  the 
idtimate  result  is  the  same  as  that  produced  by  imperfect  development  of  the 
sacral  ala^  in  a  true  Xaegele  pelvis.  There  is  loss  of  tissue,  ankylosis  of  the 
joint,  and  an  arrest  of  development  in  the  affected  part  if  the  disease  occurs  in 
early  childhood. 

Ankylosis  and  Relaxation  of  the  Pelvic  Joints. — Synostosis  may 
develop  iu  any  of  the  pelvic  joints  ;  in  the  symphysis  it  occurs  not  infrequently, 
and  often  at  an  early  age.     A  number  of  operators  have  encountered  this  dif- 


mf 


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AMEJtICAX    TKXT-liOOK   OF   OliSTKTIilCS. 


ficiilty  in  jittriiipts  rcci'iitly  to  jx'rform  symphysiotomy.  In  otliiTwisc  iiiuili- 
stnictcd  labor  synostosis  of  the  piil)ic  symphysis  is  not  a  serious  comlitioi*, 
aUhoiijfh  it  limits  the  slij^lit  c'xpan>ion  wliioli  every  nurmul  j)elvis  .shoiiUI 
exhihit  preparatory  to  and  ihn'iiifjf  labor. 

If  synostosis  of  the  saero-iliac  joint  deveh)ps  in  tlie  individual's  early 
ehildhood,  it  is  followed  by  ill  development  of  the  sacral  alio  on  the  alTeelcd 
side,  and  of  that  portion  of  the  imiominate  bone  eoneerned  in  the  formation 
of  the  joint,  an  oblicpiely-eontraeted  ju'lvis  of  the  Xae<;ele  type  beiiiir  the 
result;  but  suHi  eases  are  rarer  than  those  in  which  lack  of  development  in  the 
sacral  alie  is  the  primary  oeeurrence.  If  the  synostosis  of  the  joint  occius 
after  puberty,  the  etfect  upon  the  pelvis  and  upon  the  eoiu'se  of  labor  is  prae- 
ticallv  nil.  If  both  joints  are  early  ankvlosed,  a  form  of  laterallv-contractcd 
pelvis  like  the  Robert  pelvis  is  the  result.  This  kinii  of  contracted  pelvis  is 
rarer  than  the  transversely-contracted  pelvis  due  primarily  to  lack  of  develop- 
ment in  the  sacral  ala>. 

The  sacro-coccvjieal  joint  becomes  ankvlosed,  as  a  rule,  between  the  thir- 
tieth and  fortieth  years,  but  as  the  joint  between  the  first  and  second  coccyfr(!al 
vertebra;  is  ordinarily  nnatlected,  the  pelvic  outlet  is  capable  of  expansion 
dnrin<f  labor  in  its  antero-posterior  diameter  nearly  as  well  as  if  the  sacro- 
coccygeal joint  were  normal.  Karely  there  is  an  ankylosis  of  all  the  coccyfieal 
joints  along  with  that  between  the  sacrum  and  the  coccyx.  In  these  cases 
labor  can  be  terminated  only  by  a  fracture  of  the  coccyx  or  a  laceration  of  the 
pacro-coeeygeal  joint.  The  expulsive  forces  of  labor  may  be  sntticient  to  cause 
this  fracture,  and  the  bone  has  been  heard  to  give  way  with  a  loud  crack  as 
the  head  was  passing  through  the  pelvic  outlet.  This  accident,  however,  is 
more  likely  to  be  caused  by  the  artificial  extraction  of  the  head. 

An  abnormal  relaxation  of  the  pelvic  joints  may  be  a  simple  exaggeration 
of  that  natural  ])rocess  by  which  the  pelvic  canal  is  made  somewhat  expansil)!e 
pre]>aratorv  to  labor.  It  is  more  likely,  however,  to  be  due  to  some  patho- 
logical condition  within  the  ])elvic  joints,  as  an  inflammatory  process  follow(Hl, 
perhaps,  by  suppuration,  the  eollecticm  of  fluid  witli'n  the  joint,  osteomalacia, 
caries,  or  new  growths.  In  pregnancy  the  patl;oloi:;eal  relaxation  of  the 
])elvic  joints  may  occasion  some  difficulty  in  locomiilion.  During  labor  an 
exaggerated  relaxation  of  the  joints  predisposes  to  their  rupture. 

The  Spondylolisthetic  Pelvis. — The  spondylolisthetic  pelvis  was  first 
described  in  1839  by  Kokitansky,  who  reported  two  cases;  Kiwisch  and 
Kilian  followed  with  a  description  each  of  a  specimen  ;  bnt  we  owe  our 
knowledge  of  the  condition  mainly  to  the  indefatigable  researches  of  Neu- 
gebauer, '- who  collected  more  than  ninety  cases  and  specimens,  and  to  the 
discoveries  of  Lane,  who  has  done  much  to  clear  up  the  etiology.  The  name 
"spondylolisthesis"  *  indicates  the  condition — a  slipping  down  or  dislocation 
of  the  vertebrje.  To  affect  the  ])elvis  the  spondylolisthesis  must  be  in  the 
luni bo-sacral  region  (Figs.  325-327). 

Charactcristir.^ — As  the  name  denotes,  there  is  a  dislocation  of  the  last 
*  a-6v(h'?.nCj  vertebra,  and  uXiafii/air^  a  slipiiing  out  or  down. 


DYSTOCIA. 


Mil 


liuiibur  vortclini  ir.  front  of  tlio  siuu'iiin,  the  body  of  the  formor  sli|)|)in^  down 
ill  front  of  the  first  .sacral  vertebra,  so  that  its  inferior  border,  or  in  advanecil 
eases  its  anterior  surface,  comes  in  contact  with  tlie  anterior  fiice  of  tiie  sacrnni, 
to  which  it  becomes  united  by  bony  union,  Tlicre  is  also,  of  necessity,  an 
cxairirerated  lordosis  of  the  lumbar  vertel)ra  and  a  descent  into  the  nclvic  inlet 
of  at  least  the  fourth  and  third,  and  even  of  the  second,  lumbar  vertebra*, 
which  diminish  by  their  bulk  and  anterior  projection  the  antero-posterior 
diameter  of  the  pelvic  canal.  Ft  is  only  the  body  of  the  last  Inniliar  ver- 
tebra that  is  displaced,  and  not  the  arch,  held  fast  by  the  lower  posterior 
articular  surfaces,  nor  the  lamime  surrounding;  the  spinal  cord,  so  that  the 
latter  does  not  necessarily  suffer  compression  by  the  displacement  of  the  ver- 
tebra, although  this  result  has  been  noted  in  a  few  cases  (Fig.  320).  To 
allow  the  displacement  of  tlu!  body  of  the  last  linnbar  vertebra  the  inter- 


Kk!.  "Jti,— Spondylolisthesis,  beginning  (Schautn). 


Flu.  :'.'J7.— Last  Inmhnr  viTti'hni  of  sjioiKlylo- 
listlu'sis  Ml)  ciiiitriisttil  with  a  normal  ti.th  lum- 
l''i(i.  :i'23.— Spondylolistlu'sis,  woll  markoil  (Scliauta).  ,     bar  viTti'bra  iNcug.baut'r). 

articular  segment  of  the  spinal  arch  and  the  jwdieles  are  enormously 
lengthened  from  behind  forward  and  are  bent  at  an  angle  ilownward  (Fig. 
.'527).  After  a  time  this  segment  may  exhibit  a  transverse  fracture  or  a 
solution  of  continuity  from  i)ressnre  and  attrition.  The  deformity  is  always 
gradual  in  development.  If  it  develops  during  the  childbearing  period, 
successive  labors  become  increasingly  difficult.  As  the  vertebra  descends  it 
pushes  the  sacrnin  backward  and  downward,  and  with  it  depresses  the  pos- 
terior portion  of  the  jjclvie  brim.  To  compensate  for  this  movement  the 
anterior  half  of  the  pelvic  brim  rises  and  the  height  of  the  symphysis  is 
increased.    This  movement  of  the  pelvis  diminishes  very  markedly  its  inclina- 


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AMERICAN    TEXT-BOOK    OF   OBSTETRICS. 


tion,  and  disturbs  tlie  normal  relationship  between  the  bones  and  the  soft 
structures  tliat  overlie  them.  The  base  of  the  triangle  formed  by  the  jiubic 
hair  in  women  is  well  below  the  upper  edge  of  the  symphysis,  and  the  exter- 
nal s'enitalia  are  so  pulled  forward  that  the  vulvar  orifice  is  directed  anteriorlv 
as  the  patient  sits  or  stands.  There  are,  moreover,  the  same  displacements  of 
the  pelvic  bones  that  are  seen  in  kyphosis — a  rotation  backward  of  the  sacrum 
on  its  transverse  axis,  and  a  rotation  outward  of  the  upper  portions,  and 
inward  of  the  lower  portions,  of  the  innominate  bones  on  their  antero-pos- 


Fi(i.  328.— Wini'lii'l's  lase  of  spondylolisthesis  of  modornte  degroe. 

terior  axes.  The  descent  of  the  lumbar  vertebra)  drags  the  large  arteries  of 
the  lower  trunk  into  the  pelvic  iidet,  so  that  the  iliac  vessels  and  the  bifurca- 
tion of  the  aorta  can  be  felt  in  the  vaginal  examination.  The  degree  of  con- 
traction in  the  conjugate  diameter  of  the  iidet  depends  upon  the  descent  of  the 
last  lumbar  vertebra  and  the  degree  of  the  lordosis.  The  contraction  is  usually 
not  excessive,  but  it  may  be  so  great  as  to  preclude  the  possibility  of  the  engage- 
ment of  the  fetal  head. 

Miolof/u. — The  etiology  of  spondylolisthesis  at  the  lurubo-sacral  junction  is 
still  involved  in  considerable  obscurity.  It  has  been  attributed  to  ilireet 
injuries  of,  and  to  faults  of  development  or  ossification  in,  the  interarticular 
segments  of  the  spinal  arch.  It  is  certain  that  these  are  predisposing  causes, 
but  the  observations  of  Lane  appear  to  demonstrate  that  the  commonest  cause 
of  this  deformity  is  an  exaggerated  pressure  from  the  truidv  above  exerted 
often  upon  healthy  bone.  As  the  result  of  this  pressure  a  joint  is  formed  in 
the  intervertebral  ilisk,  and  the  interarticular  segments  of  the  last  lumbar 


DYSTOCIA. 


535 


tU..J 


VPi't'bra  undergo  stretching,  pressure,  angulation,  and  atrophy  until  the  hone 
is  actually  severed.  Following  or  accompanying  these  changes  in  the  arch, 
the  body  of  the  last  lumbar  vertebra  is  displaced  farther  and  farther  down- 
>\ard  and  forward. 

Dkujnosis. — The  di:»gnosis  of  a  spondylolisthetic  pelvis  is  not  easy,  and 
can  be  made  only  by  close  attention  to  the  patient's  history,  by  u  careful 
observation  of  her  appearance,  by  an  internal  and  external  examination  of 
the  pelvis,  and  by  pelvimetry.  In  the  history  of  the  case  it  may  appear  that 
the  individual  was  the  subject  of  a  serious  accident,  such  as  a  fall  from  a 
lioight  or  a  fracture  of  the  pelvis  by  the  passage  over  it  of  a  heavy  weight, 
or  it  may  be  learned  that  she  has  carried  excessively  heavy  burdens  for  a  long 
time.  The  woman's  height  is  diminished  and  the  length  of  the  abdomen  is  short- 
ened. Viewing  the  patient  from  behind,  there  appears  what  is  called  the  sad- 
dle-shaped or  "sway  "  back,  the  lumbar  vertebne  projecting  visibly  far  forward 


Fl<;.  3'J9.— Ahlfi'Ul's  ciiso  i)f  spdiidylnlistlK'sis. 


l"l(i.  3oO.— Broisky's  case  of  spondylolisthesis. 


and  being  displacetl  downward,  throwing  into  bold  ^'elief  the  posterior  superior 
spinous  processes  and  the  rims  of  the  iliac  bones,  ai.d  producing  quite  a  dee]> 
furrow  along  the  course  of  the  spinous  processes  of  the  lumbar  vertebrje.  The 
apposed  articular  proce>  <es  of  the  first  sacral  and  the  last  lumbar  vertebraj 
stand  out  as  button-shaped  prominences  on  the  inner  surface  of  the  posterior 
rims  of  the  ilia.  The  buttocks  are  flat  and  are  pointed  bel.)W,  giving  to  the 
region  a  cordiform  appearance.  Tn  front  there  is  a  pendti.ouj  belly  ;  a  deep 
crease  is  observed  running  across  the  lower  abdomen  a  'u  rl  distance  above 
tlie  symphysis.  Ijaterally,  the  floating  ribs  are  seen  alii'ost  to  rest  upon  the 
ci'ests  of  the  ilia  or  actually  to  siidc  between  them,  and  th(  soft  structures  of  the 
flanks  are  thrown  outward  in  prominent  fold;,  '''''•e  trunk  is  shortened,  and 
the  limbs  appear  relatively  too  long  (Fiijjs.  .'L'*^- oGO).  The  patient's  body 
bcinji;  thrown  forward  bv  the  def'ormitv  (if  the  sr.ini',  an  elfort  to  maintain  an 
equilibrium  is  nuide  by  carrying  the  sh(>ulders  fai  back;  as  the  individual  walks 


'I.- 


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A.}n'JIi'I('AX  TEXT-BOOK  OF  OJiSTL'Th'ICS. 


a  disposition  to  fall  forward  may  !)o  noted,  and  showill  state  |)erliaj)s  that  slic  i- 
nnable  to  earry  any  load  npon  her  arms  in  front  of  her  hody,  for  fear  of  to])pliiit; 
over  upon  her  face.  She  may  also  complain  ot'  a  <i:ratint;;  sensation  and  somikI 
in  the  small  of  the  back  (erepitns).  The  j>ait  is  |)ecnliar;  the  toes  are  nm 
tnrned  ontward,  and  the  feet  are  swnnjj  aronnd  one  another  so  that  the  foot- 
])rints  fall  in  a  straij^ht  line.  Upon  an  internal  examination  of  the  pelvis — 
best  condneted,  aeeordinj;  to  Ncnu'chaner,  in  an  nprijfht  or  lateral  position — the 
lordosis  of  the  Inmhar  vertebra*  is  at  once  discovered.  The  an<>;le  formed  bv 
the  attacliment  of  the  last  hnubar  vertebra  to  the  saernm  may  be  detected 
with  ease,  and  it  is  noted  that  the  body  of  this  vertebra  does  not  possess 
lateral  ])roj<'etions,  transverse  processes,  or  ahv.  J{y  their  absence  one  i> 
snre  that  he  is  not  feelinj^  a  projectin<j;  i»roinontorv.  J'nlsatinji:  iliac  arteries 
can  ))('  felt,  and  it  is  ])ossible  even  to  reach  the  bifin'cation  of  the  aorta — a 
symptom  first  j)ointed  ont  by  Olshansen.  l?nt  the  symptom  is  not  pathoiino- 
monic.  The  same  sign  is  exhibited  in  the  extreme  lordosis  of  some'  rachitic 
jM'lves  and  of  the  osteomalacic  pelvis,  also  in  himbo-sacral  kyphosis  and  in 
some  cases  of  dorso-hunbar  kypiiosis. 

The  external  })aIpation  of  the  pelvis  reveals  its  decreased  inclination.  A 
measurement  of  the  pelvis  will  show  a  marked  diminntion  in  the  external 
conjugate  diameter,  an  increased  height  in  tiie  symj)hysis  pubis,  an  increased 
ilistancft  between  the  posterior  superior  iliac  spines,  and  a  diminished  distance 
between  the  anterior  iliac  spines  and  the  crests.  There  is  also  some  diminu- 
tion ill  the  diameters  of  tli(>  outlit.  The  internal  conjngat*'  diameter  must 
be  measured  I'rom  the  lumbar  vertebra  nearest  the  symphysis  pubis — usually 
the  fourth.  This  is  called  the  "  false"  or  "elTcctive"  coii)ugate  diameter  of 
the  spondylolisthetic!  pelvis.  On  account  of  the  decreased  inclination  of  tiic 
pelvis  it  is  not  necessary  to  subtract  more  than  the  ordinary  sum  from  the 
diagonal  conjugate.  In  liict,  tlu;  diagonal  conjugate  may  approach  very  neaily 
the  length  of  tli(>  true,  or  may  actually  measure  less  than  it. 

Jiijfitcticc  iijxiii  Ij(l)t)i\ — The  iulliience  of  a  spondylolisthetic  pelvis  upon 
lal)or  is  that  of  a  fiat  pelvis.  The  obstruction  in  the  former  may  be  over<'(iine 
iuor(>  easily  mi  account  of  the  l)ow-Iike  shape  of  the  projecting  vertebra  and 
tiie  coincidence  of  the  uterine  and  ]»elvic  axes.  The  obstruction  to  labor 
depends  entirely  upon  the  ]>rojectiou  of  the  liuubar  vertebra".  This  projec- 
tion may  be  so  slight  as  scarcely  to  intluence  the  progress  at  all,  or  it  may  be 
so  great  as  to  make  delivery  by  the  natural  channel  (piite  im])ossible.  There  is 
noticed  in  labor  something  of  the  same  mechanism  that  is  seen  in  the  flat 
pelvis  llir  the  purpose  of  overcoming  the  obstruction — namely,  deerea.-ed 
flexion,  transverse  position,  and  exaggerated  lateral  inclination  of  the  head. 
<  )n  account  of  the  forward  dislocation  of  the  external  genitalia  aiul  of  the 
jM'Ivic  floor,  lacerations  of  the  latter  are  the  rule,  and  the  tears  arc  often  com- 
plete into  the  r(>ctum.  This  liability  to  injury  is  explained  by  the  fact  that 
the  presenting  ])art  impinges  directly  upon  the  middle  of  the  pelvic  floor  as 
it  <lescends  the  l)irtli-canal.  instead  of  being  directed  forward  to  the  vnlv."r 
orifice.     Fistuhe  of  the  anti'rior  vaginal    \all  are  likewise  eoiiimon,  fV"M  tli 


r)YST()('IA. 


Pl.ATF.  ^4. 


1.  ("niitri\rti'i\  uiitU't  of  ii  kypliotic  iiclvis  (HiirlHnin.  J,  Kyplintlc  luMvis  I'rniu  iilmvc  i  Hiirliiiiiri.  ;!,  I. 
I.iiniliiisiicral  kyplidsis  iprlvis  (ililectiii.  ■<.  AsyiiiiiU'ti'ii'iil  (.•inilriirtii'ii  "f  ilu'  nulht  Irciin  ky|iliosi(.linsis. 
tl-N.  'I'yiH's  iif  scnlliitic  nicliitii'  pflvi's. 


.*?/      ••» 


}pm.  ■]< 


ii  h.f  ■       '-'  '■.     ■  *   ,   " 

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1 
H    1 


DYSTOCIA. 


537 


localized  pressure  to  which  this  region  is  subjected  while  the  head  is  passing 
the  obstruction  at  the  inlet.  The  presenting  part  is  thrown  forward  by  the 
])rojccting  vertebne,  and  is  received  upon  the  prominent  ridge  of  the  pubic 
l»(tne,  greater  in  height  an<l  higiier  in  situation  than  in  the  normal  pelvis. 

Tiratmcnt  of  Labor  Ohdrui-fcd  by  SjtoniIi//o/iiitli<'fii'  Pclris. — The  maiiage- 
meiit  of  hibor  in  these  cases  is  governed  by  the  same  principles  that  obtain  in 
the  management  of  labor  in  a  fiat  pelvis.  If  the  effective 
conjugate  is  over  9.5  centimeters,  the  woman  can  be  deliv- 
ered spontaneously,  by  forceps,  or  by  version.  With  an 
effective  conjugate  of  between  7  and  9.5  continieters  the 
induction  of  premature  labor  and  the  performance  of  sym- 
])livsiotomy  must  be  considered  ;  or  craniotomy  should  be 
(lone  if  the  child  is  dead.  If  the  effective  conjugate  is 
well  under  7  centimeters,  delivery  must  be  effect'd  by  a 
Cesarean  section.  These  rules  presuppose,  of  course,  a 
child  of  average  size. 

Kyphosis. — The  ky|>hotic  pelvis  was  first  adequately 
described  in  18G5  by  Breisky,  although  its  ju'culiarities 
had  been  recognized  before  by  [jitzmann  iri  1861  and  by 
Neugebauer  in  1863.  The  condition  was  called  by  Herr- 
gott  "  s]iondyl-izema,"  a  name  adopted  by  Neugebauer  and 
others  (Fig.  331  ;  PI.  34,  Figs.  1,  2). 

Characteristics. — The  degree  of  deformity  in  a  kyphotic 
j)('lvis  depends  upon  the  situatiim  of  the  hump:  the  nearer 
this  is  to  the  sacrum,  as  a  ru\o,  the  greater  is  the  deformity 
in  the  pelvis.  Ordinarily  the  kyphosis  will  be  near  the 
(lorso-luiid)ar  junction.  There  is  a  compensating  lordosis 
of  the  lumbar  spine,  but  not  enough  to'  keep  the  centre  of 
gravity  of  the  tnnik  from  being  too  far  forward.  In  con- 
s('(pience  the  weight  of  the  trunk  is  transmitted  in  a  direc- 
tion from  before  backward,  so  that  the  sacrum  is  rotated 
on  its  transverse  axis  in  a  direction  the  reverse  of  that  seen 
in  rachitis — namely,  backward  and  downward.  The  result 
of  this  movement  is  to  Uiake  the  sacrum  straighter,  narrower,  more  curved  from 
side  to  side,  and  longer  (1*1.  34,  Fig.  2),  to  jndl  the  posterior  superior  spinous 
processes  of  the  iliac  bones  closer  togetlu^r,  and  to  separate  the  anterior  spines 
more  wide'  The  diminished  width  l)etween  the  posterior  superior  spinous 
])rocesses  is  caused  partly  by  the  pull  of  the  sacro-iliac;  ligaments.  The  sacrum 
cannot  move  in  any  directi(m  without  dragging  the  ilium  on  each  side  by 
these  ligaments,  thus  approximating  their  up])er  pitsterior  surface's.  It  depends 
also  upon  the  narrowness  of  the  sacrum.  To  compensate  for  the  movenuMit 
of  the  upj)er  portion  of  the  sacrum  backward,  the  lower  portion  of  the  bone 
|)rojects  forward  into  the  pelvic  outlet.  To  preserve  the  bo«ly  from  falling 
forward,  the  knees  and  thighs  are  slightly  flexed  and  tiie  pelvic  inclination  is 
almost  entirely  lost.     This  posture  puts  on  a  stretch  the  ilio-femoral   liga- 


K|(i.  :i;il.— Kypliosis; 
(iri'iiti'st  tniiisviTsc  di- 
aiiU'tiT  lit  outli't,  7  cm. 
(MiittiT  Museum,  <'iil- 
Iffrc  of  I'hysicimis, 
I'liiliiili'lpliiiil. 


I 


I  ! 


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AMERICAN   TEXT-BOOK   OE   OBSTETRICS. 


iiK'nt.-',  whicli  pull  oiitwanl  the  upper  portions  of  the  innominate  bones.  To 
for.iponsate  for  the  movement  outward  of  the  iliae  bones,  the  lower  segments 
of  the  innominate  bones  move  iin  -ard  upon  the  pelvic  inlet ;  in  other  words, 


/i'/d/  /wad 

Spini'  (*/  Isc/nttm. 
hchiutit . 


Kiii.  ;a2.— Uiiiil  iir"''stf(l  tiy  spiius  nf  iscliia  in  a  kyphotic  \iv\\  s  (Hurtiii). 

there  is  a  rotation  of  the  innominate  bones  upon  their  iiLtero-jiosterior  axes. 
The  result  of  these  movements  in  the  pelvic  bones  is  to  enlarge  somewhat  the 
pelvic  inlet,  espeer.ily  in  its  antero-posterior  diameter,  but  to  contract  the 


h\tal  I'u'iii/. 


Intersfthwus 


liiantt'lt-y- 


■-^ ^-' 


Fiii.  :i;;;!.— ViTtlcHl  soction  rif  kyiihotio  ja'lvis,  slidwiiin  \\w  licaii  nrrcstod  liy  the  pjiini's  (if  tlic  iscliia 

(Itiiilin). 

canal  toward    the   outlet,   where  the  diminution   of  the   diameters    is  most 
marked,  especijdly   in  the  transverse  (I'l.  34,  Fig.  1). 

In  the  rare  cases  of  lumbo-sacral  kyphosis  the  upper  portion  of  the  sacral 
bone  may  be  involved  in  the  necrotic  process,  and  the  sacrum  may  exhibit 
deformities  by  destruction  of  its  tissues  (PI.  34,  Figs.  3,  4).  The  other  cha- 
racteristic deformities  of  the  kyphotic  ])elvis  are  most  marked  in  this  type, 
unless,  as  in  one  instance,  the  boily  is  bent  almost  double,  and   it  is  necessary 


■     11  .  I 


u 


ones.  Tu 
r  sogiuciits 
lier  words, 


terior  axes, 
newliat  the 
[)iitract  the 


if  the  isrliia 

:'S    is   incst 

the  sacral 
lay  exhibit 
other  eha- 

this  type, 
^  necessarv 


DYSTOCIA. 


I'l.ATK   3"). 


1.  I.uxiitioii  111"  rijjlit  ('(■iimr.  2.  ('miixfiiitiil  liixiilinn  nt' Imih  I'finuru.  H.  l-uxatiim  i if  left  ffiiuir  mi  ddr- 
sum  iif  iliiiui,  with  liilsc  joint  iilmvi'  iicrliilnihim.  I.  ('niiticiiiliil  hixiilimi  nf  hdth  Irnioni  tiihiitii^'niph  nf 
UKiiU'll.  .').  t'dXiilKii'  pi'lvis  I  Miltlcr  Miisnim,  t'ollocf  "''  l'lijsiciiin>.  riiiliuli'lpliiii).  li.  Aiiti'iidi-  ili>lo(iiti(m  nf 
fi'innr.   7.  Coiigoiiitiil  dislociitioii  of  the  fciuurii.    S.  IVlvic  ilcl'oniiity,  Iho  r'jsult  uf  ilouhk'  I'Uib-tout  (Mi'.viT). 


ft*- 


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w 

;  ■  i ; 

w''  ' 

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ffijji; 

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sii 

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DYSTOCIA. 


;■):«» 


to  rest  the  anterior  portion  npon  an  artificial  snpport,  as  a  cane.  In  this  case 
tiie  pelvis,  althongh  relieved  of  the  weight  of  the  trunk,  is  obstructed  by  the 
overhanging  Inrnbar  vertebraj  to  such  a  degree  perhaj>s  that  the  inlet  is  practi- 
cally obliterated  (pelvis  obtecta).  In  all  cases  except  the  slightest  of  lurabo- 
.^acral  kyphosis  the  projecting  lumbar  spine  blocks  the  pelvic  inlet  and  seriously 
obstructs  labor.  In  21  labors  complicated  by  this  deformity  of  the  j)elvis  (JG 
per  cent,  of  the  mothers  and  75  per  cent,  of  the  children  were  lost  (Winckel). 

Influence  on  Labor.— TXw  influence  of  the  kyphotic  pelvis  upon  labor  is 
usually  not  felt  until  tiio  presenting  part  has  descended  to  tiie  pelvic  floor. 
In  consequence  of  the  shortened  perpendicular  diameter  of  the  abdominal 
cavity  there  is  a  tenilency  always  to  transverse  position  of  the  fetus  in  utero, 
but  this  position  is  ordinarily  corrected  by  the  first  few  labor-pains.  When 
the  head  arrives  at  the  pelvic  floor,  if  the  occiput  is  directed  backward,  anterior 
rotation  will  very  likely  be  prevented  and  there  v.'ill  be  a  persistent  posterior 
position.  If  the  occiput  is  directed  anteriorly,  the  transverse  diameter  of  the 
head  may  be  caught  between  the  approximated  tul)erosities  of  the  ischiac  bones, 
and  labor  be  brought  to  an  indefinite  standstill  (Figs.  332,  333).  Occasionally 
spontaneous  delivery  is  possible  on  account  of  the  extreme  mobility  of  the  pel- 
vic joints  in  the  kyphotic  pelvis;  in  any  case,  as  the  progreas  of  the  head  is 
retarded  only  when  it  reaches  the  pelvic  ontlet,  the  labor  ordinarily  is  easily 
managed.  The  application  of  forceps  may  be  sufficient  to  overcome  the  obstruc- 
tion, but  if  it  is  not,  a  symphysiotomy  will  pretty  surely  do  so  unless  the  con- 
traction is  extreme  or  asymmetrical.  Should  the  child  be  dead,  craniotomy  is 
readily  performed  with  the  head  so  accessible  as  it  is  on  the  pelvic  floor. 

DiagtiOKiii. — The  diagnosis  of  a  kyphotic  pelvis  presents  no  difficulties. 
The  hump-back  is  obvious,  and  the  history  is  easily  obtained  that  the  spinal 
deformity  was  developed  early  in  life.  The  pelvic  measurements  diagnostic 
of  this  deformity  show  an  increased  separation  of  the  iliac  crests  and  the  ante- 
rior spines,  a  diminished  distance  between  the  posterior  superior  spines,  an 
approximation  of  the  tuberosities  of  the  ischiac  bones,  and  some  diminution 
in  the  antero-posterior  diameter  of  the  pelvic  outlet.  Care  should  always  be 
exercised  to  detect  asymmetry  in  these  pelves,  to  discover  an  arrested  develop- 
ment with  general  contraction,  and  to  diagnosticate  lateral  contraction  at  the 
pelvic  inlet.  These  complicating  deformities  constitute  often  insuperable 
obstacles  in  labor. 

Frequency. — The  kyphotic  pelvis  is  said  to  be  somewhat  infrequent,  but  the 
practitioner  in  active  practice  will  surely  encounter  several  examj)les  in  the 
course  of  his  career.  The  writer  has  had  under  his  care  four  well-marked 
cases  of  kyphotic  pelvis,  in  one  of  which  Cesarean  section  was  necessary. 
In  the  other  three  delivery  was  spontaneous. 

Scoliosis. — In  the  scoliotic  pelvis  there  is  some  degree  of  oblique  contrac- 
tion. The  innominate  bone  toward  which  the  lumbar  vertebra  arc  bent, 
receiving  the  greater  part  of  the  weight  of  the  trnnk,  is  pushed  upward, 
inward,  and  backward  by  the  extra  ]>ressure  exerted  npon  it  by  the  head  of 
the  femur.     The  acetabulum  on  this  side  is  displaced  anteriorly  and  upward ; 


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tho  syinpliysis  is  ])nsli('(I  over  on  tli(>  opposite  side.  Tlio  dcfrrcf  of  asyniinotrv 
is  nirt'ly  stillicieiit  to  constitute  an  ol)strnetion  in  laltor.  The  scoliotic  pdvi- 
is,  however,  most  often  rachitic,  and  in  addition  to  tlie  asymmetry  of  scoliosis 
there  may  he  the  contraction  of  a  racliitic  pelvis  (IM.  .'54,  Ki;;s.  6-S). 

•  — —   •;  -        ,  -  ~       -  ;         Kyphoscoliosis. — In  a   combination 

i  of  kyphosis  and  scoliosis  of  tho  spinal 

colnmn  tiie  pelvis  will  show,  pcrhap-, 
the  cond)ined  featnres  of  both,  hnt  thi' 
kyphosis,  heinj;  of  rachitic,  not  of  carious 
orij::in,  will  not  he  antrnlar,  and  will  lie 
situated  hiirh  in  the  dorsal  rojiion,  where 
it  may  he  compensated  for  entirely  l>v 
Ininhar  lordosis  (Fij;.  3.")4  ;  1*1.  .'5(),  Fi^. 
1).  Tho  kyphoscoliotic  pelvis  is  nsuallv 
an  asynnnetrically-contractod  rachitic  jk'I- 
vis(iM.  35,  Fijr.l). 

Lordosis. — Primary  lonlosis,  not  the 
rostdt  of  pelvic  deformity  or  of  spinal 
disease,  is  very  rare.  Aside  from  some 
illustrations  ^f  it  in  an  article  by  Xeu- 
ijobanor  (/oc.  e/V.),  the  writer  knows  of 
no  reference  to  the  subject  except  his 
own  (Fl.  36,  Fij;.  '1]}^  ft  may  readily 
1)0  seen  what  an  influence  this  deformity 
would  have  upon  coition  and  ])artnrition, 
and  how  it  mii;Iit  bo  an  insu])orable 
obstacle  to  natural  completion  of  the 
latter. 

Anomalies  due  to  Diseases  of  the 
Subjacent  Skeleton  :    Coxalgia. — The 
deformity  of  the  jtelvis  due  to  coxaliiia 
in  early  childhood  is  of  two  tyj)os.     In 
one  there  is  an  oblicjuc  contraction  by  a 
dis))laceinent  of  the  innominate  bone  on 
the  hc'.thy  side  U])ward,  backward,  and 
inward,  on  account  of  the  i)ressiu'e  of  the 
femur,  the  weiixht  of  tho  body  boinu-  re- 
ceived mainly  ujwn  the  sound  leji.     This 
form  of  coxalgic  pelvis,  as  a  rule,  pre- 
sents   no    serious    obstacle    to    delivery 
unless    it    is    associate*!   with    a    rachitic 
dei'ormity  (PI.  35,  Fiu". ');  IM.  3<),  Fi<r.  3).     Special  attention,  however,  should 
always  be  paid  to  the  leuixth  of  the  conjuiiate  diameter  of  the  inlet  and  to  the 
transverse  diameter  of  tho  outlet.      In  tho  other  variety  of  coxaliric  ju'lvis  the 
deformity  is  also  an  obli(iuo  contraction,  but  it  is  the  bono  on  the  diseased  side 


Kii;.  :'.;!t.— Ky|ili(iscciliipsis  i  I.rdimliii 


DYSTOCIA. 


Pl.ATK   3rt. 


1.  I-iimhn-dorsnl  kyphoscoliosis (Sclinutn).  2.  Lordosis  from  imrnlysis  of  s]>iiii\1  muscles  illirst).  ;>.  Skil- 
cton  of  11  \!\r\  with  coxiiljiiii  iMiMlicnl  Muscmn,  t'liiver.sity  of  l'fiiii~ylvuiii;ii.  1.  liriii-  viru.  ■"•.  Siiir  view, 
of  lui  (il]lii|iicly-c(iiilnicti'rl  pelvis,  Hk'  resiill  nf  tiiliereilliius  UjsvU.H.'  ill  ulie  knee  jniut  illiist).  (i.  Seiiliosis 
frcini  uiiiliitenil  Mti'npliy  nf  Ihe  spiiiiil  iiiusele.s  (Hirst). 


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DYSTOCIA. 


641 


wliicli  is  (Irivci)  inwnni  upon  the  pelvic  canal.  Tlii.s  (lisplaeonietit  of  the 
iiiiioiiiinatc  boiif  is  tlic  result  of  an  arrested  (levelnpment  on  the  correspond- 
iiiir  side  of  the  pelvis,  and  is  very  likely  associated  with  an  atrophy  of  tiie 
siiTuI  alii  and  an  ankylosis  (tf  the  saero-iliac!  j(iint.  The  contraction  of  the 
pelvic  <'anal  is  nuieh  more  serious  in  this  form,  and  there  may  be  all  the 
ditliciilties  in   labor  onconntercd  in  the  true  \ae>;ele  pelvic. 

Luxation  of  the  Femora. —  Dislocation  of  the  thi<;h-bones,  if  congenital 
or  oeciirrint;  early  in  childlinod  and  n<»t  corrected,  has  some  elfect  npon  the 
hize  and  shape  of  the  pelvis,  bnt  usnally  not  onoiifjh  serionslv  to  oi)strnct 
lalior.     If  t»ne  tliijjjh    is  dislocated,  the  weight  of  the  IxMly  may   be  thrown 


r— - 


I'Ki. ;!;!.').  — CimKenitiil  liixiitinii 
111'  liiitli  I'l'miini :  c,  crest  of  ilium ; 
F,  tnicliiintur  of  ft'inur  (Henry). 


Kid.  ;!;!fi.— ( 'use  of  t'onRenltal  lii.\iitioii  of  tliu  foinorii. 


maiidy  njmn  the  other  leg,  and  this  may  prodnce  an  oblique  contraction  of  the 
pelvis  of  the  kind  already  described  (PI.  34,  Fig.  (j).  If  the  thigh-bone  i.s 
displaced  forward,  the  anterior  half  of  the  pelvis  may  be  driven  in  a  little 
npon  the  pelvic  canal,  and  the  head  of  the  thigh-bone,  as  in  one  case  re])ortc(l, 
may  project  over  the  horizontal  ramus  of  the  pubis  into  the  pelvic  iidct{  1*1.. 'Jo, 
Fig.  G).  In  the  congenital  lu.xatiou  of  both  femora  backward  npon  the  iliac 
boiics  there  is  an  exces.sive  rotation  forward  of  the  sacrum,  an  increased  width 
of  the  pelvic  canal,  and  from  tlu;  drag  of  the  attached  nni.scles  and  ligaments 
between  the  thighs  and  the  pelvis  the  ischiac  tuberosities  are  ])ulle<l  outward, 
upward,  and  backward,  so  that  the  pelvic  canal  is  made  shallow  and  its  outlet 
very  wide.     The  heads  of  the  lemora  move  up  antl  down  on  the  iliu  when  the 


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642 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


patient  walks,  and  the  distanoo  between  the  lower  edge  of  the  symphvsis 
and  the  inner  <jondvle.s  of  the  femora  i.  shortenetl  (Figs.  335-337;  PI  ;]:, 
Figs.  2-4,  7).  " 

In  the  absence  of  one  lower  extremity  the  pelvis  may  be  contracted 
obliquely  to  a  serious  degree,  as  in  La  Chapelle's  case,*  by  the  pressure  on 
one  side  of  the  remaining  leg.  Any  condition  which  throws  the  weight  of  tli(> 
body  mainly  on  one  leg  may  produce  the  same  effect,  as  is  shown  in  a  case  of 
the  writer's  (PI.  36,  Figs.  4,  5),  in  which  there  was  tuberculous  disease  of  a 
knee-joiiit  early  in  infancy,  followed 
by  marked  shortening  and  atroj)hy  of 
the  leg.  The  weight  of  the  body  fall- 
ing maiidy  on  the  sound  leg,  the  cor- 
responding innominate  bone  is  pushed 
upward,  backward,  and  inward,  dimin- 
ishing the  area  of  intrapelvic  space  on 


Fl(i.  :i:)7.— Alilfcld's  (iisi'  uf  luxatioii  nf  Imtli 
fcmorii. 


Flc.  ":w.— l.uxiitiiiii  unci  )uiriily>i.s  of  the  ri^ilil 
lower  liml)  (Wiiii'ki'l). 


its  own  side  (Fig.  33S).  Torggler  reports  an  interesting  case  i>f  this  kind  in 
which  the  disability  of  one  leg  was  due  to  scleroderma.'^  Iji  the  absence  of 
both  lower  extremities  there  is  the  characteristic  "  sitz-pelvis,"  in  which  tlio 
innominate  bones  are  usually  rotated  on  an  antero-posterior  axis,  so  that  the 
crests  of  the  ilia  are  aj^proximated  and  the  tuberosities  of  the  ischia  are  sepa- 
rated. Minor  deformities  of  little  ])ractical  importance  may  be  the  result  of 
unilateral  or  bilateral  chd)-foot  or  of  the  bowing  of  one  or  both  lower  extrciu- 
itios.  In  the  former  there  is  an  increased  inclination  of  the  pelvis,  an  approxi- 
mation of  the  acetabula  and  of  the  ischiac  tuberosities,  and  a  narrow  pubic 
arch  (PI.  35,  Fig.  8). 

*  Pratique  des  Accouchemenia,  iii.  p.  413;  according  to  .Scliauta,  the  only  case  on  record. 


DYSTOCIA. 


54;^ 


.).  The  Management  of  Labor  Obstructed  by  the  Commonest  Forms 
OF  Contracted  Pelvis  :  a  Simple  Flat,  a  Rachitic  Flat,  and 
A  Generally-contracted  Pelvis. 

There  is  no  situation  in  medicine  where  experience  and  good  judgment 
count  for  more  than  in  the  management  of  labor  obstructed  by  a  contracted 
pelvis.  It  is  extreniely  difficult  to  formulate  hard-and-fast  rules  for  tiie 
('•nidance  of  the  inexperienced  where  so  many  factors  must  be  taken  into 
account.  The  rules  given  below  govern  the  writer's  practice  in  the  average 
case,  but  due  attention  must  be  i)aid  to  the  history  of  past  labors,  the  size  of 
the  child,  the  age  of  the  woman,  the  build  of  both  parents,  and  the  probable 
strength  of  the  expulsive  forces,  greatest  in  the  primipara  and  less  with 
successive  labors. 

If  tlie  diagnosis  of  a  conjugate  diameter  of  9.5  centimeters  or  less  is  made 
(luring  pregnancy,  the  physician  must  choose  either  inui.ction  of  premature 
labor,  or  forceps,  version,  symphysiotomy,  or  Cesarean  section  at  term.  If  the 
conjugate  diameter  measures  as  low  as  9.5 centimeters,  it  is  a  safe  plan  to  induce 
labor  four  weeks  before  the  expected  termination  of  i)rcgnancy.  This  entails 
no  additional  risk  upon  the  child  if  its  parents  are  in  a  jiosition  to  afford  it  the 
best  care  and  nursing,  and  it  is  much  the  safest  plan  for  the  mother,  the  induc- 
tion of  labor,  done  properly,  having  no  maternal  mortality.*  It  is  true  that 
many  women  with  a  conjugate  of  9.5 centimeters  can  deliver  themselves  with- 
out difficulty  at  term.  Spontaneous  delivery  with  a  measurement  as  low  as  8 
centimeters  and  under  has  been  recorded.  But  the  majority  of  women  with 
a  conjugate  of  9.5  centimeters  will  experience  abnormal  delay  and  difficulty  in 
labor,  with  added  risk  to  themselves  and  to  tiieir  children;  and  in  a  certain 
proportion  oi' cases  a  conjugate  of  9.5 centimeters  proves  an  insuperable  obstruc- 
tion in  labor,  and  is  the  cause  of  ru])tured  uterus  or  death  from  exhaustion 
in  the  mother  or  of  injin-y  to  the  child's  brain.  These  results  aii.  t<»  be  feared 
especially  if  the  child  is  overgrown  or  if  the  mother's  expulsive  powers  are 
weak — two  conditions  impossible  to  predict  with  absolute  certainty.  For 
these  reasons,  then,  the  rule  to  induce  premature  labor  when  the  conjugate  is 
at  or  below  9.5  centimeters  is  a  safe  one.  If  the  conjugate  measures  8  centime- 
ters or  under,  the  most  successful  treatment  is  the  induction  of  premature  labor 
at  the  thirty-sixth  week,  and  then,  if  necessary,  the  performance  of  svm- 
])liysiot()my  when  it  appears  that  natural  forces,  aided,  perhaps,  by  forceps,  are 
not  sufficient  to  secure  the  engagement  of  the  head.  By  this  plan  the  majority 
of  women  with  a  conjugate  of  8  centimctci's  or  a  trifle  less  will  be  delivered 
spontaneously  or  with  no  more  serious  o|)eration  than  the  application  of  forceps. 
The  conil)ination  of  prematin-e  labor  and  symphysiotomy  will  usually  be  suc- 
cessful with  a  conjugate  diameter  at  or  above G. 5  centimeters.  If  the  conjugate 
measures  7.5  centimeters  or  less,  the  induction  of  premature  labor  four  weeks 
before  term  cannot  be  exjiec^ted  of  itself  to  secure  a  spontaneous  delivery. 
Symphysiotomy  also  will  be  required  in  the  majority  of  instances.     \n  such 

*Tlii8  statement  is  based  upon  tlio  writer's  exptirieiice  in  private  pnict ice,  and  not  upon 
hospital  statistics.     It  does  not  liold  good  for  labors  induced  before  tlie  tiiirly-sixtli  weelt. 


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544 


AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


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cases,  therefore,  tlie  operator  may  wait  until  term  before  he  operates.  But  it 
the  ohiUl  may  exj)ect  good  care,  the  writer  prefers  tlie  induction  of  prematuK; 
hibor  in  addition  to  tlie  symphysiotomy,  for  the  following  reasons :  The 
extraction  of  the  child  after  the  division  of  the  symphysis  will  be  easier, 
quicker,  and  attended  with  less  risk  to  the  maternal  soft  structures ;  the  i)o.ssi- 
bility  of  an  overgrown  child  and  of  a  failure  to  extract  it  after  the  symphysis 
is  divided  is  avoided  ;  and  by  inducing  labor  the  operator  may  set  the  time  iw 
the  operation,  and  may  consequently  make  his  preparations  without  hurry  or 
inconvenience.  With  a  conjugate  diameter  of  the  superior  strait  below  (J.o 
centimeters  the  woman  should  be  allowetl  to  go  to  term  and  shoidd  be  deliv- 
ered by  Cesarean  section. 

If  the  physician  sees  the  patient  for  the  first  time  in  labor,  or  only 
discovers  the  deformity  after  labor  has  begun,  he  must  choose  out'  tlic 
following  modes  of  delivery  :  A  waiting  policy  to  allow  the  cngaj,oU!ent 
of  the  head  by  natural  forces ;  the  a[)plication  of  forceps ;  the  performance 
of  version;  symj)hysiotomy  ;  or  Cesarean  section.  So  long  as  the  child  is 
alive  craniotomy  shoidd  not  be  considered.  The  selection  of  the  best  mode 
of  delivery  in  contracted  pelves  is  one  of  the  most  difficult  problems  in 
obstetrics.  If  the  patient  is  a  primipara  and  the  conjugate  is  above  9  centi- 
meters, natural  ibrces  will  in  the  majority  of  cases,  provided  the  child  be  not 
overgrown,  secure  the  engagement  of  the  head,*  although  it  may  be  by  the 
expenditure  of  considerable  force,  after  long  delay,  and  oidy  after  prolonged 
moulding  and  an  adaptation  of  the  size  of  the  head  to  the  size  of  the  con- 
tracted inlet  by  apparent  anomalies  in  the  position  and  flexion  of  the  former. 
It  is  wonderfid  liow  successfully  an  obstruction  may  be  overcome  even  in  cases 
of  contracted  ju'ivcs  with  a  conjugate  of  8  centimeters  or  less.  But  while 
waiting  for  spontaneous  <lclivery  the  physician  may  see  the  uterus  suddenly 
rui)ture  or  may  lind  the  child's  head  after  birth  seriously  injured.  It  is 
permissible  in  most  cases  to  wait  for  the  full,  or  almost  full,  dilatation 
of  the  OS,  keeping  careful  watch  upon  the  woman's  pulse,  temperature,  and 
general  condition,  pooh  the  situation  of  the  contraction-ring  and  the  disten- 
tion of  th(!  lower  ..ierine  segment,  and  taking  whatever  operative  measures 
may  be  require<l  in  plenty  of  time  to  forestall  the  possibility  of  uterine  rup- 
ture. The  application  of  forceps  to  the  head  above  the  superior  strait  for  the 
purpose  of  securing  its  engagement  by  forcil)le  traction  should  in  general  be 
condemned,  but  it  nnist  l)e  admitted  that  there  are  important  exceptions  to 
this  ride.  If  one  is  skilled  in  the  application  of  the  forceps,  bears  in  mind 
tilt'  transverse  position  of  the  liead,  and  can  gauge  the  degree  of  traction 
which   may  be  exerted  without  injury  to  the  child's  skull  or  to  the  maternal 

*  From  IHSl  to  1,SH7  there  was  sjiontdiicoiis  dflivery  in  one  hundred  nnd  sixty  three  out  of 
444  eiises  of  eontraeted  pelvis  in  the  N'ieinm  Hospitiil,  and  in  forty-seven  women  the  coiijuKnte 
was  not  alxive  S.")  eentimeters  ( Hrinni  n.  Iler/fehl,  l>i'r  KaiacmchniU  it.  seine  Stdhini/  zur  kinittt- 
lirlii'ii  Friihiji'lmrl,  Wi'iiihutij,  iihijiiKrhin  /iDiiiiiiiiiirrdlioiirn,  KraiiiitUnnir  l)fi  ii.  zu  deti  nininldinii 
(lihurli'H,  Wien,  ISSS,  ii.  p.  144).  In  the  Musrow  Maternity  there  were  84  eontraeted  iielves 
anion^r  40(10  hirtiis  in  lsi)4,  71  per  eent.  of  these  ciises  were  spontaneously  delivered  iKiister, 
Vaifntlhl. /.  (,'yii.,  No.  10,  ISflo). 


1     t 


DYSTOCIA. 


545 


soft  structures,  he  will  occasionally  succcctl  in  securing  an  engagement  with 
the  instrument  that  would  otherwise,  perhaps,  be  impossible.  As  a  rule,  how- 
over,  it  is  safe  to  say  that  the  choice  lies  between  inaction  and  the  performance 
of  version.  By  the  latter  operation  the  smaller  end  of  the  wedge  represented 
bv  the  child's  head  is  engaged  in  the  contracted  inlet,  and  there  can  be  exerted 
upon  the  head  ciomiug  last,  both  by  traction  on  the  body  from  below  and  by 
in-cssuro  on  the  head  through  the  abdominal  walls  above,  a  degree  of  force 
that  is  impossible  with  forceps.  It  is  well,  however,  to  bear  in  mind  the  dan- 
ixer  entailed  upon  fetal  life  when  version  is  performed  in  a  contracted  pelvis, 
'{'hero  is  a  considerable  risk  *  that  the  head  will  be  retained  long  enough  above 
the  superior  strait,  or  in  it,  to  asphyxiate  the  child  beyond  revival. f  Or  the 
pressure  upon  the  head  by  the  pelvic  walls  may  fracture  the  skull  and  crush  the 
l)rain,  and  the  force  employed  in  extraction  may  break  the  neck.  If  in  the 
judgment  of  the  operator  the  danger  entailed  upon  the  fetus  by  version  is  too 
groat,  natiu'al  forces  having  faileil  to  secure  engagement,  and  if  he  has  tried 
tlic  forceps  cautiously  without  success,  his  choice  nuist  rest  between  symphys- 
iotomy and  Cesarean  section.;):  The  ibrmer  must  be  the  operation  of  election 
if  the  conjugato  is  above  7  centimeters  ;  the  latter,  in  eases  of  greater  contrac- 
tion. These  rules  for  the  treatment  of  labor  obstructed  by  a  contracted  pelvis 
pr('sup])ose,  of  course,  a  fetal  body  and  head  of  average  size.  This  point  must 
always  be  investigated  carefully  by  abdominal  palpation,  although,  it  is  most 
(litHcult  to  determine.  §  If  the  physician  has  reason  to  believe  that  the  child 
is  over-size,  he  must  allow  himself  sufficient  latitude  to  ensure  delivery.  This 
advice  applies  particularly  to  cases  in  which  the  operator  is  in  doubt  whether 
fo  select  syuiphysiotomy  or  Cesarean  section.  \{\  on  the  one  hand,  there  is 
good  reason  to  fear  that  the  child  cannot  with  safety  to  itself  be  extracted 
through  the  birth-canal  after  the  former,  his  choice  should  rest  upon  Cesarean 
section.  On  the  other  iiaud,  if  the  child  is  under-size  (a  condition  easier 
to  detect  by  palpation  than  is  overgrowth),  spontaneous  delivery  may  be 
expected  through  a  pelvis  that  would  not  permit  the  passage  of  a  child  of 
normal  size. 


*Tlie  infantile  deatli-viUe  will  be  at  least  25  per  cent.,  or  more  likely  higher  (Nagel,  "Die 
Wcnihing  bui  engiu  J5e('ken,"  Arch.  f.  iliju.,  I'd.  xxxiv.) 

t  Nagel  reports  60  cases  of  version  for  contracted  pelvis,  with  a  fetal  mortality  of  25  per 
rent.  ^ //)/</.,  J).  KiS.) 

X  Klein  and  Walcher  declare  that  by  raising  the  bnttocks  and  letting  the  liinlis  hang  down 
as  nnieh  as  possible  the  conjnaate  diameter  is  lenglhcncd  by  almost  a  centimeter,  ('linical  tests 
of  the  method  are  described,  attended,  apparently,  witli  snccess  (Zfilarhr.  f.  Oiburh.  n.  Gipi.,  I'd. 
xxi.,  II.  I,  and  .1/if/.  Konrsji.  HI.  (/..s  Wiii-lcmli.  Arrzll.  I'.,  I!d.  Ix.  5).  The  Walcher  postnro  has 
alrciidy  been  endorsed  by  quite  a  number  of  ol)servei's  in  (iermany.  The  plan  i.s  worth  a  trial 
at  least. 

?  The  relative  size  of  bead  and  pelvis  may  be  determined  approximately  by  the  method  of 
Miiller  and  Schatz:  The  fetal  head  is  gras]ied  Itetwcen  the  extended  lingers  of  the  physician, 
and  is  pressed  down  steadily  and  for  some  time  upon  the  pelvic  brim  (see  p.  563 1,  the  direction 
of  the  force  coinciding  with  the  axis  of  the  sii|ierior  strait.  If  this  manenvre  succeeds  in 
pressing  the  head  within  the  pelvis,  then  natural  forces  will  surely  secure  engagement.  If  it 
fails,  the  converse  by  no  means  necessarily  follows. 


It' .  ? 

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AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 


6.  Obstruction  to  Labor  ox  the  Part  of  the  Soft  Maternal 
Structures  in  the  Parturient  Canal. 

Congrenital  Anomalies  of  Development  in  the  Uterus. — A  cloul>le  or 
septate  uterus   may   complicate  labor  in   several  ways.     The   bulk  of  the 


i  i 


M   '1 


I   X    'i 


i.|(r 


Fig.  339.— rterus  septus  (Cruvoilhier). 


Fi(i.  340.— rtcTus  sujitus  ((irouzL'l 


r.  tlilv 


MB  It 


Fig.  341.— rtorus  bicuiiiis  (WiiickL'l). 


Fio.  342.— I'tenis  didclphys. 


Fig.  .343— Vagina  si'pta  (uterus  liiforis). 


unirapregnatetl  half  may  obstruct  delivery,  especially  if  this  half  is  retrovortod 
and  is  increased  considerably  in  size  in  sympathy  with  the  development  of  the 
impregnated  side  and  is  hardened  iu  consistency  by  sympathetic  contracti(ni 


DYSTOCIA. 


547 


tliiring  the  labor-pains.  Tlie  septum  itself  may  prove  an  obstacle  in  labor, 
and  sometimes  labor  is  obstruete<l  by  the  strong  vesico-rectal  ligament  that 
runs  between  the  horns  of  a  bieornate  uterus.  If  the  plaeenta  is  attached  to 
the  septum,  alarming  hemorrhage  may  occur  from  imperfect  contraction  of  the 
sj)arsely-supplied  muscular  fibres  in  it :  malpresentations  and  a  faulty  direction 
and  insufficient  power  of  the  expulsive  force  are  common.  Rupture  of  the 
uterus  is  to  be  feared  on  account  of  the  ill-developed  uterine  walls.  Laceration 
of  the  septum  frequently  occurs.  It  has  been  noted  that  a  decidual  membrane 
mav  be  retained  within  the  non-pregnant  half  of  the  r.terus,  where,  undergoing 
j)utrefaction  after  delivery,  it  may  give  rise  to  septic  infection.  There  seems 
also  to  be  a  disposition  to  the  retention  of  membranes  in  the  pregnant  side  of 
(lu>  womb.  Retention  of  tiie  placenta  is  not  unconunon,  partly  because  of 
insufficient  expulsive  force,  partly  on  account  of  its  situation,  perhaps  attached 
in  both  divisions  of  the  uterine  cavity.  Tlievard"  reports  the  retention  of 
the  i)lacenta  in  a  double  uterus  for  fifty  days,  when  it  was  spontaneously  dis- 
charged. It  has  happened  in  cases  of  double  uterus  and  vagina  that  the 
jiiivsician  examined  the  wrong  side,  an<l  was  ignorant  of  the  progress  of  labor 
until  the  child  was  about  to  be  born  ;  also  that  he  examined  first  one  side  and 
thou  the  other,  finding  first  a  dilated  and  then  a  contracted  external  os. 

In  one  woman  with  a  double  uterus  there  was  noted  a  disposition  to  become 
pregnant  in  regular  alternation  first  on  one  side  and  then  upon  the  other.'* 

Closure  and  Contraction  of  the  Cervix. — The  cervix  may  obstruct  labor 
by  reason  of  atresia,  cicatricial  infiltration,  contraction,  and  rigidity,  or  there 
may  be  longitudinal  or  transverse  septa  in  the  canal.  Atresia  of  the  cervix 
in  a  pregnant  woman  must,  of  course,  be  acquired  after  impregnation  (con- 
ghitinatio  orificii  uteri  externi) ;  it  is  rarely,  however,  complete.  There  is 
always  an  indication  at  least  of  the  external  os  in  a  dimple  evident  to  the  sense 
of  sight,  if  not  to  that  of  touch.  By  pressing  upon  this  point  with  a  finger- 
nail or  with  the  tip  of  a  uterine  sound  a  small  artificial  ojjcning  may  be  made. 
Directly  this  is  secured  the  dilatation  of  the  external  os  proceeds  in  a  remark- 
ably rapid  manner,  although  hours  of  vigorous  labor-pains  before  had  been 
insufficient  to  begin  it.  If  this  plan  fails,  a  crucial  incision  must  be  made  in  the 
cervical  tissues  at  the  site  of  the  external  os.  The  dilatation  of  the  small  open- 
ing thus  made  is  then  left  to  nature.  If  hemorrhage  follows  the  incisions,  the 
bleeding  points  should  be  secured  by  sutures.  An  active  treatment  is  always 
called  for.  Without  it  the  uterus  may  rupture,  the  vaginal  portion  of  the 
cervix  mav  be  torn  oft'  from  the  womb,  or  the  head  '^  mav  emerge  com- 
pletely  covered  by  the  enormously  distended  cervix  as  by  a  caul.  Cicntririal 
contnicfion  or  ivfiUrathm  of  the  cervix  is  the  result  of  old  unrepaired  tears, 
of  operations  upon  the  cervix,  of  cauterization,  of  syphilis,  or  of  cancer.  In 
'  the  first  instance  the  resistance  to  dilatation  is  scarcely  ever  great,  and  what 
there  is  may  be  overcome  almost  always  by  hydrostatic  dilators,  by  the  appli- 
cation of  forcej)s  and  fi)rcible  delivery  of  the  head  through  the  cervical  canal, 
or  by  the  performance  of  version  followed  by  rapid  extraction.  If  the  cica- 
trices are  of  syphilitic  or  of  cancerous  origin,  the  obstruction  is  more  serious. 


mm.  I    f*j<?'5'fi3 


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It  may  bcovortHmie  bv  radiating  incisions  with  scissors  or  with  a  probe-pointed 
bistoury,  )iit  it  is  not  unliUoly  to  demand  the  portbrnianco  of  Cesarean  section. 
Rigidity  of  the  cervix  is  seen  normally  in  all  primipara),  and  to  an  exaj;- 
gerated  degree  in  elderly  primipane.  It  yields  t)ften  to  copious  donches  uC 
warm  water  directed  against  the  anterior  wall  of  the  cervix  and  fnujuentlv 
rep(>ated  —as  often  as  once  every  fifteen  minutes  if  necessary.  Chloral  inter- 
nally and  belladonna  ointment  applied  directly  to  the  cervix  have  been  rocoiii- 
niciided,  but  these  remedies  arc  not  to  be  depended  upon  except  in  the  slight 
rigidity  characteristic  of  all  primipara'.  If  there  is  delay  in  such  cases,  10 
grains  of  chloral  evi'ry  fifteen  miimtes  for  three  doses  may  advantageously  Ix; 
given.  An  anesthetic,  after  all,  is  the  most  valuable  medicinal  agent  that  we 
possess  for  the  relaxation  of"  this  as  well  as  of  other  rigid  tissues.     The  rigid 

cervix  yields  at  length  to  the  steady 
pressure  of  the  presenting  part,  and 
it  is  rarely  necessary  on  account  of 
rigidity  alone  to  resort  to  artificial 
dilatation  or  to  incisions.  In  the 
course  of  a  slow  tlilatation  of  the 
cervical  canal  and  external  os  the 
anterior  lip  of  the  cervix  may  become 
incarcerated  between  the  head  and  the 
])elvic  walls.  In  conseciuence  of  tlu^ 
pressure  and  the  disturbance  of  circu- 
lation in  the  part  the  cervical  tissues 
I'apidly  become  edematous,  and  the 
bulk  of  the  anterior  lip  becomes  so 
great  as  actually  to  <'onstitute  a  me- 
chanical obstruction  to  the  descent  of 
the  head.  It  is  usually  possible  in 
such  cases  to  push  up  the  anterior  lip 
over  the  head  and  above  the  sym- 
physis in  the  intervals  between  the 
pains.  If  there  is  hypertrophy  of 
the  anterior  lip  in  consequence  of  an  old  laceration  and  eversiou,  or,  all  the 
more,  should  there  be  hypertrophy  of  the  whole  infravaginal  portion  of  the 
cervix,  the  obstruction  may  become  (piite  serious,  and  it  may  be  impossible  to 
])ush  the  ci'rvix  above  the  head.  In  such  cases  forcible  traction  on  the  forceps 
or  radiating  incisions  in  the  cervix  may  be  necessary. 

Longitudinal  septa  in  the  cervical  canal  are  usually  seen  with  duplicity  of 
the  uterine  cavity  from  failure  of  the  jMiillerian  duets  to  fuse  completely. 
Occasionally  the  lack  of  fusion  is  confined  to  the  cervical  canal  alone  (uterus 
biforis).  Rarely  transverse  septa  have  been  found  in  the  cervical  canal.*  It 
may  be  necessary  to  cut  these  before  the  child  can  pass  into  the  vagina. 

*  Cases  are  reported  liy  Miiller,  IJreisky,  Budin,  Henry,  Bidder,  and  Bliinc  (Pozzi's  Gyiw- 
eolixjy,  vol.  ii.  p.  •loG). 


Fiii.  oil.— Dimlilc  viiKiiin. 


y 


jzzi's  Gim- 


DYSTOCIA. 


54!) 


Closure  and  Contraction  of  the  V  .gina  or  Vulva. — Tlicrc  may  be 
()l)stnu;tioii  of  the  lower  birth-canal  by  hjiigitiuliiial  and  tran.svcrso  septa,  by 
cicatrieert,  by  heniatoniata,  by  partial  atresia,  especially  at  the  upper  third  of 
liie  vairina,  by  uiiniptured  hymen,  by  amis  va<j;inalis,  by  vajfinal  tumoi-s  and 
(;vsts,  bv  eystie  and  soli«l  tumors  of  tlu^  vulva,  l)y  enlarged  earuueula)  myrti- 
formes,  by  varices,  by  vaginismus,  by  congenital  narrowness  of  the  vagina  and 
vulva,  and  by  rigidity  of  the  tissues,  especially  in  eld(;rly  j)rimipane. 

LoiH/itii(liii(d  and  Traiisvrrne  Septa. — These  uxw  not  ordinarily  v(M'v  dense 
in  structure,  and  they  give  way  commonly  ijefore  the  advanc(M)f  the  presenting 
part.  If  they  do  not  yield,  it  is  easy  to  cut  them  in  one  or  more  places,  the 
liemorrhage  being  controlled,  if  necessary,  by  sutures  afterward,  or  in  the  case 
()[■  transverse  septa  by  a  double  ligature  applied  first,  the  septum  being  out 
between,  though  then^  is  not  much  tendency  to  bleeding  even  in  those  as  thick 
as  one's  finger  (Fig.  .'{45). 

Hcmatomatn. — Hematomata  of  the  parturient  tract  usually  occur  at  the 
vaginal  orifice,  and  most  often  between  the  birth  of  twins.  They  are  con- 
sidered here  oidy  as  mechanical  obstacles  to 
]al)or  (see  p.  680).  If  the  blood-tumor  is 
large  enough  to  constitute  an  obstruction  to 
th(!  escape  of  the  child,  its  walls  must  be 
incised  and  its  contents  be  turned  otit,  and 


Flii.  345.— Transverse  septum  of  the  vatiiim 
(Ileyilor). 


Flfi.aiCi.— Aims  vestibularis:  (lotted  lines  show  the 
limit  of  nnieous  niemlirane;  thieki'neil  skin  marks  the 
normal  site  of  the  an. is  (Diekinson). 


if  heniorrhage  follow  it  nuist  be  checked  by  a  firm  tampon,  preferably  of 
iodoform  gauze,  in  the  cavity  of  the  tumor. 

Exteimvc  cicatrices  in  the  vagina  from  syphilitic,  malignant,  or  other  ulcer- 
ation, or  from  former  injuries,  may  be  stretched  siitficiently  by  hydrostatic 
dilators  or  may  be  severed  by  multiple  incisions,  followed  by  the  application 
of  forcej)s  if  the  head  is  presenting;  but  they  may  be  too  den.'^e  and  extensive 
to  yield  to  the.se  measures,  and  a  Ccsiirean  section  may  be  required. 

Unruptured  Hymen. — An  unruptured  hymen  is  not  neces.sarily  a  bar  to 
conception.  There  are  a  nund)er  of  cases  on  record  in  which  :i  persi.stent 
hymen  with  a  small  orifice  has  ob.«ti*ucted  to  .some  degree  the  e.<cape  of  the 
child's  head  in  labor.     In  two  cases  under  the  writer's  notice  the  advance  of 


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tlio  present iii<;;  part  ruptured  the  liymeneal  inenibrane  without  diftieultv,  but 
it  has  been   found  necessary  by  othjrs  to  incise  it.'" 

Atresia  (if  till'  Vafjina. — This  anomaly  of  developnient  has  its  scat  usualK 
at  the  upper  third  of  the  canal,  where  the  vagina  may  be  contracted  to  a  nar- 
row trat't  barely  ailmittin<>;  the  uterine  probe,  or  the  canal  may  be  obstructed  b\ 
an  annular  membrane  like  the  hymen.  Although  Cesarean  section  has  been 
done  for  thi:<  condition,  the  majority  of  eases  on  record  have  not  re<piired  it. 
The  advance  of  the  presenting  part  has  dilated  the  narrowed  vaginal  canal 
with  little  more  difficulty  than  it  experiences  in  dilating  the  cervical  canal. 
At  the  worst  the  obstruction  should  be  overc<»me  by  digital,  instrumental,  or 
hydro.static  dilatation.  In  complete  or  almost  complete  acquired  atresia  of 
the  lower  portion  of  the  vagina,  in  which  in.scmination  has  taken  place  by 
way  of  a  dilated  nriJthra  and  a  vcsico- vaginal  fistula,  the  imperforate  portion 
of  the  vagina  may  be  opened  by  a  transverse  incision,  the  rectum  and  bladder 
being  guarded  by  a  finger  in  the  one  and  a  sound  in  the  other. 

Anus  V(((jUi((Uh  or  Vvstibular'iK. — This  condition  may  complicate  labor  bv 
the  accumulation  of  feces  in  the  rectum,  due  to  the  unnatural  position  of  the 
anus  (Fig.  -'{46).  In  one  case  in  which  this  anomaly  was  as.soeiated  with  par- 
tial atr(>sia  of  the  vulvar  orifice  it  was  necessary  to  cut  the  perineal  structures 
upward  from  the  rectum  toward  the  pubis  in  order  to  permit  the  escape  of 
the  child's  head. 

Cydio  and  Solid  Tumors  of  the  Vagina  and  Vulva,  Edema,  Suppuration, 
and  Gangrene. — In  the  ease  of  solid  tunior.s  excision  may  be  neees,sary,  by 
transfixing  the  palicle  if  they  have  one,  and  ligating  it  to  prevent  hemorrhage, 
or  by  i.n  incision  of  the  vaginal  wall  over  them  and  their  enucleation,  followed 
by  the  immediate  extraction  of  the  child,  and  the  control  of  hemorrhage  by 
the  needle  and  thread  or  by  direct  pressure.  In  the  case  of  large  cystic 
tumors  a  puncture  is  sufficient  to  remove  the  obstruction,  (iiider"  collected  60 
ca.ses  of  vaginal  tumors  complicating  labor — 23  cysts  and  echinococcus  sacs, 
18  fibroids,  fibromyomata,  and  jwlyps,  14  carcinomata,  1  sarcoma,  and  4  henia- 
tomata.  Delivery  was  accomplished  by  the  following  diverse  methods  :  s])on- 
taneously,  14;  l)y  forcej)s,  18  ;  by  version  and  extraction,  2;  by  traction  on 
the  feet,  1  ;  by  removal  or  puncture  of  the  tumor,  16;  by  Cesarean  section, 
7  ;  by  induction  of  premature  labor  an<l  craniotomy,  2  ;  by  premature  labor, 
3;  by  laparo-elytrotomy,  1  ;  by  craniotomy,  1  ;  by  pushing  back  the  tumor 
and  extracting  the  child  past  it,  2.  Among  the  niothvrs  thcjo  were  15  deaths; 
among  the  children,  13.  In  11  of  the  mothers  and  in  22  of  the  children  the 
result  was  not  reported. 

Kdrma  of  flic  vulra  may  be  the  result  of  kidney  insufficiency  or  of  pressure 
in  a  prolonged  labor.  The  increased  bulk  of  the  dropsical  lal  i'l  may  u'terfcre 
with  the  escape  of  the  presenting  part,  or,  what  is  more  likely  the  edemitons 
tissues  lose  their  elasticity,  obstruct  labor  by  their  rigidity,  and  are  prone  to  Iccp 
tears  at  the  time  of  birth  and  to  gangrene  afterward.  Punctures  or  incisio'is  in 
the  labia  may  be  necessary  to  escape  more  serious  injury,  but  it  is  well  t(>  avcjid 
them  if  possible,  for  they  are  apt  to  be  Ibllowed  by  infi'ction  and  gangrene. 


DYSTOCIA. 


.5.51 


An  abscess  of  liurtliulin's  gluiul  is  seldom  large  enough  to  retard  labor, 
though  it  has  done  so  (Miiller),  bnt  it  is  likely  to  canse  trouble  afterward. 
It  should  be  opened  freely  in  the  early  part  of  the  first  stage  of  labor, 
ciu'etted,  swabbed  out  with  earbolie  aeid  and  glycerin,  and  packed  with  iothj- 
lonn  gau/e. 

(langrene  of  the  vulva  is  very  rare  before  the  termination  of  labor. 
Should  it  exist,  it  might  determine  an  operator  in  favor  of  Cesarean  section 


Fi(i.  ;547.— Kdi-mn  Hiul  bc'Binning  gangrene  of  the  vulvn  from  prolonged  pressure  in  an  obstructed  lubor 

(Hirst). 

in  a  doubtful  case,  on  account  of  the  rigidity  of  the  vulvar  tissues,  the  cer- 
tainty of  laceration,  amK  the  likelihood  of  grave  infection. 

Enlarged  Carimculiv  Myiilformcs  and  Varicoxe  Veins. — These  tumors  do 
not  possess  sufficient  bulk,  as  a  rule,  seriously  to  obstruct  the  last  stage  of 
labor.  They  may,  however,  be  so  bruised 
by  the  j)assage  of  the  head  as  to  slough  after- 
ward, or  the  veins  in  them  may  be  rupturetl, 
giving  rise  to  subcutaneous  or  fraidv  bleed- 
ing of  an  alarming  character. 

VaginisniUH  may  be  overcome  by  an  anes- 
thetic. Congenital  narroxcness  of  the  vagina 
and  vulva  is  usually  overcome  by  the  ad- 
vance of  the  presenting  jiart,  though  often  at 
the  expense  of  vaginal  and  perineal  lacera- 
tions. It  may  be  necessary  to  resort  to 
hydrostatic  dilatation,  or  even,  in  rare  in- 
stances, to  Diihrssen's  plan  of  multij)le  incis- 
i(>ns.  In  the  case  of  extreme  narrowness  of  the  vulva  there  may  be  a  central 
teor  of  the  perineum,  through  which  the  presenting  part  begins  to  emerge.  To 
avoid  a  rectal  tear  in  such  a  case  the  perineum  should  he  cut  from  the  anterior 
border  of  the  perforatiim  to  the  posterior  commissure  of  the  vulva  (Fig.  .348). 

Rigidity  of  the  tissues  in  the  cervix,  the  vaginal  wall,  and  at  the  outlet 


Fl(i.  348.— Central  tear  in  the  peri- 
neum, with  CDtitraetv'il  vulvar  orlliee 
(Ivilieuiiint-Hessaignes). 


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AMKRICAX    TEXT-nOOK    OF    OBSTETRICS. 


ooeasioiis  delay  in  the  majority  of  all  priniipara),  but  especially  in  the  case  of 
elderly  priinipane — those  over  thirty  years  of  age.  Kokluird  found  the 
infantile  mortality  in  such  eases  to  he  19.81  per  cent.,  the  maternal  niortalitv 
to  be  three  times  as  great  as  in  younger  primiparje  ;  and  the  necessity  for 
operative  interference  increases  steadily  with  the  age  of  the  primipane  until, 
in  those  ])ast  forty,  alnjost  two-thirds  are  delivered  by  some  operative  pro- 
cedure, usually  forcejis.  Craniotomy  should  be  done  if  the  child  is  dead. 
A^'ersion  is  the  least  successfid  ojjcration  in  tlii'se  cases. 

Displacements  of  the  Uterus. — The  uterus  in  labor  may  be  displaced 
forward;  to  either  side ;  downward;  or  backward,  by  the  so-called  "saccula- 
tion "  of  the  womb.  It  may  b(!  twisted  on  its  ])etlicle,  the  cervix,  or  it  mav 
form  part  of  the  contents  of  a  hernial  sac  in  inguinal  or  ventral  hernia. 

Anterior  Dkplaccment  of  the  Uterus  in  Labor;  PetuJiUous  Belly, — This  is  a 


Fit;.  :M'J.— Hernia  of  the  t,'riivi(l  womb  through  tlie  liiieii  alba 


common  anomaly  in  labor,  seen  to  some  degree  in  all  cases  of  obstructed  labor, 
as  in  deformed  pelvis,  and  in  all  cases  in  which  the  length  of  the  abdominal 
cavity  is  decreased,  as  in  kyphosis.  A  peculiar  example  of  forward  displace- 
ment is  seen  in  those  rare  instances  of  hernia  of  the  parturient  womb  between 
the  recti  muscles  or  to  one  side  of  the  median  line  during  the  second  stage  of 
labor  (Fig.  345)).  The  pregnant  wond)  may  fall  forward  also  into  an  umbil- 
ical hernia  or  into  a  ventral  hernia  following  celiotomy. 

The  removal  of  the  obstruction  to  labor  in  the  first  class  of  cases  will  or- 
dinarily obviate  the  anterior  displacement.  If  the  displacement  depends  not 
upon  obstruction,  but  upon  flaccid  abdominal  walls,  the  application  of  an 
abdominal  binder  surely  corret^ts  the  anteversion.  In  cases  of  hernia  of  the 
uterus  through  the  anterior  abdominal  wall  artificial  delivery  with  forceps  or 
by  version  may  be  necessary ;  when  the  uterus  is  evacuated  it  can  easily  be 
returned  into  the  abdominal  cavity.     A  tight  abdominal  binder  and  the  dim- 


DYSTOCTA. 


653 


inntion  of  intra-alKlomiiml  pressure  after  delivery  will  proinoto  the  a|>|)r()xima- 
tiou  of  the  .scjiaratod  recti  museles.  In  iiifjninal  hernia  the  pre<;naiit  womb 
in  the  hernial  sac  is  ustially  unicorn  «>r  hicorn  (Fij^.  .".oO).  Delivery  may  ho 
eH'ccted  hv  version,  anil  this  may  he  followed  by  a  reduction  of  the  hernia,  l)ut 
it  is  hest  to  lay  open  the  sac,  incise  the  womb,  extract  its  contents,  and  then 
amputate  it.* 

Lateral  Dlxplacemeni, — A  tilting  of  the  uterus  to  the  right  side  is  a  phys- 
iological occurrence  in  pregnant  and  parturient  woiuen.  The  lateral  inclination 
is  sometimes  exaggerated  to  such  a  degree  that  a  great  ])art  of  the  expulsive 
lurce  is  lost  by  the  propulsion  of  the  ])resenting  part  agan'st  the  lateral  wall 


Fiii.  ;!5(l.— Innuiiiiil  luTiiia  coiitiiiiuiig  a  gniviil 
womb  (Wiiii'kol). 


Flu.  ;i')I.— Saci'ulatinii  of  tlie  uterus 
(Oldham). 


of  the  pelvis.  The  displacement  can  be  corrected  by  turning  the  woman  on 
her  side — usually  the  right — toward  which  the  fundus  uteri  is  inclined,  and 
placing  under  her  flank  a  rolled  blanket  or  a  pillow. 

Sacculation  of  the  Uterux. — A  baiikward  displacement  of  the  gravid  womb 
in  rare  cases  goes  on  to  full  development  by  what  is  called  ''  posterior  saccula- 
tion," the  di.stention  of  the  uterus  to  accommodate  the  full-grown  fetus  being 
accom[»r.shed  by  stretching  the  anterior  uterine  wall,  the  posterior  wall  and  the 
fundus  remaining  fixed  within  the  pelvis  (Fig.  351).  In  these  ca.ses  the  cervix 
is  high  above  the  jielvic  inlet  and  is  pressed  close  against  the  anterior  abdom- 
inal wall,  the  posterior  vaginal  wall  bulges  outward  and  downward,  and  fetal 
parts  can  be  felt  through  it  with  a  distinctness  that  suggests  abdominal  preg- 
nancy. Cesarean  section  has  in  one  instance  at  least  been  performed  on  account 
of  this  anomaly,  but  a  study  of  recorded  cases  .shows  it  to  be  unneces.sarv.  By 
the  artificial  dilatation  of  the  cervical  canal  and  the  perfi)rmance  of  podalic 
version  delivery  can  be  effected  without  difficulty. 

Partial  Prolapse  vith  Hjipertrophic  Elongation  of  the  Cercix. — Tt  is  irapos- 

*  Adams'"'  lias  collected  10  cases  of  ineniiial  hernia  of  the  fri"iviil  wonili,  iiicliiding  Dor- 
ingiiis',  >vhicl)  iie  calls  "trural."  In  eight  Cesarean  section  was  done.  In  one  the  delivery 
was  spontaneous. 


-^l-- 


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564 


AMrJilCAX    Ti:A"r-JiO()h'    or   OliSTKTliirS. 


sil)l<'  for  projiiiaiicv  tn  uroccod  tc  toriii  with  coinplcti'  j)n»Inj)si'  of  the  woiiil), 
although  the  size  of  tlu'  iitcriiic  tiiiuor  projci'tiiij,^  from  th(;  vulva  in  some  cases 


Fi(!.  3')2.— Prolapse  <if  a  double  uterus  In  a  pregnant  woman  (Maygrier). 

has  given  rise  to  a  belief  in  this  possibility  (Fig.  353).  A  careful  examina- 
tion has  always  shown  the  major  portion 
of  the  uterine  body  to  be  within  the 
pelvic  and  abdominal  cavities.  Com- 
monly the  fundus  is  at  a  normal  level, 
and  the  descent  of  the  cervix  has  been 


Ki(i.  S.")!).— I'lirtiiil  prolapse  of  the  wonili  in 
liihor  (Wagner). 


Fl(t.  354.— Partial  prolapse  of  the  wonil)  ami 
hypertrophy  of  the  eervix  (Kaivre). 


accomplished  by  stretching  the  lower  uterine  segment  and   by  hypertroi)hic 
elongation  of  the  cervix  itself.     When  the  contraction  of  the  uterine  muscle 


DYSTOCIA. 


655 


licgiiis  ill  labor  a  partial  prolapse  of  the  womb  i.s  nsnally  spontanoonsly 
corroeted  by  the  rotractinn  of  the  cervix  within  the  vagina.  This  the 
writer  has  seen  in  several  instances.  In  exceptional  cases,  however — usually 
nil  at'count  of  a  rigid  cervix — the  prolapse  beconies  aggravated  or  suddenly 


Km.  I!')"!.— I'lirtliil  prDlnpso  of  \.\w  woinli  iiiul  hy|ii'rtro|ihy  of  the  rcrvix  :  A,  Inteml  position ;  B,  Uoraal 

position  (Kaivrr). 

makes  its  appearance,  and  the  cervical  tissues,  growing  edematous  and  becom- 
ing enormously  swollen,  constitute  by  their  bidk  and  increased  rigidity  a  seri- 
ous obstruction  to  the  delivery  of  the  child.  Tliis  difficulty  was  overcome  in 
an  ingenious  manner  in  a  case  reportcil  by  Faivre.*'     The  woman  was  placed 


Fi(i.  ;&;.— Displacouu'nt  of  tlio  furvix. 

in  the  dorsal  position  across  the  bed,  a  forceps  was  api)lied  to  the  child's  head, 
and  an  assistant,  standing  astride  the  woman's  body,  hooked  his  fingers  into 
the  (  rvix  and  pulled  upward  to  counteract  the  traction  of  the  forceps  upon 
the  child's  head  and  the  incarcerateil  cervical  tissues.     It  might  be  necessary 


'U 


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656 


AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 


ill  sucli  a  case  to  enlarge  the  eervioal  canal  by  radiating  incisions.  The  liem- 
orrliago  following  might  be  controlled  temporarily  by  clamjiing  sutures  ov(  r 
the  wounded  surfaces  without  uniting  them  (Figs.  .'}o4,  .355). 

Displacement  of  the  Cervix. — It  is  not  uncommon  in  primiparte  with  a  nar- 
row cervical  canal  for  the  (;ervix  to  be  displaced  backward,  so  that  the  external 
OS,  almost  inaccessible  to  the  examining  finger,  points  directly  backward  or 
even  backward  and  upward.  The  anterior  lower  uterine  .segment  is  much  dis- 
tended by  the  presenting  part  and  occupies  the  whole  vaginal  vault.  The  ex- 
pulsive force  in  labor  is  exerted  against  the  lower  uterine  segment,  and  tlie 
cervical  canal  remains  inidilated.  The  difficulty  can  be  overcome  by  aj)plyiiig 
an  abdominal  binder  and  by  hooking  the  cervix  forward  with  the  linger  dur- 
ing two  or  three  pains  (Fig.  .'55G). 

Tumors  of  the  Genital  Canal. — Carcmoma  of  the  Cervix. — In  a  large 
])roportion  of  cases  cancer  of  the  cervix  will  interrupt  gestation  at  various 


Fid.  3r)7.— Liirf-'O  fit)roi(l  lilockiiiK  tlu'  jit'lvi.s  (S|iio);i'llii'i%') 


stages,  but  in  a  certain  jiercentage  ((50,  according  to  Midler)  the  pregnancy 
goes  to  term.  If  the  disease  is  not  too  far  advance<l,  if  it  is  confined  to  one 
lip  of  the  cervix,  and  that  the  anterior,  and  if  there  is  not  too  nuicli  cicatricial 
infiltration  around  its  jjcripliery  and  up  the  cervical  walls,  the  labor  may  be 
terminated  spontaneously,  but  this  is  rather  the  exception.  The  performance^ 
of  Cesarean  section  is  commonly  the  proper  tr(>atment  for  labor  obstructed  by 
carcinoma  of  the  cervix,  and  this  operation  should  be  selected  if  there  is  guod 
reason  to  doubt  the  j)ossil)ility  of  spontaneous  or  artificially-assisted  delivery 
by  the  natural  passage-way.     The  woman's  life  is  surely  doomed  in  the  near 


DYSTOCIA. 


557 


future,  and  the  child  at  any  rate  should  be  saved,  even  at  considerable  risk  to 
the  mother.  It  may  be  desirable  to  operate  before  the  fetus  has  reached 
maturity  if  the  disease  is  making  such  rapid  progress  that  the  maternal  life  ia 
not  likely  to  endure  until  the  natural  end  of  pregnancy. 

Fibromata. — Fibroids  of  the  uterus  and  cervix  low  enough  in  situation  to 
l)ooonie  incarcerated  in  the  pelvis  are  likely  to  constitute  insuperable  obstruc- 
tions in  labor,  besides  complicating  parturition  by  favoring  abnormal  positions 
of  the  child,  by  predisposing  to  adherence  of  the  placenta,  to  prolapse  of  the 
oxtremities  and  cord,  and  to  hemorrhage  during  and  after  labor.  If  the  tumor 
srows  on  the  anterior  wall  of  the  uterus,  the  first  few  labor-pains  and  the  con- 
traction of  the  longitudinal  fibres  of  the  cervix  may  dislodge  it  above  the  pel- 
vic brim,  though  it  had  been  impossible  to  do  this  before  by  manipulation. 
The  writer  has  seen  one  such  case.  It  is  also  possible  for  tumors  on  the  ante- 
rior wall  of  the  cervix  to  be  pushed  out  of  the  vulva  in  front  of  the  presenting 
])art,  thus  making  room  for  the  escape  of  the  latter.  \\\  however,  the  tumor 
is  situated  laterally  or  posteriorly,  its 
artificial  displacement  upward  into  the 
abdominal  cavity,  so  that  the  child 
may  escape  jiast  it,  is  often  imprac- 
ticable (Kig.  357).  On  the  contrary, 
the  attempt  at  descent  of  the  present- 
ing part  in  labor  must  fix  it  more 
firmly  in  tlie  pelvic  cavity.*  In  this 
case,  if  attempts  under  anesthesia  to 
dislodge  the  tumor  and  to  push  it 
above  the  pelvic  brim  fail,  a  Porro- 
Cesareau  t)peration  should  be  per- 
formed, even  though  the  tumor  is  not 
of  such  great  size  as  absolutely  to 
|trevent  the  delivery  of  the  (ihild. 
The  physician  nuist  consider  ti-.c  etfeet 
upon  it,  owing  to  its  low  vit.ility,  of 
the  pressure  to  whicii  it  will  l)c  sub- 
jected l)v  dragging  the  child  past  it  (Fig.  .■J5S).  Sloughing,  gangrene,  and 
fiital  infection  are  likely  to  follow.  This  was  the  history  of  the  case  illus- 
trated in  Figure  .'55S,  communicated  to  the  writer  by  J)r.  J.  P.  iSii;ipsoii  of 
South  Carolina.  If  tlic  fibroid  is  submucous  and  grows  from  the  cervix,  it 
may  be  eimcleated  when  labor  begins.  The  bed  of  the  tumor  shoidd  be 
packed  with  gauze  after  labor,  f 

*  It  is  !i:iivly  possible  tliat  ii  tumor  low  down  on  tlie  posterior  wall  of  the  eervix,  tlie  most 
'iiifiivoriible  of  all  positions,  may  lie  siiildenly  elevatetl  after  many  hours  of  lalior,  and  thus 
allcnv  a  spontaiieons  delivery;  lint  this  I'vent  is  not  to  he  counted  (>n  in  ]wactiee. 

tSulnf;in  is  an  cntiuisiastie  advoeaie  of  vauinal  (i|ierations  for  all  cases  of  liliroids  impacted 
in  tlie  small  pelvis.  For  intraniura!  tnniors  the  cervix  is  split  until  the  tmnor  is  reached.  For 
suhseroiis  tnniors  the  vaginal  vault  is  opened.  Nine  such  o|)eralions,<((fc  partn  are  rejiortcd,  with 
only  one  death  {Jahvenb.  ii.  d.  (•'oi-I.'-tIi.  a.  li  (iihicle  drr  Gehitituh.,  lic,  vol.  v.  p.  17')). 


Vu;.  Ij.'is.— Small  liliniid  past  which  the  child 
was  cxtracteil.  The  tiiiiKH'  l)ecMiiie  jj;angreiiuus  and 
the  woman  died  (Simpsdu). 


'      1}  J  't'j 


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:  m 

* 

•  :■;:;■    w 

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558 


AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 


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I  ' 


It  is,  unfortunately,  a  common  error  to  overlook  a  fibroid  tumor  obstruct- 
ing the  pelvis  in  labor  or  to  mistake  it  for  the  fetal  head.  The  woman  is 
allowed  to  die  of  ruptured  uterus,  exhaustion,  or  hemorrhage  while  the  phy- 
sician is  waiting  for  the  descent  of  the  presenting  part  or  is  endeavoring  t(. 
apply  the  forceps  to  what  he  takes  to  be  the  head.  Ordinary  care  and  sonic 
little  experience  in  making  obstetrical  examinations  should  guard  a  practitioner 
against  such  an  egregious  mistake. 

The  proffnotiis  of  labor  complicated  by  a  fibroid  tumor  depends  upon  the 
early  recognition  of  the  growth  and  upon  the  treatment.  In  general  practice 
the  results  have  hitherto  been  bad.  Xauss  found  a  maternal  mortality  of  i)4 
per  cent,  among  225  women,  and  an  infantile  mortality  of  57  ])er  cent,  in  117 
cases.  Siisserott  found  in  147  cases  a  maternal  mortality  of  50  jier  cent,  and 
an  infantile  mortality  of  66  per  cent.'*^ 

A  fibroid  tumor  may  prolapse  into  the  pelvis  after  the  birth  of  the  child 
and  ])revent  tiie  delivery  of  the  ))lacenta. 

In  Lefour's  statistics  of  300  cases  of  fibroids  complicating  labor  the  mor- 
tality of  delivery  by  the  natural  passage  was  25  to  55  per  cent,  for  the  mothers, 
77  ]>er  cent,  for  the  children.^^ 

Poljipi. — Polypoid  tumors  obstructing  labor  usually  spring  from  the  cervi- 
cal canal  or  the  anterior  lip,  and  are  mncous  in  character.  They  may,  however, 
be  fibromyomatous,  fibrous,  or  sarcomatous,  and  may  have  a  situation  high  in 
the  uterine  cavity  or  in  its  wall.  They  may  increase  very  markedly  in  size 
during  pregnancy.  Their  pedicle  is  usually  small,  and  in  the  case  of  cervical 
poly])s  their  removal  is  easy.  The  operation  should  be  postponed,  however, 
until  the  woman  falls  into  labor,  for  any  operative  interference  in  this  region 
would  very  likely  interrupt  gestation.  When  the  dilatation  of  the  os  begins 
the  pedicle  can  be  transfixed  and  ligated  and  the  tumor  be  cut  awiiv.  Even  if 
these  growths  are  not  sufficient  in  bulk  to  obstruct  parturition  mechanically, 
they  have  been  known  to  give  rise  to  jirofuse  hemorrhage  in  the  first  few  days 
of  the  puorperium,  and  their  removal  is  desirable,  therefore,  even  though  they 
be  small  in  size.  In  the  case  of  fibromyomatous  polyps  of  the  uterine  body, 
the  tumor  has  on  rare  occasions  been  torn  from  its  pedicle  during  labor  and 
expelled  in  front  of  the  child. 

Tumors  of  Neighboring-  Organs. — Ovarian  OyMs. — An  ovarian  cyst  is 
a  rare  complication  in  labor.  In  17,832  births  in  the  lierlin  Frauenklinik  an 
ovarian  cyst  was  fi)und  only  five  times.  Tiie  number  of  abortions  in  preu- 
nancies  complicated  by  ovarian  cy^ts  is  somewhat  larger  than  common,  but 
still  a  large  proi)ortion  of  these  cases  proceed  to  term.  Of  321  jiregnancies 
complicated  by  the  ])resence  of  ovarian  cysts,  there  was  premature  interruption 
in  fifty-five  (Ucmy).  If  the  cyst  is  discovered  during  pregnancy,  its  removal 
should  be  attempted.  Ovariotomy  during  gestation  is  not  necessarily  a  dif- 
ficult or  dangerous  oju'ration,  nor  does  it,  as  a  rule,  interrupt  pregnancy.*     It' 

*  Dsirnc  has  collected  statistics  of  IS.")  operations  with  a  niorfality  of  ").()  per  cent.  I'roK'- 
naiicy  is  interruptwl  hy  the  operation  in  about  20  per  cent,  of  cases  (Flaischlen,  ZfitachriJ't  /iir 
Geburlshillj'e,  xxix.  p.  49). 


DYSTOCIA. 


559 


tlie  tumor  is  first  discovered  after  the  woman  has  fallen  into  labor,  and  if  it 
lias  become  displaced  downward  into  the  pelvic  cavity  and  is  incarcerated, 
resisting  all  efforts  to  displace  it  upward  even  under  anesthesia,  its  puncture 
through  the  vaginal  vault,  after  a  thorough  cleansing  of  the  vaginal  mucous 
membrane  and  with  a  thoroughly  aseptic  technique,  is  said  to  give  the  best 
results.  It  is  a  matter  for  serious  consideration,  however,  whether  Cesarean 
section  followed  by  the  removal  of  tne  tumor  is  not  better.  It  is  the 
writer's  conviction  that  it  is.  By  this  plan  many  dangers  in  the  pucrperium 
are  escajjcd.  Twisted  pedicle,  intracystic  bleeding  and  shock,  occlusion  of  the 
bowels,  rupture  of  the  cyst,  suppuration  of  the  cyst-contents  and  consequent 
])eritonitis,  are  all  surely  avoided.  A  number  of  cases  treated  thus  should 
give  a  better  mortality  record  than  has  hitherto  been  secured.  In  Heiberg's 
statistics  of  271  cases  there  was  a  maternal  mortality  in  pregnancy  of  more 
than  25  per  cent,  and  a  fetal  mortality  of  more  than  G()  per  cent.  In  deliv- 
eries by  forceps  without  puncture  of  the  cyst  the  maternal  death-rate  has  been 
50  per  cent. ;  with  puncture  almost  as  great ;  and  after  version  without  punc- 
ture more  than  50  per  cent.  Flaischlen  recommends  the  vaginal  puncture,  or 
if  necessary  a  vaginal  incision  and  thorough  evacuation  of  the  tumor,  then  the 
delivery  of  the  child,  and  on  the  ft)llowing  day  at  the  latest  an  abdominal  sec- 
tion for  the  removal  of  the  tumor.  This  procedure  does  not  seem  to  the 
writer  so  good  a  ]>lan  as  the  coincident  Cesarean  section  and  ovariectomy. 
Should  the  physician  prefer  vaginal  punctuie — which  requires,  of  course,  no 
.'ipocial  surgical  skill — he  should  remember  that  if  the  tumor  be  densely  adhe- 
rent, possess  thick  walls,  and  possibly  be  a  dermoid  cyst,  puncture  through  the 
vaginal  vault  is  likely  to  be  folk)wed  by  gangrene  of  the  tumor-contents  and 
walls  and  by  general  infection.  This  will  necessitate  a  hurried  abdominal 
section  in  the  pucrperium,  with  the  patient  in  a  bad  condition  to  endure  it. 
Moreover,  if  the  cyst  is  multilocular,  it  may  be  impossible  to  reduce  its  size 
sufficiently  by  vaginal  puncture  to  permit  the  delivery  of  a  living  infant.  The 
writer  has  experienced  both  the  disadvantages  of  this  plan  of  treatment. 

Spontaneous  delivery  in  spite  of  an  ovarian  cyst  incarcerated  in  the  pelvis 
lias  been  noted  after  the  cyst  ruptured,  after  it  had  been  spontaneously  dis- 
lodged upward  above  the  brim,  or  had  perforated  the  vaginal  vault  or  the 
rectum.  As  an  ovarian  cyst  must  be  impacted  in  the  pelvis  to  obstruct  the 
delivery  of  the  child,  it  is  easily  understood  that  there  is  more  difficulty  and 
danger  in  labor  from  a  small  than  from  a  large  tumor  (Fig.  350).  After  the 
child  is  born  a  cyst  that  had  before  been  above  the  brim  may  descend  into  the 
pelvis  and  obstruct  the  delivery  of  the  jilacenta. 

Vdc/iiKil  Entevocdc, — Vaginal  hernia  is  a  very  rare  obstruction  in  labor. 
The  writer  has  been  able  to  collect  but  27  cases  from  medical  literature.  Of 
tliese,  only  two  were  anterior  enteroceles  ;  the  others  were  lateral  and  ])osterior. 
The  distention  of  the  hernial  sac  in  labor  is  apt  to  become  excessive,  and  to 
tlu'caten  its  rupture  with  protrusion  of  intestinal  loops.  An  effi)rt  should  bo 
made  to  nMluce  the  hernia  as  soon  a:*  it  is  discovered.  The  reduction  may  be 
facilitated  by  placing  the  woman  in  the  knee-breast  posture  and  by  inserting 


ajl 


iwJ, 


f4»  :t 


aT 


iti 


560 


AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 


the  wliole  hand  into  the  vagina.  If  this  treatment  is  instituted  in  pregnancy,  it 
should  be  followed  by  the  insertion  of  a  large  tampon  or  a  globe  pessary  and 
by  prolonged  rest  in  bed ;  in  labor  the  presenting  part  should  immediately  be 
brought  down  past  tlie  hci'nial  ring.  If  there  are  adhesions  about  the  latter, 
preventing  the  reduction  of  the  hernia,  the  tumor  should  be  supported  and 
held  to  one  side  by  assistants  while  the  child  is  artificially  extracted  by  forceps 
or  after  version.  Should  the  sac  rupture  and  the  intestines  i)rotrude,  the  child 
must  be  delivered  hastily,  the  intestines  be  cleansed  thoroughly  and  re])laee(], 
and  the  opening  be  sewed  up.  In  the  case  of  a  very  large  irreducible  vaginal 
hernia  the  writer's  preference  would  be  for  Cesarean  section  in  a  labor  at 
term. 

Other  growths  or  tumors  in  the   lelvic  inlet  and  cavity  obstructing  labor 
have  been  fibrocystic  tumors  o^  the  ovarian  ligament,  requiring  an  abdom- 


Fic.  ;5,jt).— Oviiiiiiii  tiiMiiir  iiiciiictTiitc'cl  in  tlio  pelvis 
(liiriiiK  liilior. 


Fio.  SfiO.— Cysldcc'lo  (ibstruc'tinf;  Inliiir. 


inal  section  ;  fibroma  of  the  ovary ;  sarcoma  of  the  ovary ;  a  displaced 
adherent  kidney  at  the  pelvic  iidet,  nocossitafing  version  and  forcible 
extraction;*  hydatid  cysts  of  the  pelvis,  demanding  Cesarean  section;  a 
displaced  and  enlarged  spleen  ;  masses  of  exudate  ;  and  an  aneurysm  of  tlic 
gluteal  artery. 

Cvstocolpocele  and  I'ectocele  should  be  re]>lac('d  if  they  protrude  to  a  great 
extent  in  front  of  the  head,  and  i)e  held  back  until  a  forcej)s  is  applied  and  the 
head  is  brought  past  them  with  the  iiistriunent  (Fig.  3G0).  Version  and  extrac- 
tion have  occasionally  been  found  necessary.  T^arge  fecal  masses  in  the  rectum 
must  be  removed  by  an  enema  or  must  be  dug  out.f  Calculi  in  the  bhi'ltler 
should,  if  possil)Ie,  be  discovered  and  removed  by  the  urethra  or  by  vaginal 
lithotomy  before  the  second  stage  of  labor.  They  may  become  nipped  between 
the  head  and  the  pubic  bones,  and  pinch  a  hole  through  the  anterior  vaginal 

*  Kiinpe  reports  fdiir  ciises  ( Arrhir  fiir  Gjiniikrilo./li;  xli.  p.  'J9).  Tlie  writer  liiis  liiid  «iih'. 
All)ers  Sclioenberg  reports  aiiotlier  in  wliieli  the  uterus  ruptured  {Ci-iitrnlblnll  fiir  Giiiiiiknloiiii, 
Dec.  1,  1S94). 

t  Corradi  tells  of  a  ease  in  wiiieh  seven  jiounds  of  iiardened  feces  were  removed  i)efore  the 
woman  was  delivered, 


DYSTOCIA. 


561 


gnancy,  it 
»sury  and 
(liately  he 
the  hitter, 
)()rte(l  and 
by  forceps 
,  the  child 
rephiocd, 
le  vaginal 
I  hibor  at 

ting  labor 
lU  abdoni- 


ip  labor. 

displaced 
I  forcible 
section  ;  a 
,sm  of  the 

to  a  great 
h1  and  the 
nd  extrae- 
he  rectum 
u!  bladder 
)y  vaginal 
d  between 
or  vaginal 

las  liiid  villi". 

(IjliiiUcohti/ii', 

(I  hefoiH'  the 


wall  and  bladder  if  they  are  overlooked  or  neglected.*  The  diagnosis  of 
vesical  calculus  in  the  jiarturient  woman  appears  to  be  somewhat  diflicnlt :  it 
has  been  taken  for  a  pelvic  exostosis  or  some  other  pelvic  tumor,  and  in  one 
ease  at  least  Cesarean  section  was  performed  on  account  of  this  mistake.  For- 
tunately, vesical  calculus  in  the  female  is  rare.  In  10,000  women  examined 
by  Winckel  in  fifteen  years  it  was  found  only  once. 

The  following  conditions  in  and  about  the  rectum  may  present  mechanical 
obstacles  to  delivery  :  Cancer,  anus  vestibularis  or  vaginalis,  foreign  bodies, 
eoiitractioii  of  the  levator  ani  muscles,  benignant  tumors  such  as  cysts  of 
the  rectum,  ovarian  cysts  which  have  perforated  the  rectum,  and  retro-rectal 
dermoid  cysts.  Each  of  these  conditicnis  must  be  treated  according  to  the 
individual  indications.  Incisions  in  the  perineum  may  be  reciiiircd,  foreign 
bodies  must  be  removed,  resisting  muscles  on  the  j)elvic  floor  may  be  over- 
come by  an  anesthetic  and  by  the  application  of  forceps,  and  cystic  tumors 
siiould  be  punctured  or  removed  after  ligation  of  their  pedicles.  Cancer  of 
the  rectum  may  demand  the  performance  of  Cesarean  section  by  reason  of 
the  size  of  the  tumor  and  the  cicatricial  infiltration  of  the  birth-canal,  as  in 
KrcHuid's  case. 

7.  ()nsTuu(;TioN  in  Lauou  on  thk  Part  of  thk  Fktus. 

Overgrowth  of  the  Fetus. — Excessive  overgrowth  of  the  fetus  is  rare. 
The  writer  searched  the  records  of  more  than  1000  children  in  the  Maternity 
Hospital  of  Philadelphia  before  he  found  one  that  weighed  more  than  twelve 
pounds;  weights,  however,  of  fifteen,  sixteen,  eighteen,  twenty-three  and  a  half, 
and  twenty-eight  and  three-quarters  pounds  have  been  recorded.  The  causes 
of  overgrowth  in  the  fetus  are  prolongation  of  pregnancy,  over-size  and  ad- 
vanced age  of  one  or  both  parents,  and  multiparity.  Rarely  it  may  be  inex- 
plicable. The  first  named  is  in  the  writer's  experience  the  most  common  cause. 
In  6  per  cent,  of  women  pregnancy  may  be  expected  to  bo  prolonged  beyond 
the  three-hundredth  day,  and  for  every  day  that  the  fetus  is  retained  in  the 
womb  beyond  the  usual  time  there  is  commonly  some  little  increase  in  its  size 
and  weight  above  the  normal.  So  much  diffi(ndty  and  danger  may  be  expe- 
rienced from  tbis  cause  that  it  is  a  good  rule  in  practice  to  allow  no  woman  to 
exceed  the  normal  duration  of  pregnancy  bv  more  than  two  weeks.  By  induc- 
ing labor  at  that  time  one  will  occasionally  interfere  unnecessarily,  but  he  will 
often  avoid  complications  and  difficulties  of  the  most  serious  nature. 

Over-size  and  advanced  age  of  oiu;  or  both  parents  may  be  a  cause  of  over- 
growth in  the  fetus — the  latter  usually  because  it  jiredisposes  to  a  prolonga- 
tion of  pregnancy.  It  is  commoidy  asserted  that  the  size  of  children  increases 
in  successive  pregnancies  up  to  the  fourth  or  fifth,  and  then  remains  stationary 

* Kotschurowii  has  reported  a  case  in  which  labor  lasted  three  dins.  .\t  the  end  of  that 
time  a  Ki'iik^rcnmis  tumor  protruded  from  the  vulva,  which  tumor  proved  lo  he  the  bladder  and 
anterior  vaginal  wall.  Tiie  midwife  in  atteniiiiiiee  iif^rforated  the  tnrnor  with  her  linger,  where- 
upon a  calculus  eighty-five  grains  in  weight  wiis  discharged  (JdhresbcrichI  it,  d.  Forlschr.  n.  d. 
G.hietc  ikr  'leburtxh.,  etc.,  vi.  225). 


If      I 


i-    !  1 1 


ii  s 


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I 


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I  • 


!      , 


I    i 


562 


AMFJilVAN    TEXT-BOOK   OF    OBSTETRICfi. 


or  even  (lecroa.scs ;  but  theiv  arc  important  exceptions  to  tliis  rule.     The  writer 
has  seen  the  teulii  child  va.stly  exceed  in  size  the  nine  preceding;  it  weighed 


Kiu.  ;!(')l.— Dlcc'plialus 


Flu.  Sfi;!.— rioi'plmliis. 


^I'^f'^^^^^^^ 


Klu.  ;'>(;4.— Cninio|iiiKi'^ 


Kiu.  ;it)5.— Isdiioim.mis. 


fifteen  pounds,  and  it  was  necessary  to  deliver  it  by  Cesarean  section.     The 
other  children  had  been  born  naturally  through  a  flat  pelvis  with  a  conjugate 


Kici.  ::i;ri.— lii|iyiriis  iWrlls).  Ku;.  ai".  — Diiiygus  imrasitlods. 

diameter  of  i)  centimeters,     'flic  increase  in  size  of  successive  children  mu-t 
bi'  bonic  in  mind  in  cases  of  coutractcd  ju'lvis.     The  first  two  or  three  inhuii> 


I       !    feJ 


DYSTOCIA. 


I'l.ATK 


■HI    "  ■'  ■^''-   M 
■HI 

I 


I.  lii|>niso|iiis  (IIii>l  mill   rirrsnlV     ■_'.   |ii|.rciMi|iii-  i  I'lr 


Hirrl.lulhl-,       I.    I. 


Ilur    I'S-lir    kii|ll(V> 


il''ilssrlli.    :>.  l.iirui'   nu'MiiiLMccli'  niul  >|iiiiii    Mllilti   illirsi   .iiliI    I'IiTmiIi.     h.  ( ■..ii'jmil.il   i\  ^lir  ili|!liiiiiiiiisi> 
iWilsmi).    7.   riiiirii<'(i|iiiyiis  illii'st  ami  l'ii;i-siili.    s.  |ii>toiiil(il  liliuMiT  (Alillclili. 


I 


i 

i. 

.[ 

MIMI   IWldll       ■ 

! 

1     .          i   y 

J 

H^^^^^^^^BJPIWgi 

.,1 

I  I 


.11 


M 


•      tV-         t^ 


'f     |! 


i  m 


>f     J-i  1 


g    I 


I    f! 


y 


DYSTOCIA. 


663 


niav  be  delivered  spontaneously,  bnt  the  larger  size  of  the  fourth  or  fifth  may 
make  natural  delivery  impossible.* 

Overgrowth  of  the  fetus  is  the  most  difficult  condition  in  obstetric  practice 
to  diagnosticate  with  precision.  A  careful  palpation  of  the  head  and  body 
and  an  attempt  to  pusii  the  former  into  the  pelvic  inlet  may  give  one  an 
approximate  idea  of  the  relative  size  of  fetal  body  and  pelvic  (jaiial,  but  as  a 
matter  of  fact  the  large  size  of  the  fetus  is  usually  discovered  ..  practice  only 


^'f^^-. 


Fill.  3C8.— Prosopothoracopagus. 


l''i(i.  3G9.— Xiphopagus. 


Fi(i.  370.-Janicops. 


after  prolonged  delay  when  attempts  at  artificial  delivery^  especially  by  version, 
have  failed.  By  this  time  the  fetus  is  commonly  dead,  and  should  be  deliv- 
ered by  embryotomy.  But  the  ])raotitioner  nuist  be  on  his  guard  again.st 
futile  attempts  to  deliver  an  infant  too  large,  even  when  mutilated,  to  pass 
through  the  pelvis.  The  writer  has  seen  in  consultation  practice  several 
maternal  deaths  due  to  this  cause. 

Prcmafure  Omfieation  of  Cranium;  Wormian  7?onps;t  Larr/e  Heads;  Mal- 
formations  and  Tumors  of  the  Fetus. — No  single  rule  of  treatment  can  be  laid 
down  for  the  management  of  these  ca.«es.  Forceps,  version,  or  some  form  of 
emljryotomy  is  usually  demanded.  Spontaneous  labor,  however,  is  jw.ssible 
even  in  ea.ses  of  monstrous  bulk  in  which  delivery  through  the  birtli-eanal  woidd 
seem  out  of  the  question.  Thus  in  double  monsters  Joinoil  loosely  by  the  front 
or  back  (xiphopagus,  the  Siamese  twins ;  pygopagus,  the  Hungarian  sisters), 
one  child  will  be  born  by  the  head,  the  other  afterward  by  the  breech,  or  tnce 
nrsa.  In  dicepluili  one  head  may  be  pressed  into  the  neck  of  the  other  or 
may  rest  upon  the  iliac  bone  till  the  first  head  makes  its  escape  from  the  vulva. 
Even  in  thoracopagus,  the  commonest  double  monstrosity,  in  which  two  trunks 

*  I.rliiiiiinn  in  712  Inbors  tlinuiKli  I'JS  contracted  pelves  foinul  increasing  difliciilty  in  de- 
livery with  eiich  siiceeedina;  lal)or.  In  first  lalinrs  50  per  cent,  ended  spontancc)iisly  ;  in  second, 
4li.S ;  in  fimrti),  3iS.4 ;  in  fifth,  '•i'ih'j  ""il  in  labors  after  the  fifth  only  '••.S  per  cent,  (fiitiitri.  />)'.<., 
Berlin,  1S91). 

t  Or.  (trace  Pcckani  (AVic  Yark-  Mi'dknl  liimnl,  April  14,  1SS8)  has  reported  three  still- 
hirths,  attrilinted  in  each  instance  to  the  development  of  Wormian  hones  in  the  smaller  fonta- 
nelle,  and  to  the  conse(|ueiit  interference  with  overlapping  of  the  cranial  bones  at  the  sutures. 
This  ob.scrvation  ha.s  not  vet  been  verified  bv  others. 


i*^iK-': 


!'t 


1 


^ 


f 


lilt 


^,  i 


f 


i    , 

1 

I 

li' 

i 

.5(54 


AMKRICAN    TEXT- HOOK   OF   OJiSTETIilCS. 


arc  iiitimatJ'ly  joined  front  to  front  (IM.  ;}7),  spontaneous  labor  is  possible  by 
the  inechanisin  siiown  in  Fij!;ure.s  .'>74  and  875.  On  the  other  hand,  the  {great- 
est dillieuity  may  be  eneountered  in  hibor,  and  the  most  sei  'oiis  operation  may 
be  demanded  to  deliver  the  woman.* 

Fetal  tumors  obstrueting  delivery  may  be  hydreneephaloeeles,  lymphan- 
giomata,  myxomata,  saeral  teratomata.  Cystie  tumors  should  be  ptmeturcd. 
Solid  tumors  may  call  for  version  or  for 
embryotomy.  C'ranioton)y  may  be  re- 
<|uired  in  monstrous  eidargement  of  the 
eephalie  extremity,  as  in  syncephalus  or 
in  diprt)sopus.  Decapitation  may  be  neees- 
sary  in  duplicity  of  the  cephalic  extrem- 


Fk;.  371.— Myxoma  of       Fif;.  37'J.-Siicnil  tumor  (Miittcr 

neck  (l.oiiKuktT).  ilus.,  CuUfgc  iif  I'lijsiciiiiis).  Fui.  371.!.— Annsiirca. 

ity,  as  in  dicephalus  or  in  thoracopagus.  In  Keina's  case  of  tricephalus  the 
first  head  was  perforated  and  then  amputated,  the  second  was  perforated, 
crushed,  and  amputated,  and  the  third  was  amputated. 

/^- 

5n 


Fui.  374.— .Meclianism  of  labor  with  dicophalus 
(Kiistner). 


Ki(i.  375.— Mi'i'hanisni  of  labor  in  thora- 
copafius  ^Kiistnl'r). 


Diseases  and  Death  of  the  Fetus. — All  diseases  of  the  fetus  that  increase 

*  Tlieri"  are  two  recorded  deliveries  of  thorucopagi  by  Cesarean  section  (Hirst  and  Piersol, 
Human  Monstroaitks). 


I)YST(MIA. 


I'l.AiK  :iK. 


lossiblt'  by 

tlu'  <>;r('iit- 

ratiun  may 

lyniphan- 
j)unctur((l. 


rc'ii 
( 


pliaUis  till' 
perlbrated, 


in  tliora- 

hat  increase 

:st  ami  I'iersol, 


t.   Ski'Ii'tiiii    (if   lijilroi't')ilmliis    (tlirsl    ('(illcrtiim,    I'liiviTsity    nf    ri'iiiisylviiiiitii.      'J.    HyclincciilmUis 

illirsti.     :i.  Uyilrciici'iiliiildrclc  pDstcrinr  illirst  iiMil   I'iorsiili.      I.   llydrci pliiilni>ilr  Mi|iciiur.     :,.  llyilni- 

ci'liliiiliis  ilisti'iiiliiiK  IdWor  utcriiio  sokiiumiI  ( Viiniicri.    ti.  Tti|i|iiii'^'  ti  liy(lriiccpliiilii>  iIhuiil'Ii  the  spiiml  ciiiiiil. 


i- 

'M 

iff.    •'., .  li 


!■     (, 


"/■•. 


,,   1 

!'^ 

I    f 

m'iJ 

1 

I    t 


i-,    ■;  t'^'-' 


i' 


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I     ■'.   :.i't 


i'i' 


li,     -I  J 


41 


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a     1 

r    - 

y. 

"^^ 

\ 

U: 

i    ■ 

.1         ; 

1. 

1^ 


DYSTOCIA. 


505 


its  bulk  may  constitute  thcrohy  an  obstrut-tioii  in  labor.  Cystic  tumors,  ctTu- 
sions  in  tlic  serous  cavities,  anasarca,  an  enlarged  liver,  polycystic  disease  of 
the  kidneys,'"  and  distended  blad<ler  from  atresia  of  tliu  urethra*  are  exam- 
j)Ies.  Li(|uid  accumulations  should  b((  evacuated  by  pinictiu'e  or  by  incisions. 
/[i/(lroi'rj)li(tlnx  (IM.  IW)  is  tiie  most  important  condition  under  this  head.  It  is 
not  very  raro,t  is  often  overlooked,  and  is  a  tmiuent  cause  of  ruptured  uterua. 


Fig.  37(i.— TappInK  n  liydroceplmlus  tlirout,'h  the  spiiml  ciiniil  (Vnrnior). 

The  diagnosis  can  be  made  by  a  vaginal  examination,  by  abdominal  palpation, 
and  by  a  combined  examination,  or,  if  necessary,  by  anesthetizing  the  woman, 
introducing  the  whole  hand  into  the  vagina,  and  thoroughly  palpating  the 
enlarged  head  resting  above  the  pelvic  brim.  The  wide-open  fontanelles,  the 
great  width  of  the  sutures,  the  fluctuation  to  be  felt  perhaps  in  these  regions, 

*Sch\vyzer  {Arrh.f.  Gyn.,  Bd.  43)  lias  collected  13  cases  of  dilatation  of  the  fetal  bladder 
from  atresia  of  the  urethra,  stenosis  of  the  urethra,  and  obstruction  of  the  urethra  b_v  a  valve- 
like formation  of  mucous  membrane.  Miiller  re))orts  a  case  and  quotes  another  {Arch./,  (hjn., 
I!d.  47,  II.  1). 

tSi4iuchard  found  it  sixteen  times  in  r2,0->")  births;  I.achapelle  and  l)uu;es,  fifteen  times  in 
43,555;  ilerriman,  once  in  000.  In  159  cases  tiiere  were  38  maternal  deaths,  twenty  of  which 
were  from  rupture  of  the  uterus. 


V»;fr 


TTTV 


Si  *!f1^-»' 


!  •  ■■ 


If ,-' 


nw 


I         Hi 


.5()()  AJfJ'JJilCAA    TEXT-BOOK   OF    OliSTETRICS. 

llio  largo  sizo  of  tlio  head  appreciated  hy  biiuauiial  exaniiiiatioii,  and  possihlv 
tile  abnormal  mobility  of  the  cranial  bones,  and  in  some  cases  their  extreme 
temiity,  indicate  the  ct)niliti()n.  irydrocej)halns  is  very  oltcn  overlooked  in 
jM'actice  as  the  resnlt  nsnally  of  a  careless,  snperficial  examination.  A  pains- 
taking and  methodical  investigation  of  a  suspected  case  shonld  avoid  this 
error.  There  are  cases,  however,  in  which  there  is  no  increased  width  of  the 
sntnres,  no  enlargement  of  the  Ibntanelles,  and  such  slight  enlargement  of  the 
head  that  it  cannot  be  appreciated;  and  yet  the  Hnid  contents  of  the  cranium 
j)revent  coinj)rcssion  of  the  skull  and  make  the  engagenu'ut  of  the  head  impos- 
sible. The  writer  has  seen  one  such  case.  Hydrocephalus  should  always  be 
suspe<'ted  if  the  head  in  labor  remains  above  the  brim,  although  the  j)elvis  is 
nt»rnuil  in  si/e  and  no  good  reason  can  be  found  for  the  failure  of  engagement. 

The  traitiiK  lit  of  labor  obstructed  by  hydrocephalus  's  puncture  of  the 
cranium  with  a  perforator  and  evacuation  of  its  fluid  contents.  A  child  with 
this  disease  deserves  no  consideration.  Alter  the  reduction  in  the  size  of  the 
head  the  labor  n)ay  be  left  to  the  natural  forces.  If  these  prove  insulllcient, 
a  cranioclast  may  be  fastened  to  the  skull  and  the  child  be  extracted  artifi- 
cially. A  cardinal  rnle  in  the  treatment  of  these  eases  is  to  avoid  attempts  to 
deliver  with  forceps — a  common  error  in  practice,  and  one  that  has  cost  many 
a  woman  her  lile  from  ruptured  uterus,  from  tleep  tears  when  the  instrument 
slips,  as  it  will,  and  from  extensive  sloughs  after  delivery. 

If  the  pelvic  extremity  of  the  hydrocephalic  fetus  |)reseuts — as  it  does  in 
almost  a  third  oi"  all  cases — and  if  the  head  remains  inaccessible  above  the 
superior  strait,  so  that  it  cannot  easily  be  piuictured,  the  spinal  canal  may  be 
ojx'iied,  a  catlu'ter  be  passed  throngh  it  into  the  cranial  cavity  (Van  Iluevers 
methoil).  and  the  fluid  thus  l)e  evacuated  (I'^ig.  ;}7()).  Tsually,  howev<'r,  then- 
is  no  special  dillicidty  or  danger  in  tlie  delivery  of  the  afler-coming  head  of  a 
hvdrocephalic  infant.  The  force  n^piired  tor  its  extraction  not  infre(piently 
ruptures  the  walls  of  the  ventricles  and  converts  the  case  into  one  of  exlci-nal 
hydroce])liahis,  or  possibly  drives  the  lliiid  out  of  the  foramen  magnum  into 
th(-  tissues  of  the  neck  and  back,  so  riMlucing  the  bulk  of  the  head  as  to  per- 
mit its  extraction.  At  any  rat<',  the  condition  can  scarcely  escape  the  notice 
ot'  the  medical  attendant,  and  a  diagnosis  is  made  before  the  lower  ntei'ine 
segment  is  dangerously  stretched   or  ruptured. 

The  diilicnlty  in  the  delivei-y  of  a  hydrocephalic  fetus  is  not  in  direct  pi'o- 
portion  to  the  (piantity  oi'  lluid  in  the  ventricles  ;;nd  the  si/e  ol"  the  head.  In 
eases  of  extreme  distention  (he  cranial  vault  is  likely  to  rupture,  while  in 
moderate  grades  of  hytlrocephalns  the  (piantity  of  brain-substance  surronndii\g 
the  ventricles  and  the  strength  of  (he  brain-membranes  forbid  (his  means  of 
spontaneous  delivery. 

M(i/jirifti'iiltifiniis  inul  Jitiilhi  posilions  (1*1.  .")!>)  include  shoulder,  face,  brow, 
deviated  vertex,  and  compound  presentations.  All  but  the  last  are  considered 
elsewhere.  \>y  compound  presentation  is  meant,  the  presentation  of  two  or 
more  parts  at  the  same  time,  as  a  head  and  a  hand,  a  head  and  a  foot,  a  hand 
and  a  fool,  nuchal  position  of  the  arm,  or  the  head  and  all  four  ex(remi(ies. 


DYSTOCIA. 


I'l.ATi:  ;?!). 


iiiraircMiicnt. 


,  lace,  hniw, 
(>  coiisidcrcil 
1  ol'  two  or 
Coot,  a  liaiid 
ti-ciniti('s. 


m 


I  If:  I 


1 

K'' 

li 

if'i 

H"    ; 

a-.        j     1 

r  ■ 

i  ■    i 

i'-. 

- 

I.   J      Nile  l|,-|l     |.nsi|i |-  iin 

■'i.   l''illl|PUUIIi|    l.liM'lllluicill. 


'I'M 11.1     |ilVvrllljlinlM.Mll|iMi  I      (' |..ilni.|     |.lrMlll,lli,.||    l|||t>l) 


;    t 


!    ."! 


( 


'      'i 


M 


m 


DYSTorlA. 


I'l.ATK    10. 


I.'J.  'I'wiiis,  triiiisvcisf  iiml  liirr<-li.    :',.  'I'h  iti.-.  \",[U  (i;iii^\rr.-v.     1,  Tuiii-^,  In  a. I  an<l  I'lrnli. 
liulli  trau-viTsc.    I'l,  7.  'rwiii^.  \h,:\\  linuls  inr^i-iiliiii;. 


T«ilii<, 


«i_ 


'■     H. 


I 


ff. 

< 

i 

iB«i 


|l       :ji. 


DYSTOCIA. 


567 


A  compt)iind  presentation  is  met  with  abont  once  in  250  labors.  It  is 
usually  a  head  and  a  hand.  Tlie  following  table  is  fiu'nished  by  I'erniee  from 
2891  births  in  the  elinie  at  Halle: 

Jliind  aiui  lu'iul 20 

Arm  aiul  Iioiul 8 

Hand  and  unibilicul  cord      h 

Botli  liands 4 

Foot  and  liund '2 

Two  lianils,  ninbilical  cord,  and  foot 1 

Face,  hand,  and  cord 1 

Kietz  found  in  7555  labors  the  foot  and  head  presenting  in  twenty-three.'^' 

The  eause  of  eompound  presentations  is  usually  a  laek  of  eonformity  in 
the  presenting  part  with  tin;  pelvic  inlet  (as  in  !nal|)osition  of  tiie  tetus), ahead 
of  abnormal  size,  a  displaced  uterus,  twins,  hytlramnios,  contracted  pelvis,  and 
anomalous  shape  of  the  uterus,  etc. 

In  the  trcdtuwnt  of  compotnid  presentations  before  rupture  of  the  mem- 
branes an  attenipt  should  be  made  to  overcome  the  difficulty  by  postural  treat- 
ment. The  woman  should  be  placed  on  that  side  opposite  the  j)rolapsed 
extremity.  After  rupture  of  the  membranes  an  attempt  should  be  made  to 
dislodge  the  prolapsed  extremity  and  to  restore  it  to  its  natural  ])osition. 
Version  may,  however,  be  re(|uired  if  this  att(Mnpt  fails,  or  even  craniotomy 
if  the  child  is  dead,  ff  the  head  and  extremities  present,  and  if  the  former 
is  engagctl,  it  is  usually  best  to  ajiply  forceps  and  to  disregard  the  j)rolapsed 
extremities.  In  the  case  of  nuchal  position  of  the  arm  an  ellbrt  should  be 
made  to  dislodge  the  latter,  but  it  may  be  necessary  to  I'racture  it  before  the 
delivery  of  the  child  can  be  secured. 

Miillipli'  JiirfliK. — Twin  labors  are  usually  easy  and  uncomplicated  (75  per 

cent.),  but  complications  are  more  frecpient  than  in  single  labors.      ^lalpresen- 

tations  are  common  (IM.  40).     The  following  tal>le  from  Spiegelberg,  based  on 

1 1;!<S  labors,  gives  the  citmbined  presentations  in  the  order  of  their  frecpiency  : 

Both  luads  incsciitiiif? 49  per  cent. 

IIi:id  :in.l  liiwcli  31.70  "       " 

Itdlli  pi'lvic  presentations 8.(i0  "       " 

Head  nnd  transverse 6.18  "       " 

Urcccli  and  transviTse 4.14  "       " 

Both  transverse ;{5  "       " 

Ft  may  be  noted  that  ii  transv(>r.se  position  is  found  in  1().G7  per  cent,  of  cases. 
.Mcchauiciil  dillit'idties  in  hibor  are  fre(|uent,  the  uterine  muscle  is  usually 
weakened  by  overstretching,  ;ind  there  m;i,  le  trouble  in  the  third  stiige  of 
lai)or  in  the  <lelivery  of  the  placentii.  Some  form  of  openitive  interference  is 
demtmded  in  about  '25  per  cent,  of  ;dl  ciises. 

In  the  majority  of  ctises  (7!*  per  cent.)  the  int<'rv;d  between  the  delivery  of 
twins  is  less  than  an  hour.  A  longer  delay  tlnm  this  indictitcs  the  liUelihood 
of  .some  obstruction  to  the  birth  of  the  second  infant  or  a  failure  of  expulsive 
forces. 

Serious  dinieidts'   in   twin   lahtn's  iiiav  tirise   in  one  of  three  wtivs  :  Both 


'*-  '    ii 


-f . 


/ 


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U- 


r 


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S 


!  ■■. 


568 


AMERICAN    TEXT- BOOK    OF    OliSTETRIVS. 


heads  present  at  once,  Diie  a  little  in  advance  of  tlie  other,  the  second  impacted  ii 
the  neck  of  the  first  (Fii^.  877);  the  first  child  descends  by  the  breech,  and  tli 


Fk;.  'M'i. — Iiii|iac'ti()n  of  heads  in  twin  labor.  Vu-.  :>7.s.— l.dcliiiig  of  lu'.-iils  in  twin  liibor. 

head  of  the  second  diild  is  cautj;ht  by  the  chin  of  the  first  and  pushed  into  the 

pelvis  (Fioj.  378) ;  one  child  sits  astride  of  the  other,  which  is  transverse.     If  both 

children  should  be  found  atteniptinoj  to  en>z;a<>;e  ity  the  head  in  the  superior 

^  strait  at  one  time,  one   child    should  be  retarded 

while  the  other  is  artificially  extracted.     If  this  is 

impossible,  the  first  head  should   be  extracted  by 

forceps,  the  second  be  treated  in  like  manner,  and 

then  the  trunks  should  be  delivered  one  after  the 

other.     Embryotomy  is  a  last  resort,  but  is  scarcely 

ever  necessary. 

A  eoilint;  of  the  cords  (Fi^.  379)  and  their  eii- 
tano;lemeut  may  be  a  source  of  difficulty  and  delay 
in  iniioval  twins.  It  may  be  necessary  to  cut  one 
or  both  cords  between  ligatures  before  the  children 
can   i)e  delivered. 

In  cas(>  one  child  pres(>nts  by  the  head  and  the 
other  by  the  feet,  both  may  come  down  together, 
and  the  two  hea<ls  become  locked  in  the  pelvic 
entrance  and  canal.  An  ctVorr  iiiay  be  made  tn 
push  back  the  child  presenting  l)y  the  head.  If 
this  su<'c<M>ds,  the  child  presenting  by  the  breech 
should  be  extracted  immedi.atcly,  for  it  is  in  immi- 
nent <langer  from  asphyxia.  It  may  Ix;  possible  with  forceps  to  pull  the  child 
j)rcsenting  i)y  the  licati  |»ast  the  body  of  its  fellow  presenting  by  the  breech. 
Failino-  ii)  these  attempts,  the  <'liild  presenting  by  tli^'  breech  will  almost  surely 
have  died  and  there  will  be  no  pulsation  in  its  cord.  It  should  then  be 
decapitated,  whereupon  the  infant  presenting  by  the  licad  can  be  extracted 
without  difficulty  by  forccj)s. 


'■*<i^^»^^gjjjjf*^ 


V\ii.  :i7l».— I'.nliui^'li'inriit  of 
in  tw  ins  ( Wine  kcli. 


inl> 


DYSTOCIA. 


669 


111  any  case  of  twin  labor,  as  soon  as  the  first  cliild  is  born,  and  the  oord, 
liirated  with  a  double  ligature,  is  cut,  the  attendant  should  ininiediatily  inves- 
tiirate  the  position  and  presentation  of  the  second  eliild.  A  negleet  of  this  rule 
loads  very  often  to  the  inipaetion  of  an  unreeogni/ed  shoulder  presentation  in  the 
mcond  child,  and  its  eonsecjuent  death.  If  an  abnormality  is  discovered  in  the 
presentation  of  the  second  child,  it  should  at  once  be  corrected.  Then,  after  wait- 
ing perhaps  half  an  hour,  the  anuiiotie  sac  should  be  ruptured,  and  ergot  may 
be  administered  in  a  full  dose  to  secure  a  speedy  delivery,  or,  if  the  stomach 
will  not  retain  it,  the  hypodermatic 
svringe  should  be  used,  for,  the  birth- 
canal  having  been  dilated  thoroughly, 
there  is  no  obstacle  to  the  birth  of  the 
soc(md  infant  in  twin  lab(»rs,  and  con- 
sequently no  objection  to  the  employ- 
ment of  ergot,  which  not  only  hastens 
the  conclusion  of  labor,  but  j)romotcs 
subserpient  contraction  of  the  much- 
distended  uterus,  and  so  prevents  ])ost- 
])artum  hemorrhage.  As  a  further 
])recaution  against  this  accident  the 
fundus  shoidd  be  compressed  for  a 
long  time  after  birth  by  the  nurse. 

There  may  be  difficulty  in  the 
delivery  of  the  placentte  in  twin 
labors.  Commonly  the  children  are 
horn  first  and  the  placenta;  .'ifterwavd. 
Their  bulk  may  make  expression  dif- 
ficult, and  it  is  oflen  necessary  to 
make  some  traction  upon  the  cords — 
first  upon  one  and  then  upon  the  other 
— to  determine  which  j)lacenta  will 
come  first  and  to  assist  in  its  expul- 
sion. Occasionally  one  and  rarely  both  placciuje  may  be  expelled  after  the 
birth  of  the  first  child.  Tn  a  case  of  the  writer's  the  ])laccnta  of  the  first  child, 
prolapsing  in  front  of  the  second,  necessitated  a  dillicuU  forceps  operation  titr 
the  extraction  of  the  second.  On  account  of  the  frequent  and  extensive  anas- 
tomoses between  the  vessels  of  the  placenta*  in  unioval  twins  it  is  a  necessary 
precaution  to  tie  the  cord  of  the  first  child  with  a  double  ligature  and  to  cut 
it  between  the  ligatures;  otherwise  the  second  infant  might  bleed  to  death. 

The  prof/)ioNi,s  of  twin  labors  is  always  doubtful.  There  are  so  many  possible 
dangers  for  both  mother  and  childnMi  that  nudtiple  labors  nnist  be  regarded 
as  distinctly  pathological.  Albuminuria  in  the  mother  is  the  rule  in  multiple 
pregnancies,  and  eclampsia  is  ten  times  more  frequent  than  in  single  births.* 
There  is  a  disposition  to  inertia  uteri  during  and  after  birth  from  distention 
*  Of  027  cases  (if  cnlatii|isi:i,  sixty-iiino  were  multiiile  iin'jjiiiuicies  (Wiiu'kel). 


iNi.— Twins,  linid  iiiiil  hrci'cli. 


if 


M 


!      .  t ' 


if     U' 


570 


AMEBICAN    TKXT-liOOK   OF   OB:STETRICS. 


^■:\. 


I 


III 


of  the  cavity,  aiul  ('oiiso(|iioiitly  a  likelihood  ot"  post-partiim  hoinorrhago.  Some 
operative  interference  or  iiitra-iiteriiie  iiianipiilatioii  i.s  called  tor  in  about  25  per 
cent,  of  cases,  and  this,  in  addition  to  tiie  frecpicncy  of  kidney  insufficiency,  pre- 
disposes to  sej)sis.  Finally,  there  may  he  insiij)eral)le  obstruction  in  labor  if 
locked  twins  are  not  nianau;cd  properly,  and  the  woman  may  die  of  ruptured 
uterus  or  of  exhaustion.  The  maternal  mortality  in  the  Budapest  iNIater- 
nity  was  foiu'  times  as  <rreat  as  in  the  sinu'le  births,  and  Klein wiichter's  statis- 
tics ji'ivc;  a  mortality  of  ]."j  per  cent.  For  the  children  then;  is  greater  danger 
than  Ibr  the  mother.  Twin  [)regnancy  is  almost  always  j)rematurely  inter- 
ruj)tcd,  and  even  if  it  is  not  the  children  are,  as  a  rule,  under  the  normal  size 
and  weight.  There  is  always  the  possibility  that  the  development  of  one 
child  at  least  will  be  seriously  intertered  with  by  the  lack  of  room  in  the 
uterine  cavity.  Ilydranniios  of  one  sac  and  oligohydramnios  of  the  other  are 
not  uncommon.  Jn  labor  there  are  the  frc<picnt  complications  from  malposi- 
tion, operative  interference,  entanglement  of  or  pressure  upon  the  cords,  and 
more  rarely  the  engagement  of  both  bodies  at  once  in  the  pelvic  canal.  In 
Kleinwiichter's  and  Ke/marszky's  statistics  the  fetal  mortality  was  nearly  40 
j)cr  cent.  Of  38  children  in  cases  of  locked  twins,  only  six  survived — a  mor- 
tality of  84  per  cent. 

Cases  arc  on  record  in  which  an  extra-uterine  fetus  has  obstructed  the  deliv- 
ery of  the  intra-uterinc  twin.  It  has  been  necessu'v  to  mak((  a  vaginal  incision 
through  which  the  former  was  extracted  betbre  the  latter  could  be  born. 

Death  of  the  fetus  during  or  before  labor,  followed  by  rigor  mortis,  has 
proven  a  source  of  obstruction  in  labor  by  the  rigidity  of  the  child  and  the  con- 
scfpient  intcrtl'rence  with  the  normal  mec'lianism  of  its  delivery,  and  cspeciallv 
of  the  shoidders  and  trunk.-'"  Ankylosis  of  the  large  joints  of  the  extremities 
may  have  the  same  etfect  to  a   less  degree. 

Labor  Complicated  by  Abnormalities  in  the  Fetal  Appendages. — 
Mciiihrdiiis. — if  th(!  membranes  are  too  thin,  they  may  rupture  prematurely, 
and  thus  give  rise  to  what  is  calletl  a  "dry  labor,"  in  which  the  birth-canal 
must  be  dilated  by  the  hard,  unyielding  presenting  part  instead  of  by  that  con- 
servative hydrostatic  dilator,  the  bag  of  waters.  Such  lai)ors  are  longer  and 
inoi'e  painfid  than  the  average,  and  there  is  a  greater  likelihood  in  them  of 
lacerations  in  the  cervix  and  a  more  fre(|uent  demand  titr  an  artificial  termina- 
tion with  I'oi'ceps.  If  tli(!  membranes  are  too  thick,  they  rupture  late,  being 
preserved  ])erhaps  until  the  child's  head  presents  at  the  vulvar  orifice,  or  even 
until  the  complete  escape  of  the  head  from  the  mother's  body.  In  these  cases 
the  head  and  face  are  covered  by  the  mend)ranes  as  though  by  a  veil,  and  care 
must  be  taken  to  ih'v  the  mouth  and  nose  (piickly,  that  respiration  nuiy  be 
instituted  without  interference.  The  membranes  thus  covering  the  head  and 
face  are  spoken  of  as  a  "caul."  It  is  possible  for  the  whole  ovum  to  lie 
extruded  uid)roken  at  term.  The  writer  has  seen  this  occur  as  late  as  the  sev- 
enth month,  and,  as  stated,  it  is  actually  recorded  at  the  full  period  of  gestation. 

Dilliculties  in  labor  may  be  encountered  in  eonse(|uence  of  an  abnormality 
in  the  (piantity  of  liquor  aninii.      If  there  is  too  little,  the  labor  has  the  same 


't 


i' 


DYNTOCIA. 


0/1 


;liiiif'al  foatiircs  as  tlioiijijh  tliorc  had  Iktii  a  preniaturo  laceration  of  the  lucin- 
Ijihik's.  IC  there  is  too  iiiiieh  Ii(|Uor  ainnii,  there  may  be  inertia  as  the  result 
(if  overstretehinjj  of  the  uterine  niiisele-fibres. 

['iiihi/ic<i/  (,hr(L — If  the  unihilieal  cord  is  too  sliort,  it  may  cause  jirema- 
iiirc  (letaehment  of  the  ])laeenta  or  may  ])reven'  the  advance  of  the  eliild. 
flic  (llaj/iioHis  of  a  short  cord  in  labor  is  always  ditTicult.  It  may  bo  sus- 
pected, however,  if  there  is  exai!;<>;erated  pain  at  the  jjlacental  site,  marked 
r('<'cssion  of  the   head   after  each   pain,  and   an  obvious  retardation  of  labor 


I'lii.  .Jxl.— rinliilical  imuiI.  cuu'-.'lit  in  llio  iixillii,  (■iH'ii'cliiiu'  llu'  shnuMiT  iiiul  iimlupscMl. 

without  otiier  ascertainable  cause.  Forceps  sliould  be  applied  in  such  a  case 
it'  the  prcsentati(»n  is  cephalic.  If  the  cord  is  too  lonu',  it  may  possibly  prn- 
liipse  slioidd  there  be  other  conditions  in  the  labor  I'avorablc  to  stich  an  ai'ci- 
ilctit  ;  or  it  may  l)e  coiled  about  the  child's  neck,  tnud<,  or  extremities,  and 
may  cousecpieiitly  be  fatally  com|)ressed  duriiiti'  labor  (  Fi>i'.  381 ). 

Obstruction  of  a  mechanical  character  in  labor  on  the  part  of  tln^  placenta 
i-^  seen  only  in  placenta  pnevia  and  in  jirohqwe  of  the  placenta.  The  placenta 
may  be  adherent  as  the  result  of  syphilitic  or  other  inflammation  of  the  cikId- 
iiH'triuni  durinti'  |)re<j;nancy,  and,  becoming-  partially  detached  in  the  third  >taij;e, 


i  -:|; 


im 


iv 


I 


a~. 


'St' 


r 

i 

B*; 

I    i>h 


nm  \'' '^'jw' '  ^m 


ii:  i  I 


fW, 


r,72 


AMKRIVAN   TEXT- HOOK   OF   OBSTETRICS. 


may  cause  alarming  liemorrliago.  It  i.s  very  commonly  .simply  retained  in  tlic 
lower  uterine  .segment  or  in  the  vagina,  whence  it  may  be  cxpresised  by  the 
proper  application  ot'Cre(le'.s  method.  In  .some  cases  the  atmospheric  pre.ssiiir 
obstructs  tiie  delivery  of  a  retained  placenta  .so  ett'ectually  that  it  is  necessarv 
to  hook  one's  finger  over  the  edge  of  it,  to  allow  the  a(!cess  of  air  behind  it. 
before  its  expre.ssiitn  is  possible.  Retention  of  the  placenta  may  be  due  to  its 
great  bidk,  as  in  twin  placenta;,  or  to  tumors  increasing  its  size.  In  such  cases 
it  may  be  necessary  to  extract  the  placenta  manually. 


REFERENCE    LIST. 


10. 

11. 

12. 


'I: 


/)((.'(  rn(\e  Urrkrii. 

Lit/niann ;  "  Drei  VortriiKe  iiber  die 
(iesi'liiohte  von  der  Lclire  der  (lehiirt 
bt'i  I'liffi'in  lic'fken,"  in  Iiis  Ueburt  bei 
('iit/nii  Jicrkrii,  tic,  1884. 

Tr(innactioiii<  of  the  American  Gynecological 
Sodrti/,  181)0,  p.  8()7. 

Miilli'r'.s  llunilhnck. 

Robert  Wallace  John.son  :  ^1  AVic  Si/nlem 
of  Midu'iferij,  etc.,  London,  17(1!). 

Hirst  :    I'niirrsit;/  M,<lintl  Mu<inzine. 

"Die  Hecken  Anomaiien,"  by  Friedrich 
Schauta,  in  .Miilk-r's  llandhnch  der  llc- 
burt.'iliiilj'r,  I!(l.  ii.  ;  Ik'tschler,  Aniialcn 
der  UlniKchen  Anstalteii,  i.  pji.  24,  (iO  ;  ii. 
p.  !U  ;  Engi'lkcn,  />/.«.  liKutf/.,  Miincbcn, 
1878  ;  "  Ziir  Kentniss  der  extra-median 
Einstellinii;  de.s  Kopl'es,"  Kobn,  Vraijer 
ZeitKehrij}  flir  Hrilhtnde,  Bd.  ix. 

rrai/er  Ziitichriftfiir  Heilkumle,  I5d.  ix.  II. 
4  and  •"). 

Die  ILiftelherf/er  kliiti^chen  Annalen,  I5d.  x. 
]).  44i).  .More  elaborately  described  in 
his  folio  atlas,  Jhis  Selirii;/  reretii/te 
Jieckeii,  tiebM  eineni  Anhaiuj  iiber  die  irich- 
ti;/nte)i  Fehler  des  Weibl,  liee/cetin  l^eber- 
liaupt,  mit  IC)  Tallen,  Mainz,  18;}.7. 

Stiiilil  di  (Mefriria  e  (;iiuTi,l.,  .Milan,  18<,I0, 

Jahrc.fherirht  iiber  d,  Furtnehr.  <i.  d.  Gebiete 
der  (t'eburlfili.,  ele.,  vol.  iv.  |).  188. 

Franz  Lndwisj  NeUKebauer  :  "  Hericlit  iiber 
die  neueste  Kasuistik  nnd  Litteratur  der 
Spondylolisthesis,"  etc.,  Zeltnehrlj't  J'iir 
(lebtirt.-fliiilfe  iind  Gjpilikolor/ie,  Hd.  xxvii. 
II.  ii.  1808;  "Spondylolisthesis  et 
Spondylizenio,"  Rcitiimv  dex  lieclierrliex 
litternires  et  permtiellc  depitin  /<W0 
jimju'en  1S!)J,  I'aris,  (i,  .Stt-inheil, 
1892;    "Contribution  a  la    I'athogenie 


18. 


14. 
If). 
16. 
17. 
18. 

1<). 

20. 


21. 

22. 
28. 

24. 


2(!. 


et  an  f)ia,i!;nosti(iue  du  Hassin  vicie  par 
le  ()lis,senient  vertebral,"  Auiudex  </.■ 
Gijneedlnijie,  Feb.,  1884;  Zur  Enlwieke- 
hnKjMienehiehte  ties  Spondijbilixlheli.-'nhin 
Jieekcns  und  .winer  Diaf/uone,  Halle  and 
Dorpat,  1882,  p.  294;  see  also  Areldr 
J'iir  (ri/niik<>b)<iie,  Hd.  xx.  II.  i.  and  ltd. 
xxi.  II.  ii. 

Ilii-st:  "The  Influence  of  the  Ili.biluiil 
Inclination  of  the  I'elvis  in  the  Ereci 
Posture  u|>on  the  Shape  and  Size  of  the 
Pelvic  Canal,"  UiiieerKitj/  Medic(d  Mmju- 
zine. 

Centr(dbhitt  fiir  Gi/niikohfiie,  1889,  [i. 
()12. 

XouvelleK  ArchircK  d'  Obxtctriiine  et  de  Gijw'- 
coloi/ie,  1890,  p.  C40. 

Soutbermann  :  lierliner  medicinixche  W'url,- 
ensrhrijl,  1879,  41. 

Jeutzen  :  Archives  de  Tocologie,  Paris,  189it, 
If.  8. 

Ablfeld :  ZeituchriJ't  fiir  (leburtahiilfe  uml 
Gijniiknlogie,  Bd.  xxi.  p.  160;  ibid.,  Hd. 
xiv.  p.  14. 

"  Ueber  (icscbwiilstc  der  Vagina  i\\> 
Schwangei-schaft  nnd  (ieburts-konipli- 
kationen,"    Disn.    Innng.,  Bern,   1889. 

Adams:  "Ilerniji  of  the  Pregnant  I'tc- 
rus,"  Amerirnn  Jimrmd  of  Obslelrle.<. 
vol.  xxii.  p.  22."). 

Xouvelles  A  rehires  d'OhMeiri<iue,  1890. 

Sutugin  :  loc.  eif. 

Phillips:  liritixh  Medical  Journal,  188S,  j. 
p.  881. 

Fussell  :  Medical  Xetr.t,  Philadelphia,  1891, 
p.  40. 

Dm.  Lmug.,  Berlin,  1890. 

Feis  :  "  I'cber  intrauterine  Leichenstarre," 
Archie fiir  Gyniikologie,  Bd.  4(),  II.  2. 


DYSTOCIA.  673 


2.  Dystocia  due  to  Accidents  and  Diseases.* 

1.    ACCIDKNTH   TO    I'lIK    UmHILICAK   CoUI>. 

Tli(>  cord  iLsimlly  meusuros  about  20  inches,  but  it  may  have  twice  or  thrice 
that  length,  or  may  even  be  lonj^cr.  In  v'onse(|neuce  of  this  Increased  len<rth 
jti'olapse  is  liable  to  occur.  (Jreat  lenj>'th  of  the  cord  at  least  permits  more  or  less 
iHMiierous  coils  or  "circulars"  of  the  finils  about  the  fetus  or  its  members.  In 
consequence  of  these  circulars  the  cord  may  i)e  shortened,  or  there  nuiy  be 
a  natural  shortness  of  the  cord.  The  cord  has  been  known  not  to  exceed 
10  centimeters  (4  inches)  in  leni>;th,  but  most  generally  iUs  shortness  results 
from  its  coiling  around  the  fetal  parts.  This  brevity,  whether  natural  or 
accidental,  interferes  with  labor,  and  may  cause  conditions  more  or  less  grave 
to  the  child  and  to  the  mother,  for  a  ruptured  cord,  a  detached  placenta,  or 
even  an  inverted  uterus,  may  be  among  the  accmlents  resulting  from  the 
anomaly,  t'ompleti'  absence  of  the  cord  has  been  observed,  the  vessels  pass- 
ing directly  from  tlu^  abdomen  of  the  child  to  the  adjoined  placenta.  The 
reason  is  therefore  plain  for  including  in  a  single  group  anomalies  oi",  and 
accidents  to,  the  (H)rd. 

Prolapse  of  the  Cord. — By  prolapse  is  meant  descent  of  the  cord  with, 
or  in  advance  of,  the  presenting  part  of  the  fetus.  The  prolapsed  loop  may  be 
ielt  mobile  in  the  waters  when  the  membranes  are  unrnptiu'ed  ;  or,  the  amnial 
liquor  having  been  discharged,  the  loop  may  be  in  the  vagina  ;  or,  finally,  it 
may  be  external  to  the  vulva  (Fig.  381).  Thus  there  are  threef  varieties  of  pro- 
lapse, thnugli  some  authorities  describe  the  first  variety  as  presentation  of  the  cord. 
The  second  variety  of  prolapse  may  be  met  with  though  the  first  was  not 
observed  or  even  did  not  occur,  the  loop  having  suddenly  been  carried  into 
the  vagina  by  a  free  discharge  of  anmial  licjuor.  In  most  eases  the  two 
liaK'es  of  the  loop  are  in  a))position,  but  in  some  cases  the  i)resenting  part 
may  intervene.  Thus  in  presentation  of  the  head  one  half  of  the  loop  may 
be  on  one  side  and  the  other  half  on  the  other  side  of  the  presenting  i)art;  or 
in  presentation  of  the  pelvis  the  cord  may  be  between  the  thighs. 

The  frequency  of  j)rolapse  of  the  cord  is  variously  statcil.  According 
to  Winckel,  clinics  give  from  1  in  65  to  1  in  500;  this  accident  is  oftener 
observed  in  hospital  practice  than  in  private  practice. 

Etiolopy. — The  essential  cause  of  prolajise  of  the  cord  is  want  of  corre- 
spondence between  the  presenting  part  and  the  lower  portion  of  the  uterus, 
for  if  the  former  'illy  occupies  the  space,  there  will  be  no  room  for  the  cord. 
Among  causes  :.iat  contribute  to  this  accident  are  great  length  of  the  cord  ; 
the  woman  starding  or  sitting  when  the  membranes  rupture  ;  an  excessive 
quantity  of  amnial  liquor;  smallness  of  the  fetus;  multiparity  ;  implantation 

*  The  superior  figures  (M  occurring  throiighoiit  tlie  text  of  this  .irticle  refer  to  the  hiliIiogra|ihy 
given  on  jiage  644. 

t  The  elussificution  nutdu  hy  Jucquemier,  Manud  ilea  Accoitrhement.-i,  184t),  has  been  adopted. 


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AMERICA y^   TKXT-BOOK   OF   OBSTETRICS. 


of  tho  placonta  in  tlic  lower  portion  of  the  nteriis ;  marginal  attac-luncnt  of 
the  cord  ;  pendulous  abdomen  ;  plural  proffnancy  ;  the  birth  of  a  male ;  a  com- 
plex presentation — as,  for  example,  descent  of  a  hand  w'th  tho  head  ;  present- 
ation other  than  of  the  vertex  or  the  face ;  and,  more  important  than  any  of 
these,  narrowing  of  the  pelvis.  Kaltenbach '  remarks  that  prolapse  of  the 
cord  in  presentation  of  the  head  occurring  in  a  primipara  should  alwavs 
excite  suspicion  of  a  narrow  ])elvis.  Predisposition  has  also  been  mentioned 
as  a  cause,  the  accident  having  been  observed  in  suc<;essive  pregnancies ;  but. 
of  course,  to  admit  i)redisposition  as  a  cause  no  other  obvious  cause  must  be 
present.  Roper  ^  has  given  a  case  in  which  the  accident  occurred  in  three  suc- 
cessive pregnancies,  but  there  was  notable  lessening  of  the  conjugate.  The 
prolapsed  loop  usually  descends  in  front  of  one  of  the  sacro-iliac  joints  or  in 
front  of  the  cotyloid  cavity,  and  rarely  directly  anterior  or  posterior. 

The  (Ikuinos'iH  of  prolapse  of  the  cord  can  immediately  be  made  if  the 
membranes  have  ruptured  and  the  loop  is  in  tho  vagina,  and  still  more  readily 
if  the  cord  is  external  to  the  vulva.  A  mistake  in  either  case  woidd  seem 
impossible  ;  but  with  the  membranes  intact  and  with  the  pulsation  absent  the 
diagnosis  is  more  difiicidt.  The  obstetrician  feels  with  his  fingers,  in  tho  in- 
terval of  uterine  contraction,  a  soft,  floating  body,  the  thickness  of  a  finger  ;  he 
can  define  it  as  the  cord  by  hooking  his  finger  in  the  loop  and  pressing  it  against 
the  i)rosenting  part  or  against  the  uterine  wall :  if  pulsation  is  detected,  there 
is  no  possibility  of  doubt.  Winekei '  called  attention  to  the  fact  that  if,  in 
auscultating  '^he  fetal  heart,  the  sounds  become  slower,  there  is  probable 
pressure  upon  the  cord,  and  an  examination  may  leail  to  the  discovery  of 
prolai)se  of  the  cord. 

PrognoHix. — Danger  to  the  mother  is  exceptional  in  prolapsed  coid.  In 
eonse([uence  of  the  cord  being  stretche<l  tightly  over  the  head  of  the  child,  or, 
in  pelvic  presentation,  of  tho  child  being  astride  of  the  cord,  there  may  be  su<'li 
an  accidental  shortening  of  tho  cord  that  dotachmont  of  tho  placenta  witli 
Ijomorrhago  results.  Moreover,  the  operations  which  the  prolapse  may  re(|iiirc 
in  its  treatment — mainial  or  instrumental  reposition,  iiodalic  version,  or  ex- 
traction with  the  fitrceps — are  not  to  bo  regardtnl  as  trivial  matters  and  with- 
out peril  to  tho  mother,  although  that  peril  is  slight.  The  danger  to  the  child, 
however,  is  very  great.  Probably  it  is  correct  to  give  the  mortality  as  not 
less  than  40  per  cent. 

The  danger  to  the  fetus  is  comj)ression  of  tho  cord,  death  resnltinir 
from  asphyxia.  The  danger  varies  also  with  the  |)resentation,  being  great- 
est in  that  of  tho  head,  but  much  loss  in  shoulder  or  breech  presentation. 
Karly  prolapse  is  nioro  unfiivorable  than  late  prolapse.  If  tho  cord  is  im- 
planted upon  tho  margin  of  the  placenta  and  the  placenta  occujiies  a  low 
position  in  tho  uterus,  or  if  tho  insertion  is  volamentous,  or  tho  pelvic  con- 
traction (a  fiictor  in  causing  the  disorder)  is  great,  tho  prognosis  is  more 
unfavorable  than  when  opposite  eonditions  arc  |)resent.  Finally,  the  anioinit 
of  tho  ])rolapsed  portion  and  the  part  of  the  pelvis  in  which  it  descends  should 
be  considered. 


DYSTOCIA. 


575 


ittaolunent  of 
male ;  a  coin- 
ead ;  present- 

tlian  any  of 
olapse  of  tlic 
lionld  always 
?n  mentioned 
nancies;  but, 
aiise  mn.st  bo 

in  tbrec  suc- 
jngate.  The 
J  joints  or  in 
(sterior. 

made  if  the 
more  read! I v 
!  wotdd  seem 
Dn  absent  tiie 
rs,  in  the  in- 
f  a  fin<;;er  ;  he 
iing  it  against 
eteeted,  there 
et  that  if,  in 

is  probal)le 
liseovery  of 

1  cord.  Ill 
die  ehihl,  or, 

may  be  sueli 
hieenta  with 

may  re(|iiire 
rsion,  or  cx- 
rs  and  with- 

to  the  child, 
tab'ty  as  not 

di  resnltinjr 
being  great- 
)resentation. 
cord  is  im- 
iipies  a  h)\v 
pelvic  con- 
sis  is  more 
the  amount 
ends  slioidd 


Treatment. — If  it  is  certain  that  tlie  child  is  dead,  a  purely  expectant  plan  of 
treatment  is  indicated  in  prolapse  of  the  cord.  The  diagnosis  of  death,  however, 
should  be  made,  not  solely  from  finding  the  cord  pulseless,  for  ])ulsation  may 
l)e  absent  in  it  for  several  minutes  and  yet  the  child  be  alive,  but  by  careful  and 
repeated  abdominal  auscultation.  Again,  if  the  prolapse  is  simply  a  compli- 
eati(»n  of  placenta  prievia  or  of  shoidiler  presentation,  the  treatment  of  the 
essential  disorder  is  first  in  importance,  and  it  may  prove  best,  too,  for  the 
complication.  In  ordinary  cases  restoration  of  the  prolapsed  cord,  if  this 
be  possible,  is  the  ol)stetrician's  first  duty. 

In  the  first  variety  or  degree  of  prolapse,  f'rerjuently  called  "  |)resentation 
of  the  cord,"  the  patient  should  be  recunnbent  anil  great  care  should  be  taken 
to  avert  early  rupture  of  the  mendiranes.  It  will  ha  l)etter  for  the  patient 
to  lie  upon  the  side  opposite  to  that  (tn  which  the  prolapse  o<«urs,  and  her 
head  should  be  low.  Ilicks  advises  that  the  patient  assume  the  knee-elbow 
position  and  that  entrance  of  air  into  the  vagina  be  se<.'ured. 

In  the  second  degree  of  ])rolapsc — namely,  a  loop  of  the  coid  in  the  vagina 
— if  the  pulsation  is  good,  the  (^ord  being  at  the  side  of  the  head,  in  front  of 
one  of  the  sacro-iliac  joints,  and  the  descent  of  the  head  being  rapid,  so  that 
spontaneous  delivery  will  sjwedily  ocinir,  it  is  better  to  wait,  interference  with 
forceps,  for  example,  being  determined  by  the  ptdsations  in  the  cord  becoming 
feebler  or  ceasing.  La  Motte,  whose  rule  in  cases  of  prolapsed  cord  was 
podalic  version,^  gives  a  graphic  account  of  one  of  his  cases  ending  favorably 
for  both  mother  and  child.  lie  did  not  discover  that  the  cord  had  descended 
until  he  found  it  in  the  vagina,  and  the  uterine  action  was  so  great  and  con- 
stant that  he  could  not  attempt  to  turn.  In  his  Rcflix'Um  he  observes  that 
probably  his  "  ignorance  was  the  safety  of  the  child." 

If  speedy  delivery,  either  spontaneous  or  instrumental,  is  im|)ossiblc,  repo- 
sition of  the  cord  is  indicated.  This  replacement  is  postural,  manual,  or  the 
two  combined.  Instrumental  reposition  nn'ght  have  been  included,  but  there 
is  no  instrument  equal  to  the  hand  for  this  purpose,  hence  reference  to  the 
various  repositors  will  be  omitted.  If  the  postural  method  is  employed,  the 
patient  is  put  in  the  knee-ell)ow  position.  The  hand  niay  also  be  used  at  the 
same  time,  as  advised  by  Kaltenbach,  but  it  is  preferable,  if  mamnd  assistance 
be  required,  that  the  patient  should  be  upon  the  side,  for  then  oidy  can 
anesthesia  fully  and  satisfactorily  be  cinj)loyed.  IJraxton  Ilicks  gives  the 
folhtwing  directions  :  "  The  anesthetic  having  been  given,  the  patient  remain- 
ing in  the  ordinary  lateral  obstetric  ])osture,  one  hand  is  placed  over  the  abdo- 
men and  the  position  of  the  child's  head  is  made  out.  This  may  be  done  by 
separating  the  thighs  and  passing  the  hand,  preferably  the  right,  between  them. 
The  left  hand,  having  its  back  greased,  is  passed  into  the  vagina,  and,  gather- 
ing the  funis  together,  carries  it  past  the  head,  which  is  at  the  same  time 
pressed  sufficiently  aside.  When  the  funis  is  restort><l  the  external  hand 
presses  the  head  down,  and  the  fingers  inside  receive  it  and  adjust  it  in  the 
OS.  Six  or  more  labor-pains  having  occurred,  the  internal  hand  may  be  re- 
moved, although  it  might  have  earlier  been  removed,  and  rein*:rotluceil  to  feel 


11  .e 


■:       .    "^ 


-'■;■ 


57<5 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


if  the  funis  is  still  up.  The  patient  can  then  be  plaeetl  on  her  hack,  while 
the  outer  hand  is  kept  a  little  lon-^er  to  seeure  the  adaptation  of  the  lower 
uterine  zone  to  the  heatl."  * 

The  writer  has  two  remarks  to  make  in  regard  to  the  metlio*!  suggested  by 
Hieks.  The  use  of  the  left  hand  tor  replaeinj^  the  cord,  the  patient  being 
upon  her  left  side,  is  suitable  if  the  prolapse<l  loop  of  cord  bt*  upon  the  right 
side  of  the  pelvis,  but  if  the  funis  has  tleseendiHl  upon  the  left  side,  then  the 
woman  should  In*  in  the  right  lateral  position,  and  the  right  hand  is  the  pref- 
erable one  for  introduetion,  while  the  left  hand  is  used  externally.  Further, 
when  the  cord  is  restored  it  is  well  to  hook  it  over  some  part  of  the  child, 
the  knee,  for  example,  or  pass  it  above  the  chin :  the  method  of  placing  tli(> 
cord  over  one  of  the  lower  limbs  to  prevent  its  again  falling  was  probably 
first  recommended  in  1786  by  Croft."  By  whatever  method  the  cord  has 
been  replaced,  pn)lapse  is  very  liable  to  recur.  So  great,  iudee<l,  is  this 
liability  that  some  classic  writers  on  obstetrics  have  compared  its  restoration 
with   the  task  of  the  Danaides  and  with  that  of  Sisyphus. 

Manual  reposition  having  failed,  podalic  version  best  meets  the  emergencv 
of  prolapsed  cord.  Spicgdberg^  takes  the  grounil  that  it  is  not  well  to  spend 
too  much  time  in  trying  to  replace  the  cord,  such  ettbrts  in  themselves  disturb- 
ing the  umbilical  circulation,  and  perhaps  injuriously  alfecting  the  subseciuent 
course  of  the  uterine  contractions. 

After  version  the  question  of  immediate  delivery  will  be  determined  bv 
the  condition  of  the  fetal  circulation,  for  if  this  remains  good  it  is  better  to 
leave  the  expulsion  of  the  child  to  the  forces  of  nature.  Winekel  advises,  in 
shoulder  presentation  complicated  by  prolapsed  cord,  immediate  extraction 
after  version,  because  the  latter  can  hardly  be  etfected  without  great  pressure 
upon  the  cord.  If  in  pelvic  presentation  the  child  is  astride  of  the  cord,  an 
etlbrt  should  be  maile  to  draw  down  enough  of  the  loop  to  permit  its  being 
passed  over  one  thigh  :  if  the  loop  does  not  permit  this  lengthening  or  if  there 
is  dangerous  stretching,  it  is  better  to  divide  the  cord. 

Coils  or  Circulars  of  the  Cord. — The  cord  encircles  the  fetus  once 
in  about  every  six  cases  of  delivery.  These  coils  or  circulars — adopting  the 
ecpiivalent  of  the  French  circulabrx  as  applied  to  this  condition — are  nnieh 
more  frequently  about  the  neck  of  the  fetus,  but  they  may  be  around  the  body 
or  around  the  members.  There  may  lx>  one  or  several  circulars  ;  for  example, 
the  cord,  while  usually  around  the  neck  once  or  twice  only,  may  encircle  it  six, 
seven,  or  even  eight  times.  The  optimism  of  Jacquemier  led  him  to  believe 
that  cii'culaires  were  a  wise  provision  against  prolapse  of  the  cord.  This 
anomaly  is  generally  associated  with  great  length  of  the  cord,  but  in  some 
cases  the  length  is  normal,  and  in  a  very  few  it  is  less  than  normal. 

Etiolorjif. — Winekel '  mentions  as  causes  of  circulars  a  long  cord,  a  largo 
quantity  of  amnial  liquor,  the  yielding  uterine  walls  of  multiparae,  marginal 
and  velamentous  insertion  of  the  funis,  and  smallness  of  the  child.  Of  cours<' 
the  movements  of  the  fetus  are  the  immediate  cause  of  the  anomaly.  Chan- 
treuil  observes*  that  experience  does  not  confirm  the  opinions  of  Michgorius, 


nvsToru. 


677 


Mine.  Boivin,  ami  others,  who  attribute  ciiciUarH  to  the  excessive  raoveiiK'nta 
ot'  tlie  mother. 

The  injurious  results  of  circuhirs,  so  far  as  hihor  is  concerned,  usually  arise 
{yam  brevity  of  the  cord — a  Iv-evity  which  is  then  called  "accidental,"  tliouj^h 
l)v  njany  the  adje«'tive  "relative"  is  applied  to  the  condition  to  distinguish  it 
Iroin  "absolute"  brevity.  The  accidents  resulting  from  shortness  of  the  cord 
will  be  considered  in  the  next  secition. 

Natural  or  Accidental  Shortness  of  the  Cord.* — By  natural  short- 
i)(>s  of  the  cord  is  meant  that  the  length  measured  fntm  the  uml)ili(;us  to 
ilic  placental  insertion  is  insutli(;ici:t  lo  permit  expidsion  of  the  child  without 
rupture  of  the  cord,  placental  devaehment,  or  uterine  inversion.  Accidental 
slmrtness,  usually  arising  from  coils  alwut  the  neck  of  the  child,  is  similarly 
(Icliucd,  cxce|)t  that  the  pctiiit  of  the  fetus  from  which  the  measurement  is 
liikcn  is  no  longer  the  umbilicus,  but  is  the  neck. 

It  is  evident  that  the  length  (»f  the  cord  will  vary,  in  case  of  absolute 
lircvitv,  with  the  degret?  to  which  it  can  be  stretched,  and  in  aci'idental  brevity 
uitii  this  elasticity,  and  also  with  the  tightness  of  the  coils  caused  by  the 
strain.  Fiu'thcr,  the  point  of  placental  attachment,  either  in  the  upper  or  the 
lower  part  of  the  uterus,  and  the  insertion  of  the  cord,  whether  marginal  or 
(•out ral,  must  also  Ix'  taken  into  consideration.  Matihews  Dinican*  assumed 
(iiat  "  it  is  impossible  to  make  a  (piite  exact  statement  of  the  length  of  any 
mrd  while  i>roving  itself  a  cause  of  difficult  labor."  Lamare  says,  accepting 
the  statement  of  Xegrier  that  the  length  of  the  genital  canal  at  the  time  of 
expulsion  of  the  fetus  is  '22  centimeters  (8j  inches),'"  that  true  brevity  begins 
at  2")  centimetei-s  (10  inches),  and  that  only  belo\.  this  length  does  the  cord 
inevitably  cause  accidents.f 

Shortness  of  the  c(»ril  does  occur,  notwithstanding  the  scepticism  of 
DeweeSjJ  though  the  instances  of  it  arc  infrc(pient.  The  consequences  of  this 
condition  are  painful,  protracted  labor;  in)possibility  of  spontaneous  deliv- 
ery ;  there  may  be  fatal  pressure  upon  the  cord,  or  it  may  be  torn  and  there 
may  be  hemorrhage  from  <letachment  of  the  i>lacenta,  and  even  invei'sion  of 
th(>  uterus.  Rigby  gives  an  instance  of  a  cord  which  was  only  2  inches  long 
l)cing  torn  at  its  placental  insertion,  the  delivery  being  spontaneous.  Kales" 
delivered  with  the  forceps  in  a  case  in  which  there  provetl  to  be  accidental 
sliorteiiing  of  the  cord.  On  making  traction  during  a  pain  he  foiuid  there 
then  occurred  a  notable  depression  at  the  fundus  of  the  uterus,  the  depression 
disappearing  when  the  traction  ceasetl — one  of  the  signs  of  this  anomaly, 
according  to  some  authorities,  although  denied  by  others.     Werder'*  reports 

*  Most  authors  use  the  terms  uhsnliile  imd  relalhv,  but  the  writer  tliinks  thiit  tlie  adjectives 
wliicli  lie  licre  employs  are  preferable. 

t  Kalteuhach  { Li-lirhiich  <ler  Gi-hitrhhiil/f,  1803)  Mates  that  if  the  placent.il  insertior  of  the 
cord  is  at  tiie  fundus  3")  centimeters  is  too  short,  while  in  deeper  insertion  20  centimeters  is 
sulllcient. 

t  "  I  shall  not  positively  deny  the  existence  of  such  a  condition  ;  hut  I  nnist  say  I  have  never 
seen  an  instance,  and  also  that    I  entertain  strong  doubts  of  its  possibility." — C'umpendiuua 
*j/.t(?Hi  of  Midififcnj,  8th  ed.,  I'hilada.,  1837. 
37 


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AMF.RK'AN    TKXT-JiOOK    OF    OliSTETltirS. 


a  oaso  ill  wliidi,  the  diild  iH'iiij;  di'livorc*!  with  foreops,  tiie  cord  was  found 
torn  at  the  uiid)ilinis,  and  with  it  a  largo  cin-nlar  Hap  of  skin :  the  cord  wa- 
Icss  tlian  4  int'lios  lonj*;.  Fclkiii '"'  nari'atos  a  case  of  spontaneous  delivery  in 
wliieh  the  cord,  oj  inches  in  lenjith,  was  torn  and  the  placenta  was  cxjM'lled 
with  the  ehihl,  severe  heniorrha<;e  occurring.  In  a  second  case  of  accidental 
sliortness  of  the  cord,  there  being  five  coils  about  the  ueck  and  one  around  tlic 
body,  the  delivery  was  spontaneous  and  inversion  of  the  uterus  .M-currrd. 
Dyrcnfurth  of  Jircslau,'*  in  a  case  of  hydrocephalus,  punctunMl  the  head  ami 
delivereil  it  with  the  crauioclast  ;  there  was  then  delay  in  extracting  the 
shouhlers,  and  when  this  dilficulty  was  overcome  and  the  labor  was  ended 
it  was  found  that  the  cord,  which  measured  but  3  centimeters,  was  torn  halt' 
a  centimeter  from  the  umbilicus.  Malgoiiyre  had  a  patient  in  labor  at  term, 
and  immediately  after  the  rupture  of  the  mend>ranes  the  child  and  placenta 
were  expelled,  the  cord  being  tbund  to  be  2  inches  and  8  or  1)  lines  in  length. 
In  a  case  reported  by  Leroux '"  the  umbilical  cord  was  so  short  after  tlu- 
escape  of  the  fetus  that  the  umbilicis  was  closely  applied  to  the  vidva,  and 
the  child  could  not  be  taken  away  until  the  ])laceuta  was  cxjiclled. 

It  has  been  establishtnl  by  Xegrier  '^  that  if  there  be  accidental  shortening 
of  the  cord  because  of  a  loop  around  the  neck,  ]>artial  delivery  may  occur,  the 
child  breathing,  and  then,  unless  suitable  assistance  be  rentiered,  the  child  will 
be  strangled  from  constriction  by  the  «)rd.  Maekness,'^  in  a  ease  of  placenta 
pnevia,  after  iwrforming  j)odalic  version,  bringing  down  one  foot,  and  finding 
the  hemorrhage  not  arrested,  brt)Ught  down  the  other  foot ;  after  extracting 
the  boily  further  i)rogress  was  arrestwl  because  of  the  cord  passing  between  the 
child's  leijs.  It  was  necessarv  to  cut  the  conl  before  the  head  could  be 
delivered. 

DUignonlii, — The  signs  usually  given  of  brevity  of  the  cord  are  severe 
pain  at  the  place  of  the  supposed  placental  attachment ;  depression  of  this 
part  during  a  uterine  contraction  or  when  traction  is  made  with  the  forceps; 
marked  recession  of  the  head  in  the  interval  of  contractions,  this  recession 
beintr  yrreater  than  can  be  attributcnl  to  the  resistance  and  elasticitv  of  the 
lower  part  of  the  birth-canal;  irregular  discharges  of  blood;  and  arrest  of 
pains.  Napier '*  regards  uterine  inertia  as  a  more  important  diagnostic  sign 
than  retraction  of  the  head.  Dr.  King,"  who  has  made  several  important  con- 
tributions on  the  subject,  states  as  a  characteristic  sign  that  the  patient  has  ii 
persistent  desire  to  .sit  up. 

Coils  about  the  body  niay  be  known  in  some  eases  by  auscultation,  in  still 
rarer  cases  by  abdominal  palpation.  Ilaake  was  the  first  (in  IHGo)  to  discover 
coils  around  the  neck  by  rectal  touch.  But  the  only  certain  way  to  ascertain 
that  there  is  shortness  of  the  cord  is  to  feel  it  and  actually  to  know  that  it  is 
tight  and  stretched.  This  niay  be  done  in  breech  presentations,  when  the 
child  is  astride  of  the  cord  or  after  the  breech  is  born,  by  j)assing  one  or  twn 
fingers  up  to  the  umbilicus,  and  finding,  by  judling  toward  the  placental  end. 
the  cord  so  taut  that  it  is  impossible  to  draw  any  ])art  of  it  down.  In  \>\\'<- 
entation  of  the  head,  after  expulsion  as  far  as  the  umbilicus,  a  similar  method 


3   '■ 


DYSTOCIA. 


579 


nul   could  1)0 


of  oxaiuination  may  also  be  employwl.  Hicks  "  narrates  a  case  in  which  he 
iiiiulc  the  diagnosis  of  short  cord  ;  after  the  delivery  of  the  breech  he  luul  to 
tliviile  the  cord  before  the  rest  of  the  child  could  Iw  born.  The  cord  proved 
to  l)e  Init  4  inches  long. 

Treat menl. — In  regard  to  the  treatment  of  shortness  of  the  cord  but  little 
can  l)e  said.  Koederer,  and  many  obstetricians  since  his  day,  urged  the 
importance  of  pressing  the  uterus  downward,  the  obvious  benefit  of  which,  of 
coiu'se,  is  to  bring  the  placental  attachment  nearer  the  fetus.  King"  seeks  to 
iiccoinplish  the  same  object  indirectly  by  having  the  woman  "  take  a  kneeling, 
sitting,  or  sfjuatting  ))osition,  or  by  so  elevating  the  shoulders  that  she  is 
placed  midway  between  lying  upon  her  back  and  sitting."  Jn  comicction 
with  J)r.  King's  method  the  following  citation  from  Dcnman*  is  of  interest: 

"  If  the  child  shoidd  not  be  born,  when  we  have  wait(!il  as  long  as  we  be- 
lieve to  be  proper  or  consistent  with  its  safety  or  with  that  of  the  parent  it 
will  be  riHpiisite  to  change  her  position,  and,  instead  of  sufl'ering  her  to  remain 
in  a  recumbent  one,  to  take  her  out  of  bed  and  raise  her  upright  to  permit  her 
to  bear  her  pains  in  that  situation  ;  or,  according  to  the  ancient  custom  of  this 
country,  to  let  her  kneel  before  the  bed  and  lean  forward  upon  the  edge  of  it ; 
or,  as  is  now  ])ractised  in  many  places,  to  set  her  upon  the  lap  of  cue  of  her 
assistants." 

It  is  better  that  the  child  should  be  delivered  by  ]>resstn'e,  fetal  expression, 
than  with  the  forceps.  Instrumental  delivery  is  the  last  resort.  Of  course, 
when  a  short  cord  is  discovere<l,  which  will  usually  be  only  af\er  jiartial  expul- 
sion of  the  fetus,  the  cord  shoiiM  be  dividetl.  When,  in  accidental  brevity 
of  ihe  cord,  the  strain  is  not  relieveii  by  cutting  the  cord  or  by  removing  one 
or  more  of  the  coils  over  the  head,  the  child  is  usually  delivered  by  what 
Duncan*'  terms  a  movement  of  spontnneous  evolution  :  "in  consequence  of  the 
strain  upon  the  i-ord  the  fetus  so  revolves  that  its  anterior  surface  is  brought 
to  look  forward."  Duncan  adds  that  in  cases  of  ct)ils  about  the  neck  this 
revolution  is  in  a  diiection  to  undo  partially  the  encircling,  and  thus  to  lessen 
the  strain  upon  the  cord,  and  that  this  part  of  the  evolution  may  artificially 
be  perft)rmed  to  aid  the  delivery. 

Rupture  of  the  Cord  and  of  its  Vessels. — The  cord  may  be  torn  or  there 
may  be  rupture  of  one  or  more  of  its  blood-vessels  ;  in  other  words,  there  may  be 
cdinplete  or  partial  rupture.  Some  illustrations  of  rujjtures  of  the  coril  have 
been  given  in  the  pnveding  section.  This  accident  occurs  most  frecjiiemly  in 
('()nse(|uence  of  absolute  or  accidental  shortness,  omitting  those  cases  in  which 
the  obstetrician  tears  the  cord  in  an  effort  to  extract  the  placenta.  The  strength 
(if  the  funis  has  been  the  subject  of  experimental  study.  The  experiments  of 
Duncan  and  TurnbulP'  show  that  the  average  resistance  of  the  cord  to  a  strain 
on  it  is  eight  and  a  (piarter  poiuids,  the  weakest  cord  yielding  to  five  aiul  a 
half  pounds,  and  the  strongest  to  fifteen.  The  experiments  of  Lamare"  prove 
that  in  order  to  ru])ture  a  cord  of  50  centimeters  by  a  weight  falling  25  cen- 
timeters, it  is  sufficient  that  this  weight  may  in  the  mean  e(pial  lotK)  or  2UU0 
grams,  and  it  may  even  be  as  small  as  GtIO   grams.     He  has  shown  also 


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AMKIiK'Ay    TEXT- HOOK   OF   OliSTKTHJCS. 


that  tlio  liviiij;  cord — that  is,  tlip  cord  liaviiij;  its  vessels  filled  with  warm 
water — breaks  with  a  slightly  less  force  than  the  dead  cortl. 

It  is  evident  that,  as  has  repeatedly  Iwen  provcnl,  the  cord  may  Ix*  torn 
simply  hy  the  weigiit  of  the  child,  expulsion  taking  place  while  the  nutther  is 
erect  or  even  semi-erect.  Moreover,  there  are  instances  of  the  cord  giving  wav 
in  childbirth  while  the  woman  was  lying  in  bed.  Spaeth's  ease*  illustrates 
this :  In  a  primipara,  the  first  stage  of  labor  being  tedious  and  the  second 
stage  lasting  btit  half  an  hour,  a  violent  contra<'tioii  m-curred  while  the  mid- 
wife was  placing  a  cushion  under  the  patient's  hips,  and  the  child  was  driven  out 
a  distance  of  ')0  centimeters  from  the  genital  organs.  The  cord,  thick,  gelat- 
inous, and  friable,  was  broken  :  it  was  30  centimeters  l<»ng,  and  the  rupture 
was  in  its  middle.  liudin  "■"  has  given  a  similar  case  :  The  patient,  a  secundip- 
ara, made  violent  expulsive  efforts,  and  the  child  was  rapidly  expelled.  The 
cord,  which  encircle<l  one  of  the  thighs  of  the  child,  was  torn  10  centimeters 
from  the  umbilicus:  its  entire  length  was  42  centimeters,  liudin '^  has  also 
given  a  ease  in  which  the  weight  of  the  phu-enta,  which  was  suddenly  expelled 
and  fell  to  the  floor,  ruptured  the  cord  near  the  umbilicus.  The  attendant, 
while  waiting  for  the  pulsations  in  the  ftuiis  to  cease  before  ligating,  was  sur- 
prisinl  by  the  abrupt  discharge  of  the  placenta  from  the  genital  canal. 

In  several  instances  the  i-ord  has  been  rui)tured  at  the  umbilicus  by  the 
attempt  to  remove  circulars  from  the  neck. 

Cases  are  rworded  of  partial  rupture,  the  tear  involving  only  the  vein  or 
the  vein  and  one  of  the  arteries :  the  tear  being  also  in  the  sheath  of  the  cord, 
the  hemorrhage  is  external,  but  when  the  sheath  is  entire  the  blood  may  form 
a  hematoma  of  the  cord.  McDongall  ^  found  in  the  cord,  2  inches  from  the 
umbilicus,  a  collection  of  blood  the  si/e  of  a  hen's  egg.  Kirkpatrick  ^'*  recorded 
a  very  remarkable  case  of  thrombus  in  the  cord  :  "  The  I'unis  formed  a  loop 
the  sides  of  which  weie  adherent  to  one  another,  and  in  conse(|iience  of  the 
pressure  on  the  curve  of  the  loop  during  labor  a  clot  formed  and  the  circula- 
tion stopped  in  the  funis."  Hamill  ^  reported  a  case  of  fatal  hemorrhage  from  a 
large  branch  of  the  mnbilical  vein  running  across  the  fetal  surface  of  the  ])la- 
centa,  a  considerable  mass  of  coagulated  blood  being  found  beneath  the  annjioii. 
Velpeau'^  attributes  ruptures  of  the  blood-vessels  to  disease  causing  dilatation, 
*'  small  aneurysmal  or  varicose  pouches,"  and  he  states  that  he  has  "  seen  these 
dilatations  torn  at  term,  and  communicating  with  a  large  clot  which  covered 
a  part  of  the  placenta  and  which  had  not  ruptured  the  amnion." 

In  velamentous  insertion  of  the  cord,  while,  according  to  Winekel,  18  per 
cent,  of  the  children  jwrish  from  asphyxia  resulting  from  compression  of  the 
vessels  of  the  cord,  a  still  larger  proportion  die  from  rupture  of  these  vessels, 
Spiegelbcrg  states  that  occasionally  the  obstetrician  ruptiu'es  the  cord  while 
performing  version,  and  even  oftener  during  extraction.  It  i.s  established  that 
the  cord  ruptures  more  frequently  at  the  fetal  than  at  the  placental  end,  and 
also  that  "  .spirals  and  va.seidar  anomalies  are  weak  parts,  and  the  cord  is  pecu- 
liarly liable  to  tear  at  those  points."  Hemorrhage  is  much  less  likely  to  occur 
*  Quoted  by  Laniiirc  :   Klinik  der  Geburtshiilfe  mid  Gyiiiikol.,  1885.    Cliiari,  IJraim,  and  Spaetli. 


DYSTOCIA. 


681 


iVorn  a  torn  than  from  a  cut  coril.  In  183  cast's  of  torn  cord  collected  by 
Klein  there  were  twenty-one  in  wliich  the  cord  was  rupture<l  at  the  umbilicus, 
and  in  none  of  them  was  there  bleedinp.  Xeverthehws,  in  exceptional  cases 
ot"  rupturetl  funis  there  may  be  considerable  bleeding  both  from  the  fetal  and 
from  the  placental  end. 

Trcalmvnt. — The  treatment  of  ruptures  of  the  cord  is  chieHy  prophylactic. 
HoniemlK'ring  the  causes  of  this  accident,  the  obstetrician  will  endeavor  to 
avert  them,  anil  he  will  thus  prevent  the  patient  from  being  delivered  in  other 
tlian  a  recuml)ent  position,  unless  in  quite  exceptional  cases,  and  he  will  not 
permit  too  rapid  escai)e  of  the  fetus.  When  the  coiil  is  accessible  to  touch 
and  is  so  tense  that  tearing  is  threatened,  he  will  divide  it ;  furthermore,  he 
will  prefer  to  sever  the;  coils  about  the  neck  of  the  child,  rather  than  to  use 
force  for  the  removal  of  one  or  more  of  the  coils.  In  velamentous  insertion 
of  the  cord  he  will  delay  rupture  of  the  membranes  as  long  as  possible,  and 
if  one  or  more  of  the  vessels  should  Imj  torn,  he  will  deliver  the  child  as  soon 
as  possible.  In  case  the  child  is  born  and  the  cord  is  found  torn,  ligation  is 
advisable  even  though  no  hemorrhage  be  present.  As  has  been  statetl,  almost 
all  tears  at  the  umbilicus  do  not  bleed,  but  should  they  do  so,  the  vessels  are 
to  1k'  drawn  out  with  a  tenaculum  and  tied.  This  methwl  was  successfully 
employed  by  Hraxton  Hicks. 

2.  Dystocia  on-:  to  Hp:MoHHnA(iR. 

Placenta  Prsevia. — If  the  placenta,  in  whole  or  in  part,  be  implanted  in 
that  ])ortion  of  the  uterus  which  must 
be  dilat(Hl  Ibr  the  passing  of  the  child, 
it  is  called  "  pnevia."  The  lower  seg- 
niout  of  the  uterus  in  pregnancy  is 
halt  of  a  spheroid  ;  in  labor  this  hemi- 
sphcroid  must  be  changed  into  a  canal 
or  hollow  cylinder  having  a  diameter 
of  about  11  centimeters  (4^  inches). 
15y  the  lower  segment  of  the  uterus  is 
meant  that  portion  bounded  below  by 
the  internal  os;  its  upper  boundary  is 
from  '2ii  to  3  inches  above,  measuring 
along  tile  uterine  wall.  In  this  lower 
segment  occur  the  pathological  phe- 
nomena of  placenta  prajvia. 

Hegar^   in  1863  stated  that  too 
extensive   formation    of   the   serotina 

.......  »o..c»  ^1  -    .>1..„„..4-..  *„  ^..^i^^i^  :.,*«  Fio.  382.— Partial  placontii  prcDVia,   The  uterus  is 

may  cause  tl      placenta  to  project  into    ^5,;,,^.^  j^^^  ^^^^^,  ,„„^,, .  ^^^J  ,  ,  j^  j,,^.  ,4,,^.  ^^.,,.,,„ 

the   area   of   expansion    of  the    uterus,  marks  the  boundaiybetwuens.z,  the  .superior  zone, 

I       1  onr\     TT    i>       •      w             1     1    1    J-  anil  E.z,thee(iuntorial  zone ;  3,4,  is  tlie  line  ("  lUirnes' 

hi    1890,   Hotmeier'™   COncludal    trom  boundary-line")  which  murks  the  limit  between  the 

the    examination    of    the    uterus    of    a  eq'mtorial  zone,  K.z.imd  the  inferior  zone,  i.z.    A- is 

,    .         .        1       /. /.  1                 1       />  *''^'  ITievial  Map  of  tlie  plaeenta,  upon  which  the 

woman  dying  111  the  hftli  month  ot  a    head  rests  lUames). 


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682 


AMHIilVAX    TEXT-HOOK    OF   OUSTKTR/CS. 


twill  j)ivj;nnii<'_v  that  in  "most  if  not  all  caHt's"  placenta  |>rii«via  ori<rinattMl  frmn 
tlu'  il(!Vt'l<ijnn('nt  of  the  placenta  within  the  reflexa  ofthe  lower  pole  of  the  ovum. 

Figure  383  represent^ 
admirably  this  view. 
U|H)n  examining  tlic 
illustration  it  will  Iw 
noticed  that  a  part  of 
the  reHexa  upon  whiili 
the  placenta  has  foriiuil 
is  not  yet  tniiteil  witli 
the  vera.  Kaltenhaeh^' 
states  that  "  by  prepa- 
rations from  early  pe- 
riods of  prej;naney  Hi  d'- 
mcier  and  the  autiior 
have  proved  that  in 
placenta  pnevia  the  de- 
velopment of  the  pla- 
centa takes  j>lace  with- 
in the  reHexa  of  the 
inferior  pole  of  the 
ovum."  The  under 
surface  of  the  present- 
in};  placenta  is  c<»ver(Ml 
with  smooth  reflexa 
which  later  is  united 
with  the  opposite  vera. 
The  explanation  of  the  orijjin  of  placenta  pnevia  |i;iven  by  Hofmeier  and 
Kaltenbach  has  been  aceeptetl  by  many  ob.stetricians,  among  whom  may  bo 
mentioned  Olshausen  and  Martin  ;  but  there  are  some  who  dissent — for  ex- 
ample, Ahlfold,  Winckel,*  Berry  Hart,  and  Gottschalk.^'  Hart,  in  expressing 
his  dissent,  gave  the  following  statement :  "  I  must  now  state  the  view  I 
advocate  for  the  occurrence  of  placenta  prsevia.  It  is  that  of  primary  iniplaii- 
tation  ofthe  impregnattnl  ovum  low  down,  or  even  over  theos  internum.  The 
forcible  objection  that  Kaltenbach  urges  against  this  view  seems  to  me  not 
quite  valid.  He  hoUls  that  the  small  ovum  wotdd  pass  into  the  wrvieal  canal 
and  be  lost.  \Vc  must  rememl)er,  however,  that  the  hypertrophied  and  foldeil 
decidua  there  will  practically  obliterate  the  os  internum,  and  thus  implantatinii 
over  it  may  (jccur.     But  why  should  such  a  l(tw  implantation  happen?     Wo 

*  Winckel  remarks,  referring  to  the  views  of  Ilofnieier  and  Kaltenbach :  "  Ahlfeltl  liii.< 
justly  disputed  the  correctness  of  this  explanation,  and  from  a  case  in  which  the  placenta  w:is 
entirely  situated  in  the  lower  uterine  segment  lias  given  ground  for  the  old  ojiinion  of  tlw 
primary  grafting  of  the  ovum  in  the  inferior  third  of  the  uterine  cavity  "  ( Lehrbuch  der  Gebwis- 
hulfe,  '2d  ed.,  189:i). 


Fio.  383.— riiicenta  pntvia  in  pregnancy  with  twins  (Hoftncier). 


:ij. 


nVSTOC/A. 


583 


iiiilv  know  that  it  is  niorc  apt  to  iHt'iir  in  cases  where  the  nuieons  nienibrunu 
has  been  nnliealtliy.  The  iiyintthesis  1  would  advance',  but  merely  as  an 
livpothesis,  is  that  the  human  ovum  can  graft  only  on  a  surface  denudcil  oC 
epithelium,  and  that  thus  it  docs  not  graft  in  the  Fallopian  tube,  but  in  nonie 
piirt  of  the  uterine  cavity  where  the  epithelium  has  been  removed  by  menstru- 
ation. If,  then,  the  ovum  does  i,ot  meet  with  the  eon ncctive-t issue  surface 
until  it  has  passed  low  down  in  the  uterine  cavity,  some  form  of  placenta 
prievia  will  hapiM'U." 

Dr.  Robert  Harnes  first  announced  in  1847  his  theory  of  placenta  prievia, 
;md  ho  has  made  several  contributions  to  the  sidtject  since,  the  most  recent  of 
tlicse  being  a  paper  road  by  him  in  1892  before  the  International  Congress 
of  Diseases  of  Women  and  Obstetrics,  in  Hrussels.  In  justice  to  one  of  the 
most  eminent  anil  able  obstetric  writers  and  teachers,  as  well  as  in  justice  to  the 
theory  itself,  which  certainly  was  an  important  advance,  and  from  the  fact  that 
the  |)nu'tice  founded  upon  that  theory  is  upheld  by  some  obstetricians,  {u-om- 
incnt  among  whom  is  Murphy  of  Simderland, — the  latest  public  exposition  of 
his  views  is  hero  presented.  The  paper  referred  to  being  in  French,  a  trans- 
lation of  a  part  is  here  presentetl.  Dr.  Barnes,  after  having  stated  that  his 
theory  is  represented  in  Figure  .'J82,  proceeds  as  follows: 

"It  is  seen  from  the  illustration  that  the  uterus  is  divided  into  three 
/ones : 

(1)  The  superior  or  fundal  zone; 

(2)  The  equatorial  or  middle  zone  ; 

(3)  The  inferior  zone. 

The  superior  zone  is  separated  from  the  e((uatorial  by  an  imaginary  line  (1,  2) 
which  may  be  called  the  '  superior  polar  circle.'  This  line,  it  is  true,  has  not  been 
anatomically  demonstrated.  IJut  it  serves  to  mark  a  distinction,  which  I  be- 
lieve real,  between  the  characters  of  the  superior  and  eipiatorial  zones  in  their 
relations  to  the  placental  attachments  and  to  hemorrhage. 

"The  equatorial  zone  is  separated  fn^m  the  inferior  zone,  otherwise  called 
the  inferior  uterine  segment,  by  the  line  .'],  4.  This  line  is  the  line  of  demar- 
cation of  Barnes,  Barnes'  boundary-line  (1847-1 8;")7).  This  line  was  called 
'  the  internal  os  of  Branne '  in  1 872  ;  it  became  the  '  ring  of  Bandl '  in  1876  ; 
and  later,  the  *  contraction-ring '  of  Schroeder.  It  may  also  be  called  the 
'  inferior  polar  circle.' 

"  The  superior  zone  (s.  z.)  is  the  seat  of  fundal  placenta ;  it  is  the  safest 
region  of  attachment.  The  equatorial  zone  (e.  z.)  is  the  seat  of  lateral  or 
('(|natorial  placenta.  The  lateral  placenta  may  give  place  to  that  form  of 
liomorrhage  called  'accidental ;'  nevertheless,  the  equatorial  zone  may  be  con- 
sidered as  site  of  attachment  normal  and  safe.  This  security  is  still  greater 
when  the  placenta  is  attached  in  part  in  the  superior  zone  and  in  })art  in  the 
ef|uatorial  zone.  The  danger  begins  when  the  placenta  is  attached  in  part  in 
the  inferior  zone — that  is,  when  there  is  partial  placenta  praivia.  The  portion 
of  the  placenta  which  encroaches  upon  the  interior  zone  (r.  z.)  is  liable  to 


nsi 


AMi:iii<'Ay  Ti:\"r-ii(K)h'  or  onsTirmics. 


prcinatiiro  s<'|)!iratii)ii.  ('i)iii|)l(>t<'  placenta  pru'via,  calKKl  also  phicetitd  pniiia 
fcnfrii/in,  is  t'oiiixl  wlini  the  ciitirc  plarcnta  or  tlie  greater  part  of  it  is  attaclicti 
ill  tlu'  inferior  zone  ainl  covers  the  internal  os. 

•'  In  the  last  case  the  jfcstation  would  Ix-,  justly  s|H'akinjr,  an  ••  ^.pioficstation 
(or  out  of  place),  for  the  ovtiiii,  or  an  iinportani  part  of  it,  is  (levelo|MHl  in  the 
inferior /one  4»f  the  uterus,  a  part  which   is  not  (lesijfiie<l  l>y  nature  tor  tiii> 
function.     The  eurve<l  line  tracni  in  the  inferior  zone  marks  the  jwtsition  ol 
the  total  head.     The  line  of  demarcation  (3,  4)  corresjMinds  alinofit  exactly 


fUNDAL 


Kin.  ."Wl.— Vnrietii's  of  iiliiccntn  pra'vin  :  in  A  there  arc  seen  tlu'  imrninl,  latcriil,  iniil  iiiarKiiml  iiii|iliiii 
(Rtioii:  ill  It  tlieri'  are  reiircsentLMl  tlie  iiiipluiitatioii  of  the  placenta  at  the  fnmliis,  whieli  is  rare,  and 
Imiihintatloii  over  tlie  internal  on,  in  ('  lateralini|iIaiitatioii  and  that  of  a  eotyledon  iinineiliately  over 
the  internal  os  ;  an<l  in  |l  partial  Implantation. 


sM^ 


t 


With  the  efjuator  of  the  fetal  head,  and  often  it  nearly  corresponds  with  the 
entrance  of  the  pelvis." 

Vark'lU'H  of  JHacvnln  Pnevla. — The  accompanyiiif;  illustration  (Fig.  384) 
shows  different  forms  of  placental  implantation  in  the  lower  portion  of  the 
uterus,  and  the  names  applied  to  them,  and  also  implantation  at  the  fundus 
and  at  the  fundus  and  side.  Some  confusion  has  arisen  from  jjiving  so  many 
varieties,  and  from  diflTerences  in  the  application  of  terms  desi}rnating  them. 
Thus,  one  author  calls  that  "partial"  which  another  names  "lateral,"  illii.<- 
trating  the  ambiguity  which  comes  from  what  Lord  liacon  spoke  of  as  "  the 
unsteady  use  of  words."     The  writer  thinks  it  better,  as  Schroedcr,  Budin, 


iimrniiml  iiiii'liin- 
I  l\ich  is  ran',  nml 
iiniiR'(liuti.'ly  nvir 


Diids  with  tiie 


DYSTOCIA. 


:.S;) 


unil  sonio  others  Imvc  done,  tn  liinkc  hut  two  varieties,  I'omjtlcti  and  laUraL 
IJy  complete  phieeiita  prii'via  is  meant  that  eoiiditii>ii  in  wiiicii  (he  internal  o> 
is  entirely  covoreil  hy  placenta.  It  corresponds  with  what  many  others  have 
(ill le<l  "central  implantation  of  the  jdacenta  ;"  that  is,  the  (jcntre  of  the  pla- 
centa is  supposed  to  1m'  directly  over  the  internal  os.  Pinard''-  statcsl  tiiat  in 
10,000  acconehements  he  never  met  with  tlu;  insertion  centr;' I'or  cent r«',  <"<>»- 
seqiiently  he  has  the  right  to  say  that  this  vnriety  is  excci-^lingly  rare.  Liileial 
implantation  of  the  phurnta  includes  those  cases  in  which  the  great  mass  of 
tlie  placenta  is  at  the  &ideof  the  uterus,  a  margin  more  or  less  near  the  interiitd 


/'CTiijf  vnp  ant 

Os  aUrn  ^~^ 

Vrtlhrft 

Cor/i  cavtrrX'-  diior.-^ 

■ — ^Sis 

Pmc/iiU  cUtor-^^ 

CUUns.  --- 

^'-^H 

Ifii  mm  (ttxt     "' 

^__^ 

laimydext  — 

'    I'J 

Fio.  385.— Placenta  pracvia  :  child  removed,  placcr'n  remaining  (Winter). 

OS ;  indeed,  in  some  eases  the  margin  may  partially  extend  over  the  os.  The 
lateral  variety  is  much  the  more  frequent. 

Figure  385  shows  a  not  infrequent  c  r.idition,  a  single  cotyledon  over  the  os, 
while  the  great  ma.ss  of  the  placenta  is  at  the  side :  the  fir.st  is  known  as  j)la- 
centa  suceenturiata. 

Authorities  generally  agree  that  lateral  is  much  more  frequent  than  comj)letc 
or  central  placenta.  Nevertheless,  Trask  **  gives  169  of  the  complete  to  88  of 
the  lateral,  and  Mi'iller's  statistics,  which  include  tho.se  of  Trask,  show  a  slight 
prcKlominance  in  favor  of  the  complete  variety.     Read's  statistics^*  show  a 


?:i.^: 


i^K' 


H*. 


^ 


586 


AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 


l\  :i 


■I  f 


similar  result.  UnfortiUiritely,  in  many  of  the  cases  given  by  Read  there  is 
a  failure  to  state  the  placental  presentation,  and  some  others  are  described  as 
"almost  complete"  or  "nearly  complete,"  and  hence  nncertain  conclusions 
onlv  can  be  made.  Miiller  has  shown  that  in  complete  placenta  praevia  the 
smaller  lobnle  was  situatwl  at  the  left  in  thirtv-seven  out  of  56  cases.     In 


Via.  386— Partial  placenta  priiviti  (Alilf'cld). 


lateral  placenta  pnevia  the  placenta  is  in  50  cases  at  the  right  side  to  31  at 
the  left  side.  As  will  be  seen,  there  is  a  correspondence  between  these  results. 
Frajucnci/. — The  proportion  of  cases  of  placenta  pra;via  to  the  entire 
number  of  deliveries  is  usually  given  as  1  to  1000,  1  to  1500  (Winckel), 
and  1  to  1500  or  1600  (Kaltenbaeh).  I'azzi*''  gives  the  proportion  of  1  in 
748.  As  illustrating  how  misleading  limited  statistics  may  be,  we  quote  the 
statement  of  Townsend'*  as  to  cases  of  placenta  pnevia  in  the  Boston  Ijying-in 
Hospital :  In  the  last  twenty  years  there  were  28  cases  of  placenta  prajvia  in 


DYSTOCIA. 


587 


Road  there  is 
doscribetl  as 

I  conclusions 

II  prievia  the 
>6  cases.     In 


side  to  .31  at 
these  resuhs. 
to  the  entire 
no  (Winckel), 
ortion  of  1  in 
we  quote  the 
)ston  Lyinjjj-iii 
nta  proovia  in 


(1700  deliveries.  Thus  there  was  1  case  of  placenta  praevia  in  239  labors, 
or  more  than  4  in  1000.  Of  course,  as  Townsend  remarks,  tiiere  are  more 
cases  of  this  anomaly  in  hospital  than  in  private  practice,  but  still  such  a 
liu'lie  proportion  as  he  found  is  not  the  expression  of  a  general  trutii.  No 
iiije  is  exempt,  for  placenta  pra?via  has  occurred  in  a  girl  of  thirteen  years 
and  in  a  woman  of  fifty.  It  is  most  frequent  from  thirty  to  forty  years, 
tor  out  of  248  cases  127  of  tiie  subjects  were  in  that  ten  years  (Miillcr). 

A  uoma/ica  of  the  Placenta  when  it  is  Pnvvia. — The  placenta  is  not  oval, 
hilt  is  irregular  in  form  ;  tiie  prajvial  placenta  extends  over  a  larger  surface, 
hut  is  thiimer,  than  the  placenta  having  a  normal  site.  •  A  placenta  succcntu- 
riata  is  not  infrequent,  or,  again,  the  placenta  nuiy  be  composetl  of  twt)  lobes, 
and  the  bridge  of  tissue  connecting  these  lobes  may  be  directly  over  the  os ; 
lionce  an  error  in  diagnosis  is  possible.  Tiie  form  of  the  placenta  presents 
otlier  varieties.''^  Thus  it  lias  been  found  in  the  shape  of  a  half-mpon  or  a 
horseshoe,  or  it  is  pyriform  or  cordiform  ;  Gilroy  ^  described  one  as  lozenge- 
sliapcd,  the  cord  being  attached  to  one  of  the  angles. 

In  placenta  prtevia  there  are  frequently  abnormal  adhesions  between  the 
placenta  and  the  uterine  wall.  Miillcr  found  such  adhesions  in  fifty-four  out 
of  142  cases,  and  Sabarth  of  Reichenbach  in  seven  out  of  14  cases.  This 
condition  may  cause  more  or  less  serious  delay  and  difficulty  in  the  third  stage 
of  labor,  and  of  course  it  gives  a  certain  liability  to  infection.  The  insertion 
of  the  cord  in  numy  cases  is  marginal  and 
sometimes  is  velamentous.  DepanP"  directetl 
attention  to  the  fact  that  the  membranes  in 
placenta  prrovia  seem  thickened  as  if  infil- 
trated, and,  further,  that  the  chorion  presents 
externally  (juite  characteristic  rugosities  which 
alone  suffice,  even  when  the  placenta  cannot 
l)c  felt  either  by  its  surface  or  at  its  border, 
to  authorize  one  in  affirming  that  the  j)la- 
ccnta  is  near. 

(hitscK. — Spicgelberg^  states  that  pre- 
vious abortions  predispose  to  placenta  \)rie- 
via,  and  that  it  is  more  frequent  in  the 
poorer  classes,  }H)ssib]y  owing  to  hard  work 
at  the  beginning  of  pregnancy,  and  still 
more  to  the  subinvolution  of  the  uterus 
which  is  so  common  in  this  class.  So  far 
as  tlie  first  statement  is  concerned,  it  seems  to       .,     ,„,„..,,       ,         ,, 

'  _  Kio.  3«7.— Purtiiil  pliu'i'nta  imrviii,  wr- 

the  writer  that  both  abortions  and  prrovial  tox  iiresoniution :  the  os  biKimiint,'  to 
j)lacenta  should  be  attributed  to  a  common  ""t^' (■'"*'■ 
cau>e,  a  diseased  condition  of  the  endonu^truim.  The  accident  is  more  fre- 
(pu'iit  in  nuilti))ar!e  than  in  primipane — two-  or  three-fold  (Winckel) — and 
according  to  Miillcr"  85  per  cent,  are  multipara?.  Anomalies  of  the  uterus, 
such  as  uterus  bicomis  and  unicornii*,  cancer  anil  myoma  of  the  uterus,  relax- 


U  'Ai 


l>    hi 
<  <   (if > », 


,y  i. 


<■{■   i^iiS^':  '    ii 


■ri 


nnrr 


Ih'h 


mm 


U  !;  I! 


:4 


■'  '3 


588 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


atioii  of  the  uterine  walls,  opening  of  the  oviducts  in  the  lower  part  of  the 
uterus,  as  in  two  cases  reiK)rte(l  by  Ingleby,  and,  more  important  than  most 
and  more  frequent  than  any  of  these,  endometritis  with  hypersecretion,  aiv 
causes  of  placenta  prajvia. 

Osiander^"  believes  that  lying  on  the  back  favors  insertion  of  the  ])laconta 
at  the  fundus,  lying  upon  one  side  lavors  a  lateral  attadunent,  and  standing 


Fig.  388.— Central  placenta  proDvJa,  the  os  partly  tlilntcd  (Hunter). 

or  sitting  favors  implantation  over  the  os ;  hence  ho  considered  lying  on  the 
back  or  on  one  side,  continueti  some  time  after  copulation,  as  necessary  for  a 
fortunate  situation  of  tlie  ovum.  Stein  and  others  attribute  the  origin  of 
placenta  prsevia  to  the  sjwcific  gravity  of  the  ovum.  Miillcr  .states  that  others 
accu.se  conception  during  menstruation  or  while  the  uterus  has  a  more  vertical 
position,  thus  coitus  while  standing,  as  a  chief  ground. 


DYSTOCIA. 


589 


'%%^. 


In  1874,  Angus  Macclonald  *'  reported  a  case  of  twin  pregnancy,  the 
ti'tnses  being  transverse  and  each  j)h»centa  presenting  at  the  internal  os. 
He  regarded  phicenta  prtevia  with  twins  as  a  very  rare  anomaly,  and 
assortal  that  "  the  expectation  of  the  concurrence  of  twins  with  placenta 
pran-ia  is  only  1  in  44,500  cases  of  labor,"  and  that,  of  course,  the  prob- 
ability would  be  much  less  with  both  placentse  presenting.  Miiller  found  it 
YWiv  in  plural  pregnancy,  but  Barnes  has  spoken  of  it  as  not  uncommon,  and 
\Vinckel  states  that  plural  pregnancy  pretlisposcs  to  placenta  prrevia,  the  acci- 
(li'iit  in  his  experience  beinj;  relatively  four  times  more  frequent  in  plural  than 
ill  single  pregnancy.* 

Roamy  ^^  suggests  that  placenta  prasvia  may  originate  in  sexual  intercourse 
being  deferred  until  fifleen  or  sixteen  days  after  menstruation  for  the  purpose 
of  avoiding  conception.  If  this  delay  were  a  cause,  probably  the  number  of 
cases  would  be  much  greater.  Pinard  has  asketl  if  travelling  early  in  preg- 
nancy, with  conse(juent  jolting  in  I'ailroad  cars  or  in  carriages,  may  not  cause 
placenta  pnevia.  The  retnirrence  of  placenta  pra}via  in  the  same  subject  has 
been  observed.  The  cases  recorded  by  Ingleby  are  explaine<l  by  the  abnormal 
))oint  of  entrance  of  the  tubes  into  the  uterus.  Fitzpatrick  ^  reports  the  case 
of  a  woman  tiiirty-six  years  old  who  had  nine  pregnancies,  the  first  four  normal 
and  ending  in  the  birth  of  living  children  at  term ;  in  five  successive  preg- 
nancies she  had  placenta  pnevia. 

Siimptoms  and  I)l<(r)noH'ix. — The  most  characteristic  symptom  of  placenta 
prrevia  is  hemorrhage  occurring  in  the  latter  part  of  pregnancy  or  at  the 
l)('ginning  of  labor  without  obvious  cause.  The  hemorrhage  frequently 
begins  when  the  patient  is  sitting  quietly  or  even  when  lying  asleep  in  bed. 
FiOmer  found  in  only  thirty  of  136  cases  that  the  first  hemorrhage  w.as 
caused  by  some  bodily  exertion,  such  as  liftingj  straining,  or  coughing. 
Miiller  mentions  coition  as  a  cause.  Winckel  states  that  in  lateral  placenta 
prievia  the  first  hemorrhage  generally  occurs  after  the  thirty-second  week, 
and  in  the  central  variety  between  the  twenty-eighth  and  the  thirty-sixth 
week.  In  rare  cases  not  only  of  lateral  but  also  of  central  implanta- 
tion of  the  placenta  there  is  no  bleeding  until  a  few  days  before  labor,  and 
in  still  rarer  cases  not  until  labor  begins.  Since  Rigby's  admirable  essay" 
the  hemorrhage  occurring  in  placenta  pra'via  has  been  calletl  *'  unavoidable," 
while  that  which  may  happen  when  the  placenta  occupies  its  normal  site  is 
known  as  "accidental."  In  1873,  Matthews  Duncan"  took  the  position  that 
the  hemorrhages  occurring  during  pregnancy  on  account  of  placenta  pra;via 
were  not  unav(jidable,  but  accidental,  their  occurrence  being  promoted  by  the 
unusual  conditions  present,  and  especially  by  increased  blood-pressure  result- 
ing from  the  lower  position  (X'cupied  by  the  placenta.  Yet  those  who  have 
read  the  essay  of  Rigby  will  remember  that  he  referral  only  to  the  hemor- 
rliagos  of  labor,  in  case  of  i)lacenta  prsevia,  as  being  unavoidable. 

While  not  many  years  distant  some  authorities  regardcnl  the  hemorrhage  as 

*  One  of  the  most  renmiknble  cnses  of  jdncenta  prii'via  is  that  \i\\cn  by  W.  J.  Harris  (Lancet, 
18()3).    A  woman  was  twice  i>regnant  with  twins,  and  in  eacii  pregnancy  iiad  placenta  prnpvia. 


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placental,  it  is  now  usually  conceded  that  it  is  uterine,  and  should  the  child 
die  its  death  would  be  not  from  loss  of  blood,  but  from  asphyxia.  From  tlie 
fetal  circulation  may  come  a  small  quantity  of  blooil  in  case  the  chorionic  villi 
are  torn.  Why  the  blealing  occurs  in  the  latter  part  of  pregnancy  is  a  (juestioii 
that  has  had  different  answers.  Jacquemier  held,  on  the  one  hand — and  his 
view,  with  qualifications,  was  accepted  by  Depaul — that  the  development  of 
the  lower  part  of  the  uterus  was  more  rapid  than  that  of  the  placenta,  henco 
detachment  of  the  latter;  on  the  other  hand,  Legioux  assertetl  that  the  pla- 
centa grew  more  rapidly  than  the  uterus,  that  is,  grew  away  from  the  uterus. 
Barnes  has  been  especially  prominent  in  upholding  the  latter  view.  Spiegel* 
berg,  first  referring  to  placenta  prsevia  predisposing  to  abortion,  said  :  "  Owing 
to  the  loose  vascular  connections  of  the  placenta  and  to  the  higher  blood-pressure 
in  the  placenta  when  inserted  low,  any  shock  is  liable  to  cause  rupture  of  its 
vessels  and  detachment ;  perhaps,  also,  shocks  affect  the  lower  portion  of  the 
uterus  oftener  than  the  upper  during  the  first  months  of  pregnancy  (coitus, 
especially  straining  at  stool).  For  the  same  reasons  premature  labor,  too,  is 
relatively  common ;  indeed,  I  am  convincal  that  even  the  hemorrhages  which 
occur  during  the  latter  months  of  pregnancy  depend  upon  commencing  labor — 
that  it  is  not  the  hemorrhages  which  induce  premature  labor,  as  is  generally 
su])posed,  but  that  the  converse  relation  is  the  true  one." 

The  hemorriiage  is  not  only  abrupt  and  apparently  causeless  in  occiu'rence 
— though  this  first  hemorrhage  may  be  fatal — but  usually  it  ceases  after  lasting 
a  few  hours,  or  even  in  less  time,  and  often  spontaneously.  The  hemorrhage 
returns  at  irregular  intervals,  and  is  greater,  occurs  earlier,  and  is  more  frequent 
in  those  cases  in  which  the  placenta  completely  covers  the  os7> 

Auvard  *®  mentions  as  symptoms  unfavorable  presentation  of  the  fetus — 
presentations  other  than  those  of  the  head  *  are  found  in  from  20  to  nearly  50 
per  cent,  of  cases,  according  to  different  authorities — the  occurrence  of  prem- 
ature labor,  and  premature  rupture  of  the  membranes,  Winckel  remarks 
that  in  the  relaticjn  of  the  funis  in  ]>lacenta  prsevia  there  is  also  offered  a 
certain  predisposition  to  bleeding.  He  states  that  Scanzoni,  Hugenberger, 
and  the  author  found  marginal  and  velamentous  insertion  of  the  c<ir(l 
frequent. 

Hemorrhage  occurring  in  the  last  two  or  three  months  of  pregnancy  with- 
out obvious  cause,  and  especially  if  the  patient  has  not  albumiinu'ia,  would  at 
once  suggest  the  strong  probability  that  it  resulted  from  ]ilacenta  ])nevia. 
Spencer"  claims  that  it  is  jKissible  by  abdominal  palpation  to  determine  tlic 
site  of  the  placenta  when  it  is  situated  in  the  upj)er  part  of  the  uterus,  and 
also  by  tliis  means,  on  finding  it  absent  from  its  usual  site,  it  may  be  discovered 
in  the  lower  jiortion  of  the  uterus. 

Tn  examining  the  patient  she  lies  u])on  her  back,  the  bladder  being  jirc- 
viously  emptied.  The  examination  should  be  gentle  and  be  made  in  tlio 
absence  of  pains,  and  should  be  prolonged  over  several  minutes  or  be  repeateil 

*  Of  rourse  the  frcqiicnev  of  abnormal  presentations  is  in  part  to  be  attributed  to  the  fact 
that  in  many  cases  labor  is  pri'iuature. 


I  !! 


DYSTOCIA. 


-591 


if  necossarv.  Spencer  gives  the  following  additional  directions:  In  an  ordi- 
nary vertex  presentation  (placenta  in  the  iipjwr  segment)  the  occiput,  forehead 
(at  a  higher  level),  and  side  of  the  head  may  under  favorable  circumstances  be 
lolt  distinctly  in  the  lower  segment  of  the  uterus  by  means  of  abdominal  pal- 
pation. In  a  case  of  placenta  prtevia  in  which  the  head  presents  the  head  is 
not  felt  where  the  placenta  is  situateil ;  it  is  distinctly  felt  where  the  placenta  is 
absent.  In  cases  where  the  placenta  is  in  front  the  organ  is  felt  as  an  elastic 
mass,  of  the  consistence  of  a  wetted  bath-sponge,  that  kecj)s  the  examining 
iiiiger  oft'  the  head.  The  edge  of  the  placenta  may  be  felt,  and  has  the  shape 
of  a  segment  of  a  circle.  Within  the  circle  all  is  obscure  to  the  touch  ;  out- 
side the  circle  the  head  or  other  part  of  the  child  is  i)iainly  felt.  Impulses 
to  the  head  are  not  clearly  felt  through  the  placenta ;  impulses  to  the  head 
through  the  ])lacenta  are  distinctly  felt  at  the  spot  from  which  the  placenta  is 
absent.     The  same  api)lies  to  combined  vaginal  and  abdominal  examination. 

Vaginal  examination  shows  great  softening  of  the  cervix,  and  the  bluish 
discoloration  is  well  marked,  extending  to  the  external  genitals.  The  pulsa- 
tion of  vessels  in  the  lower  j)art  of  the  uterus  and  vagina  is  distinct.  The 
presenting  partof  tlie  child  camiot  be  recognized  distinctly  through  the  nterine 
wall  and  the  overlying  placenta.  Probability  becomes  certainty  *  only  when 
the  finger  can  enter  the  os  or  penetrate  the  cervical  canal,  and  the  sponge-like 
structure  of  the  placenta  can  be  felt.  We  distinguish  complete  from  lateral  placenta 
praivia  by  the  finger  touching  in  the  former  jjlacental  tissue  at  all  parts  sur- 
rounding the  internal  os,  while  in  the  latter  the  membranes  can  be  felt,  and 
j)()ssibly  only  placenta  reached,  by  passing  the  introduced  finger  toward  one  or 
the  other  side.  It  should  be  remembered  that  complete  is  much  less  frequent 
than  lateral  placenta  praivia,  and  that  in  the  latter  the  bleeding  may  not  occur 
until  labor  begins. 

ProejnoHifi. — The  prognosis  is  graver  the  earlier  hemorrhage  occurs  and  the 
more  completely  the  placenta  covers  the  os.  Not  only  is  there  danger  from  bleed- 
ing before  birth,  but  also  afterward,  fi)r  the  relaxed  lower  segment  does  not  com- 
pletely close  the  vessels  opened  by  detachment  of  the  placenta.  There  is  danger, 
also,  especially  in  the  so-called  aeconcheincnt  force,  of  fatal  tearing  of  the  cervix 
and  of  the  lower  uterine  segment.  Finally,  the  examinations  and  manipula- 
tions and  the  means  used  for  the  arrest  of  bleeding  may  lead  to  infection,  so 
that,  according  to  Kaltenbach,  almost  as  many  women  die  from  sepsis  and 
])yen»ia  as  from  bleeding. 

^Maygrier^^  narrates  fom*  cases  of  fatal  syncope  in  patients  with  placenta 
prtevia,  showing  that  severe  hemorrhage  from  this  anomaly  can  cause  such 
grave  anemia  that  death  may  come  suddenly  after  the  arrest  of  all  bleeding. 
INIiiller  gives  the  maternal  mortality  as  23  per  cent,  and  the  fetal  as  64  per  cent. 
King's^"  statistics  show  a  maternal  mortality  of  22.5  jier  cent,  and  a  fetal 
mortality  of  57.2  per  cent.  Winckel  believes  the  mortality  from  placenta 
])rievia  should  not  exceed  5  to  10  ])er  cent.    Such  a  low  mortality  as  5  per  cent. 

*  Niuiche  I'liiimed  that  l)y  liis  inctroscono  pulsation  in  placental  vessels  could  be  recog- 
nized; but  the  claim  was  not  veritied,  and  the  metroscope  is  now  almost  unknown. 


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may  be  secured  in  hospital  but  hardly  in  private  practice.  According  to  Lomer, 
GO  per  cent,  of  the  children  die  during  labor;  Barnes  states  that  by  his  method 
he  has  hail  33  per  cent,  of  living  children  born  ;  and  Winckel  says  that  the  mor- 
tality of  children  is  seldom  less  than  50  per  cent.,  and  in  some  statistics  is  as 
high  as  from  70  to  75  per  cent.  If  spontaneous  labor  occurs,  the  mortality  of 
children,  accortling  to  Midler's  statistics,  is  only  50  per  cent.  The  chances  of 
the  child  surviving  in  placenta  pra?via  appear  so  small  that  some  writers  seem 
to  take  the  ground  that  its  life  is  not  to  be  considered  in  determining  the  treat- 
ment. But  this  is  wrontj,  and  we  fullv  endorse  the  words  of  Dr.  Barnes:''" 
"  However,  in  admitting  frankly  that  it  is  our  first  duly  to  save  the  mother,  I 
insist  upon  the  correlative  law  whicii  does  not  permit  us  to  sacrifice  the  child 
to  this  end  without  conclusive  proof  that  it  is  only  at  this  price  the  mother 
can  be  saved." 

Trcdhiivnt. — There  is  no  single  method  of  treatment  in  placenta  prajvia 
apjdicable  in  all  cases  and  at  all  times ;  therefore  the  obstetrician  will  act  most 
wisely  who  chooses  means  corresjwnding  with  the  special  features  of  the  case 
in  hand  and  with  the  emergencies  that  arise. 

If  the  bleeding  occurs  in  pregnancy,  is  not  great,  and  uterine  contractions 
are  absent,  rest  in  bed  only  may  be  advisable.  Should  the  hemorrhage  bo 
severe,  Winckel  directs  vaginal  injections  of  hot  water  or  of  vinegar  and  hot 
water,  and  also  the  colpeurynter.  Martin  advises  that  there  be  provided 
aseptic  balls  of  cotton-wool,  with  which  the  midwife  or  nurse  should  tampon 
the  vagina  after  the  use  of  an  antiseptic  injection,  so  that  the  hemorrhage  may 
be  arrested  at  once  while  awaiting  the  arrival  of  the  physician.  The  induc- 
tion of  i)remature  labor  in  placenta  jn'sevia  was  advocated  in  England  several 
years  ago,  chiefly  by  Greenhalgh,  and  in  America  mainly  by  Thomas.  For 
some  years  past  Murphy  of  Sunderland  has  followed  this  practice,  and  his 
results,  so  far  as  saving  mothers  is  concerned,  have  been  remarkably  good. 
His  method  of  treatment  will  be  referred  to  again.  We  believe  that  in  many 
cases  Spiegelberg  is  correct  in  saying  that  the  hemorrhage  in  the  latter  months 
is  caJisetl  by  commencing  labor.  The  obstetrician  will  simply  then  accept 
Nature's  plan  and  facilitate  her  action. 

Should  there  be  hemorrhage  in  labor,  the  os  dilatable,  and  lateral  placenta 
pnevia  with  presentati(m  of  the  head,  let  the  membranes  be  ruptured,  for,  as 
Martin  states,  we  may  expect  the  inferior  pole  of  the  fetus  to  occupy  entirely 
the  lower  portion  of  the  uterus,  and  the  presenting  part  to  press  upon  the 
bleeding  ])laeental  site  and  to  excite  uterine  contractions.  In  most  cases 
of  this  variety  of  jmevial  placenta  no  other  interference  will  be  recpiired  ;  if, 
however,  delay  demands  active  interference,  the  forceps  may  be  used.  If  the 
pelvis  presents,  the  same  i)lan  of  treatment  is  to  be  ]>iu'sued,  except  that  it  is 
advisable  to  bring  down  a  foot.  In  transverse  presentation,  of  course,  podalic 
version  is  indicated.  But  now  supp.,.  o  the  physician  is  called  to  a  ease  of 
placenta  pra?via  in  which  the  Meeding  is  severe,  whether  in  pregnancy  or  in 
labor,  and  the  os  barely  admits  the  finger  and  is  rigid,  or  the  cervical  canal  is 
not  readily  penetrable :  most  obstetric  authorities  agree  in  advising  a  tampon. 


f    •! 


DYSTOCIA. 


593 


W'iiickol  uses  for  this  purpose  iodoform  cotton,  and  others  advise  iotloforn) 
"iiuize  (Fig.  389);creoIin  j^aiize  would  be  just  as  useful  and  has  no  unpleasant 
<tilor.  Auvard  *  recoinnionds  cotton  or  charpie.  1500  frrams  being  needed: 
this  niaterinl  is  made  into  balls  the  size  of  a  walnut,  which  are  place<l  in  a  2 
per  cent,  solution  of  carbolic  acid,  or  in  a  4  per  cent,  solution  of  boric  acid, 
or  in  a  1  :  1000  solution  of  corrosive  sublimate,  until  thoroughly  saturated. 
Before  being  used  the  fluid  absorbwl  bv  these  balls  is  squeezed  out,  and  to 
facilitate  their  introduction  and  to  secure  thorough  packing  an  antiseptic  cerate 
is  used.     Fifty  or  sixty  ol"  the  balls  will  be  needed. 

A  Sims  speculum  greatly  facilitates  the  introduction  of  a  tampon.    Winckel 


Fi(i.  389.— I'liu't'iita  prii'via  :   vtifjiim  tiiiiipdnod  witii  tiniize. 

states  that  a  tamj)on  may  be  applied  so  thoroughly  that  not  a  drop  of  blocxl 
can  escape  from  the  vulva.  He  leaves  the  tampon  in  place  in  central  and 
lateral  placenta  pra}via  until  the  os  is  completely  dilated,  so  that  either  the 
])n'senting  part  of  the  child  can  enter  the  os,  thus  itself  making  a  tampon,  or, 
by  the  introduction  of  the  hand,  the  hi])s  are  brought  down,  thus  accomplish- 
ing the  same  end.     Barnes  f  would  not  leave  a  tampon  in  the  vagina  longer 

*  Piijot  has  said  tliat  a  liatfiil  of  the  material  will  be  required. 

t  The  following  pas.sige  is  taken,  not  from  his  jiaper  at  the  IJrnssels  ("oiigress,  but  from  liis 
Ohshlrir  ^f^•(^i(•iln•  ami  SiinnTi/ :  "Vaginal  plugs  are  treacherous  aids,  ivquiring  the  most  vigor- 
ous watching.  The  plug,  introd'ieed  with  so  much  pain  to  the  patient,  soon  becomes  com- 
pressed, blood  runs  past  it  or  aceunndates  aliove  or  around  it,  and  the  tide  of  life  ebbs  away 
unsuspected.  Never  leave  the  patient  trusting  to  vaginal  plugs.  Feel  her  pidse  fre(|uently, 
\v;ilch  her  face  closely,  examine  to  see  if  any  blood  or  tinged  serum  is  oozing  externally. 
Hciiiove  the  plug  in  an  hour  at  furthest,  and  feel  if  the  os  is  dilating." 
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tlian  an  lioiir,  but  Bailly  lots  it  remain  for  twenty-four  hours,  and  Tarnior  {uv 
twelve  hours  :  the  last  praetice  is  probably  the  best.  Some — I'ajot,  for  instaniv 
— let  the  tampon  be  expelled  with  the  ehild. 

The  praetice  which  has  in  reeent  years  been  received  with  most  favor  bv 
the  profession  is,  when  the  os  can  be  entered  by  two  fingers,  the  performance 
of  bimanual  version  according  to  the  method  of  Braxton  Hicks,  and  bringiiin 
down  a  foot,  so  that  tamponing  is  etfec^ted  first  by  the  leg,  then  by  the  thigli. 
and  finally  by  the  hips,  of  the  ehild  (Fig.  390).  The  labor  is  not  hastened 
unless  there  is  some  special  demand  for  its  prompt  ending,  but  gradual  dila- 
tation of  the  OS  is  made.  In  ease  it  In?  impossible  to  reach  the  membranes  in 
complete  placenta  pnevia,  the  placenta  is  perforated. 

It  appears  that  Martin,  at  a  meeting  of  the  Naturforseher  at  Hamburjr 
(1876),  and  then  in  his  Guide  to  Obdetric  Operations  (1877),"  made  a 
definite  projjosal  for  the  suceessfid  treatment  of  the  majority  of  c;\ses  of 
placenta  prajvia,  which  treatment  has  later  ueen  established  by  Bchm,  lIoC- 
nieier,  Schiilein,  and  others.  The  chief  point  in  this  treatment  is  bringinir 
<lown  the  hips,  so  that  by  their  pressure  bleeding  from  the  loosened  placenta 
may  be  stopped  and  at  the  same  time  uterine  action  may  be  developed. 

If  hemorrhage  contimies  after  the  birth  of  the  child,  manual  removal  of 
the  placenta  is  performed.  If  hemorrhage  still  continues,  the  injection  of  hot 
water,  compression  of  the  uterus,  the  administration  of  ergot,  compression  of 
the  aorta,  autotransfusion,  injection  into  the  rectum  at  frequent  intervals  of  nor- 
mal salt-solution,  such  as  will  be  mentioned  in  the  treatment  of  post-j)artiiiii 
hemorrhage,  and  also  the  hypodermatic  injecticm  of  the  salt-solution,  are  among 
the  important  means  to  l)e  employed.  A  bleeding  tear  in  the  cervix  may  be 
stitcheei.  Broths  and  milk  may  be  given  as  freely  as  they  can  be  taken,  and 
there  may  be  required  alcohol  stimulants  as  well  as  the  hypodermatic  use  of 
etlM?r.  Winck.'l  commends  the  method  of  Breisky  and  of  Klotz,  of  compressing 
the  bleeding  lower  part  of  the  uterus  with  one  hand  in  the  vagina  and  tlic 
other  upon  the  abdomen,  the  compression  being  continued  for  half  or  three- 
quarters  of  an  hour. 

Dr.  Barnes,  in  the  paper  already  referred  to,  gives  the  following  rdsume  of 
his  metliod  of  treating  placenta  pnevia  : 

"  1.  IJupture  the  mend)rancs  ;  this  disposes  the  uterus  to  contract. 

"  2.  Apply  a  firm  bandage  over  the  abdomen. 

"3.  A.  tampon  may  be  introduced  to  gain  time,  but  it  is  not  necessary  to 
do  it.     Watch,  observe  with  vigilance. 

"4.  Detach  all  the  placenta  adhering  within  the  inferior  zone,  and  always 
watch.  If  there  is  no  hemorrhage,  wait  a  little.  Tiie  uterus  may  perhaps  do 
what  is  necessary.  If  this  fails,  dilate  the  cervix  with  the  hydrostatic  dilator. 
Wait  and  watch.  If  the  natural  forces  fail,  employ  the  forceps  which  gives 
the  best  chance  to  the  child,  or  as  a  last  resort  perform  version. 

"  5.  Avoid  as  far  as  possible  everything  which  disposes  to  septicemia.  There 
are  four  factoi-s  which  dispose  to  it :  (a)  The  bruising  and  other  lesions  of  tlic 
uterus  ;  (h)  the  retention  in  the  uterus  of  fragments  of  placenta  or  membranes 


necessarv  to 


DYSTOCIA. 


o95 


or  of  clots  J  (e)  deficient  contraction  of  the  uterus;  {(})  activity  of  absorption, 
iiicrcaseil  by  loss  of  blood.  All  these  causes  are  reducefl  to  a  niininium  in 
t'dllowing  the  precetling  thcra|ieutic   principles.     But  there  are   still  other 


I'li^.  :!'Jii.— One  k'K  bus  htM'ii  flrawti  down,  so  Uiat  the  os  is  tampiined  and  tlio  |)lai'i.'ntu  diroctly  compressed 

by  the  liips  of  the  child  (Miller).     . 

special  precautions.  After  the  placenta  is  expelled  examine  it  carefully  to 
<oo  if  it  is  entire.  If  the  uterus  does  not  contract  well  and  if  blood  flows, 
inject  hot  water,  temperature  of  45°  C,  adding  a  little  iodin  or  carbolic  acid, 
or  else,  if  the  hemorrhage  persists,  the  perchlorid  of  iron.     It  would  be  more 


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AMK/ilCA.X    TJJXT-HOOh'    OF   OIiSTi:TIiI('S. 


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nsi'f'iil  to  repeat  tlie  utcrino  injections  dnily  for  n  week.   The  activity  of  absorp- 
tion indicates  the  nse  of  a  jj;eneronH  diet." 

In  connection  with  the  nictluMl  of  J)r.  liarnos,  as  above  jriven,  n'ferencc 
niav  be  made  to  the  phm  pursued  by  another  celebrated  liritish  obstetrician 
(Radfoni)  in  1826 :  "A  multipara  in  tiic  seventh  month  of  pregnancy  luu  I 
severe  hemorrha<rt%  f«>r  which  a  tiunpou  was  used  ;  a  montii  after  this  there 
was  slitjht  flooding,  whicii  yielded  to  rest,  etc. ;  labor  came  on  two  w(M'ks  siih- 
80(piently,  and  there  was  considerable  hemorrhage.  Upon  examination  the  os 
was  the  size  of  a  crown.  As  the  pains  were  now  frecpicnt  and  strong  and  the 
«lischarge  eontimied,  after  placing  a  regulating  bandage — one  end  l)eing  fa-t- 
ened  to  the  be«l  and  the  other  held  by  the  mirse  and  tighteniHl  as  required — 
I  passcnl  my  hand,  and  first  detached  a  considerable  portion  of  the  placenta, 
and  then  ruptured  the  membranes.  The  bandage  was  drawn  so  as  eiiuaily 
and  firndy  to  supi>ort  and  compress  the  uterus  as  its  si/e  lessene<l  by  contrac- 
tion and  the  escajK?  of  the  waters."  The  result  was  favorable  for  Inith  mother 
and  child.  Radford  gave  the  reason  f(»r  detaching  the  placenta  thus  :  "  I  de- 
tached the  placenta  as  freely  as  I  thought  necessary  for  the  passage  of  tlie 
child,  as  it  is  better  svstematicallv  to  do  this  rather  than  run  the  risk  of  the 
tearing  of  the  structure  of  tiiis  organ  by  th(>  force  it  nuist  sustain  at  each  pain, 
when  the  os  uteri  has  to  be  dilatetl  by  the  head  of  the  child  after  the  membranes 
have  been  rupturetl." 

The  ])oint  of  interest  in  c(»mparing  these  methods  is  that  each  obstetrician 
<letached  jiartially  the  placenta,  though  for  a  diflferent  reason. 

Murphy,  who  has  for  years  advocated  antl  i)ractised  the  induction  of  labui- 
in  placenta  prsevia,  recently  made  the  following  statement:''^  "In  every  case 
where  i)lacenta  ])ra)via  is  evident  after  the  seventh  month,  or  even  before  then, 
1  bring  on  premature  labor  and  remain  with  the  patient  until  she  is  delivered, 
treating  her  on  the  lines  laid  down  by  Barnes."  ^furphy  has  now  had  (Jl 
cases  with  oidy  two  deaths,  and  one  of  the  two  was  moribund  when  first 
seen.  Instead  of  the  fiddle-bag  dilators  of  Barnes  some  liave  usctl,  for  tlie 
indu(!tion  of  labor  and  at  the  same  time  to  prevent  hemorrhage,  the  bixUon  of 
Champetior  de  Ribes.  Harris*'  recently  recorded  very  successful  results  from 
dilating  the  os  uteri  with  his  fingers  in  placenta  praivia.  Parks  Ritchie"  narrate^ 
two  cases  of  placenta  prsevia  in  which  the  mothers  and  children  were  .saval  by 
uccoucheiiient  fonu'.* 

Accidental  Hemorrhag'e. — The  hemorrhage  resulting  from  premature 
separation  of  the  placenta  occupying  its  normal  site  is  called  "  accidental  "  (Fig. 
.■j91).  This  detachment  may  occur  in  pregnancy  or  in  labor,  but  is  much  ntorc 
frequent  in  the  former ;  it  may  be  (XJinplete  or  partial ;  the  latter  l]a])|u'ns 
much  oftener  than   the  former.      Premature   detachment  of  the  ])lacenta  is 

*  AVlien  tlie  placenta  was  in  advance  of  the  child,  or  jUim  ante  pnfrem,  as  Par*?  said  it  \v,is 
called,  accouchement  force  was  held  hy  the  old  accoucheurs  as  the  essential  method  of  deliverv. 
(luillemeau  (l()4!>i,  accordiuj;  to  Dunal,  was  the  true  inventor,  or  rather  promoter,  of  this 
obstetric  operation ;  hut  in  recent  years  many  of  the  cases  reported  us  necnnchement  Jarre  aiv 
instances  simply  of  rapid  delivery,  no  violence  heinjj  employed,  and  the  term  has  thus  lutii 
changed  in  its  signilicntion. 


[y  of  absiM-jt- 

cn,  n'f"»'rcnc( 
I  obstt'tru'iaii 
cgiiaiu-y  had 
•r  this  there 
o  \v(H*ks  suli- 
iKition  the  us 
roiifj  iuhI  the 
1(1  boitij;  i"a-t- 
is  rcHiuiretl — 
the  phicoiita. 
so  as  c(|ually 
h1  1)V  coiitrae- 
r  botli  mother 
thus  :  "  I  «le- 
Kissago  of  the 
he  risk  of  th<> 
\  at  each  ])aiii. 
the  nieiubraiies 

ch  obstetrician 

u'tion  of  labor 
II  every  case 
m  before  then, 
le  is  delivered. 
s  now  had  01 
w\  when  iirst 
used,  for  the 
the  ballon  nf 
1  results  from 
tehie**  narrates 
were  saved  by 

i)ni  premature 
•idental "  (Fi.ii'. 
is  much  niore 
latter  bai)pens 
he  placenta  is 

s  Vht(-  saiil  it  w:'-* 
thod  i)f  (lelivt  ly. 
promoter,  of  tlii- 
iiclivmriil  J'oiri  :ni' 
in  lias  thus  Ikch 


DYsTOrlA. 


nWl 


lint   a  common  event,  for  Goodell   in  1H7()  collected  only  105  cases  of  the 
iieeidont. 

J'!llol(t(/if. — Amoiifx  the  causes  of  accidental  hcmorrhaf^o  some  of  the  acute 
infectious  diseases,  such  as  variola  and  scarlatina,  have  been  assertcil  ;  but 
more  obvious  and  more  jicncraily  accepted  are  traumatisms,  as  from  falls, 
blows,  concussion,  joltiuj;,  etc;  so,  too,  direct  pressure  upon  the*  abdomen, 
violent  sneezinj;,  couj;hin<;,  strainin<;,  or  V(»mitin<;.  Hut  in  how  many  him- 
dnnls  of  eases  many  of  these  may  occur  without  the  placenta  bcinj^  separated 
I'rom  the  uterine  wall  !  lirevity  of  the  cord,  <rreat  distention  of  the  uterus, 
as  from  plural  prc<:;nancy  or  excess  of  amnial  lifiuor,  and  simply  the  normal 
contractions  of  the  titerus  in  prct^nancy,  have  been  included  among  the  causes. 
Kaltenbach  states  that  if  the  placenta  is  detached  by  the  contractions,  it  must  be 


Upper  end 

nfctot 

/lembr. 


rtTrrrfJu 


Fici.  3'Jl.— Accidi'iitiil  iK'morrliHKt'.  RIiukI  ciil- 
Iccti'd  bctwi't'ii  pliici'iitu  mul  part  nf  lucmbriiiK's 
anil  till'  utiTiiH'  wall  (I'lnanl  and  Varnler\ 


■■•V;5iV< 


Kui.  392.— Premature  rtotachment  of  the  pla- 
ci'iita  (icciiipyiiit;  its  iiorinal  site.  I'roziMi  socticm 
(if  an  midi'livcriMl  woman  dt'adi>fi'i'laiii)isla  (aftiT 
l>r.  Winter).    A  blood  mass  undor  the  placenta. 


assumetl  that  changes  in  the  inner  portion  of  the  serotina  have  made  the  tissue 
friable  and  readily  torn.  The  importance  of  nephritis  as  a  cause  for  prema- 
ture separation  of  the  placenta  has  been  established  by  Winter;  but,  as  Veit  has 
said,'"''  we  cannot  explain  the  origin  of  the  bleeding  in  renal  maladies  without 
the  medium  of  endometritis  ;  he  maintains  that  the  chief  cau,*ie  of  premature 
detaehnunt  is  disease  of  the  decidua\  That  the  plai-euta  in  these  cases  is 
diseased  has  been  ]iroved  by  .several  ob.scrvers;  infarcts  have  been  found,  also 
indammation,  and,  in  the  case  reported  by  Coe,"*  fatty  degeneration. 

Of  81  cases  of  accidental  hemorrhage  recorded  by  Johnston  and  Sinclair 
(/'/Y»'//m^  J/Zf/HvYf'/v/),  no  cause  could  be  foimd  for  its  occiuM-ence  in  forty-six. 
Uiaefe''^  has  recently  published  a  case  of  premature  |)Iacental  detachment  in 


if*,  ■ 


I" 

■  i 


^^,.  { 


/ 


a'%. 


'1 


nns 


AMHliK'Ay    TKXr-IiOOh'   OF   OliSTKTItlCS. 


'i: 


which  shortncHH  of  tho  cord  wiis  the  (juuhc  of  the  accident ;  the  lonnth  wa.s  only  .'!  I 
centimeters.  The  patient  was  a  priniij^ravithi,  and  th('  first  l)le(Hlinj;  (MX'iirred 
about  the  time  of  the  descent  of  tiie  head  into  the  pelvit;  cavity — that  is,  al)oiit 
four  or  five  weelis  i)efore  the  mtrmal  end  of  prej;nancy,  btil  in  this  case  ten 
days  before  hii)or.  It  was  believeil  tliat  partial  detachnient  resulted  from  the 
strain  upon  tiie  cord  in  tiie  th'scent,  th«!  primary  separation  l)ein^  in  tlie  loltc 
t(t  whicii  the  cord  was  attaciied  ;  after  birtli  tlie  navel  was  immediately  in  front 
of  the  vulva.  Underhill"*  has  published  a  case  in  which  severe  pressure  upon 
the  abdomen  was  the  innnediato  cause  of  the  d<;tachment :  A  large,  powerliil 
woman,  quite  heavy,  in  the  ninth  month  of  pregnancy,  was  engaged  hanging 
clothes  out  of  a  window  to  dry,  the  greater  part  of  her  weight  being  siip- 
portetl  by  the  window-sill,  upon  which  her  alxlomen  pressetl.  Violent  uterine 
lieniorrhagj^  at  once  occiu'red,  and  the  loss  of  bUxtd  was  so  great  that  she 
fainted.  The  writer  had  a  case  in  which  partial  separation  of  the  placenta 
was  caused  by  a  fall,  the  woman  being  at  the  end  of  the  seventh  ujonth  ;  nearly 
a  quart  of  blood  was  almost  immediately  dischargetl,  and  then  the  flow  ceased. 
This  patient  went  to  term,  being  then  deliverctl  of  a  living,  well-developed 
child. 

Si/mpfomt*. — The  bleeding  is  internal  (that  is,  latent)  or  external.  The 
illustration  (Fig.  392),  from  Winter,  shows  a  partially  detached  placenta 
with  a  mass  of  blood  effused  l)etween  the  placenta  and  the  uterine  wall 
and  also  penetrating  between  the  membranes  and  the  uterus.  In  some 
instances  the  central  portion  of  the  placenta  is  first  detached,  and  then  the 
adjacent  part,  until  tlu;  entire  organ  is  separated  except  at  the  margin,  whi(;li 
remains  firm  ;  there  is  thus  formed  a  large  ciq)-shaj)0(l  cavity  filUnl  with  blood. 
Dr.  Coe  gives  the  following  as  the  signs  of  latent  accidental  hemorrhage:  Irreg- 
ularity and  feebleness  of  uterine  "pains,"  the  fundus  only  contracting;  the 
uterus  is  excessively  .sensitive;  the  .sounds  of  the  fetal  heart  are  irregidar  and 
feeble;  af\er  a  time  increase  in  the  si^-o  of  the  uterus,  ami  the  patient  coin- 
j)lains  of  its  excessive  distention  ;  palpation  of  the  fetus  is  diflficidt  or  inipos- 
sible,  and  in  some  cases  there  is  a  notable  proininei.  -o  at  that  part  of  the 
uterus  in  which  pain  has  been  felt ;  finally,  there  are  the  constitutional  mani- 
festations of  great  loss  of  blood.* 

Graefc,  in  considering  the  diflf'erential  diagnosis  of  this  accident,  refers  to 
the  possibility  of  confounding  the  condition  with  rupture  of  the  (itern.s,  or  with 
hemorrhage  into  the  sac  of  the  ovum  or  into  the  abdominal  cavity  in  ectopic 
])regnancy. 

The  cases  in  which  there  is  no  external  bleeding  are  rare.  Usually  after 
a  longer  or  shorter  time  blood  escaj)es  externally,  and  then  the  diagnosis  can- 
not be  doubtfid. 

The  accompanying  illustrations  (Fig.  393,  A,  b)  show  the  blood  escaping 
externally  in  accidental  hemorrhage. 

*  Kritsch  in  the  dia^nn.sis  states  that  the  l)aK  of  waters  remain.s  tense  and  resistant  dnriiiL' 
tlie  intervals  of  uterine  contractions,  and  tliat  it  is  impossible  by  touch  to  reach  the  placenta 
(Klinik  der  GebuHnhuljlichen  Opemlioneii). 


DYSTOCIA. 


r)!i«) 


I'luxjunHiH. — The  |>n));nosi.H  in  iicMtlciital  li(iii<)i'rliii^i>  is  had  for  tlio  niotlu  r, 
or  at  least  very  j^ravc,  and  still  worse  for  tlu'  cliild.  (JckmIcH's  statistics  in- 
clude 1()<)  eases,  and  the  maternal  mortality  was  tit'ty->oi:r,  while  of  107  chil- 
dren only  six  lived  ;  ninetiHMi  mothers  were  saved  ont  of  .'$"2  reetyrdwl  hy  Hrnn- 
ton.  (ialal)in  in  the  statistien  of  (iny's  Hospital  fonnd  .>1  casen  of  aeeidental 
hemorrhage,  twenty-one  of  them  heinj;  severe  ;  five  of  the  mothers  and  (56  ])er 
cent,  of  the  <-hildren  |M>rished.  Johnston  and  Sinclair  in  HI  cases  had  ordy 
|i)Mr  deaths  of  mothers;   and   in  (Jraefc's   14  eases  only  two  mothers  died. 

As  Schidt/e  has  pointed  out,  the  death  of  the  child  in  premature  detachment 
dl"  the  placenta  is  to  he  attril)Ute<1  not  to  loss  of  blomi,  hut  to  tlie  failure  in 
(lie  elimination  of  carhonic  acid.  The  i)ro<;no8is  is  more  favorable  in  external 
than  in  internal  hleedinjj;,  and  more  favorable,  too,  if  the  condition  of  the  os 
uteri  permits  prompt  delivery. 


Fl(i.  3911.— SliouinKHopnnitioii  of  tin'  |iltu'oiitii  witli  fxtoriml  lilfcdini;. 

Treatment. — If  external  hemorriiage  should  occur  durinj;  pregnancy,  and 
if  the  fjuantity  of  blcuMl  discharged  ;,hould  not  be  great,  the  obstetrician  will 
l»e  content  with  enjoining  the  recumbent  posture,  cold  drinks,  the  body  lightly 
covered,  and  giving  an  opiate ;  in  short,  he  will  pursue  a  course  similar  to 
that  re(]uire<l  in  threatened  abortion.  Even  if  th(>re  has  been  a  copious  dis- 
ciiarge  of  blood,  but  bleeding  has  ceased,  his  (^hief  efforts  will  be  to  relieve 
the  patient  from  her  prostration,  no  dirt>ct  interference  with  the  uterus  being 
indicated.  Possibly,  as  in  the  case  under  the  care  of  the  writer  that  has  been 
previously  mentioned,  the  pregnancy  will  not  be  interrupted  and  a  living 
child  will  1k'  born  at  term.  Nevertheless,  such  a  patient  uMist  be  carefidly 
watched,  and  the  practitioner  be  jirepared  to  act  promj)tly  should  serious  bleed- 
ing return;  in  brief,  his  state  will  be  that  of  armed  expectation. 

Shoidd  there  be  continuous  and  considerable  flow  in  pregnancy  or  in  labor, 
and  the  os  not  be  in  a  condition  to  admit  innualiate  or  speedy  delivery,  8pie- 


i! 


J 


I    I   ' 


i  'I  I' ft" 


S>    I 


I  ^  : 


i  i': 


'  ) 


()f)0 


AMERICAN   TEXT-BOOK   OF    OliSTETlilCS. 


{^olberg  regards  tlie  tampon  as  the  best  treatment.  It  should,  however,  l)c 
borno  in  niiiul  that  thereby  an  open  may  be  eonverted  into  a  eoneeale<l  hem- 
orrhage;  and,  tiioiigh  the  pressure  of  a  tampon  in  the  vagina  iiastens  dihitation 
of  tlio  OS  and  evt»kes  uterine  eontraetions,  tiiese  results  are  not  constant.  I'lic 
internal  bleeding  may  be  very  great,  for,  as  William  Hunter,  in  referring  to 
the  eapaeity  of  the  pregnant  uterus,  said,  "  We  are  apt  to  consider  the  uterus, 
when  containing  the  Ictus  and  mend)ranes,  as  being  tight  and  distended,  so  as 
to  preserve  its  shape  when  taken  out  of  the  body  ;  sometimes  it  may  be  so,  but 
in  the  state  it  generally  is  at  the  ninth  month  it  will  hold  a  pint,  a  (juart,  (u- 
now  and  then  two  ipiarts,  or  even  more.  It  is  in  rather  a  loose  state,  not 
quite  tight,  and  only  about  three  jmrts  full." 

The  tampon  will  be  employed  in  oidy  exceptional  cases  and  but  tempoi-a- 
rily.  ypiegclberg's  injunction  must  be  remembered:  ''The  onset  of  internal 
liemorrhage  must  be  looked  for,  and  be  prevented  by  carefully  supervising 
the  body  of  the  uterus  with  the  hand."  It  may  be  well  to  add  that  after  the 
rupture  of  tiie  membranes  the  tampon  is  positively  forbidden. 

If  the  labor  can  be  ended  promptly,  rupture  of  the  membranes  is  indi- 
cated, for  discharge  of  the  anniial  licjuor  is  generally  followed  by  stronger 
pains  and  arrest  of  the  bleeding.  This  rupture  is  usually  delayed  until  the  os 
is  half  dilated,  and  then,  should  the  hemorrhage  continue,  artificial  delivery 
may  be  elfecteil  in  a  comparatively  short  time.  Coe  advises  stimulants  by  the 
month,  by  the  rectum,  and  hypodermatically,  niaiuial  dilatation  of  the  os  fol- 
lowed by  ru])ture  of  the  membranes,  and  delivery  by  podalic  version  ;  if 
delay  occurs  from  insufficient  dilatation  for  the  extraction  of  the  head,  crani- 
otomy is  done  ;  ergot  is  also  used.  (tockIcU  in  his  classic  monograph '*  advi<ed 
early  rupture  of  the  membranes,  immediately  followed  by  the  application  cif  a 
very  tight  binder  and  c(im[)resses  to  the  abdomen,  ti»e  free  administration  of 
ergot,  and  promi)t  delivery  by  the  forceps  or  by  version. 

The  Cesarean  section,  which  has  recently  been  recommended,  is  of  (piestion- 
able  propriety,  even  in  grave  cases  of  accidental  hemorrhage.  Of  course  the 
usual  means  for  securing  contraction  of  the  uterus  when  the  labor  is  ended 
will  be  employed.  So,  too,  those  remedies  that  will  compensate  the  loss  of 
blood  and  hasten  its  restoration  are  indicated. 

Hemorrhage  after  the  Birth  of  the  Child. — Severe  bleeding  after  the 
child  is  born  may  have  dift'erent  sources.  It  may  be  causeil  by  tears  of  the 
vagina,  of  the  external  sexual  organs,  or  of  the  cervix ;  it  may  l)e  a  result  ol" 
rupture  or  inversion  of  the  uterus.  Rut  the  ju'cscnt  discussion  includes  only 
liemorrhage  from  the  uterus  occurring  independently  of  lesions  or  displace- 
ment of  that  organ. 

Great  loss  of  blood  may  occur  before  or  after  the  delivery  of  the  ])lacent:i, 
but  in  the  former  case  the  placenta  must  be  i)artially  or  coiiiplctely  detached, 
for  while  it  is  completely  adhen^nt  to  the  uterine  wall  it  is  jilain  there  can  be 
no  hemorrhage.  (Jrave  hemorrhage  during  or  after  (he  third  stage  of  lalmr 
is  rare,  and  many  a  careful  and  intelligent  obstetrician  will  pass  his  professioii.il 
life  without  witnessing  a  ease,  at  least  in  his  own  practice.     Herman'"'  says 


DYSTOVIA. 


601 


lienniin  ^'  sav. 


that  the  statistics  of  Guy's  Hospital  furnish  but  one  case  of  dangerous  post- 
partiini  h('nu)nhati;o  in  2()4()  hihors ;  of  St.  Tlionias's  Hospital,  one  in  2172; 


in  I'rnssia,  acconhujij 


tn  II 


(•u;ar,  one  in  o 


i;5i.    II 


ennan 


fmtl 


ler  states,  ai 


ultl 


le 


profcssittn  will  a<;r('e  in  the  statement,  that  when  so  large  a  number  of  eases 


have  recently  been  reportcnl  in  winch  the  i(Hk>iorm-j>;auze  tampon  ot  tlie  uterus 
was  claimed  to  have  arrested  bleeding,  the  presumption  is  tiiat  many  of  these 
were  cases  in  which  tiie  hemorrhage  was  slight.  It  might  be  added  that  in  so 
large  a  nnmbiT  of  eases  some  were  proofs  of  careless  obstetrics,  for,  as  Spie- 
o-elberg  has  said,  "I  certainly  do  not  exaggerate  when  I  say  that  severe  post- 
partum hemorrhage  is  almost  without  exeej)tioi>  ;'..>  fault  of  the  attendant." 
h'tio(o(/i/. — Atony  of  the  uterus  is  the  most  fre(ptent  eau'^e  of  liemorrhage 
alter    the    child's    being   «lelivered ;    this  hemorrhage,   indeed,  is    frecpiently 


calUH 


1  "at 


onic  hleedniir. 


The  ciMises  of  this  failure  of  the  uterine  muscle  to 


Th 


contract  j)roperIy,  eiosnig  the  moutiis  or  bleeding  vessels,  are  many.  1  he  con- 
dition has  been  observed  after  a  brief  as  well  as  after  a  long  labor;  it  may 
follow  a  ease  of  great  distention  of  the  uterus,  as  from  plural  preguaney  or 
from  ainuial  dropsy  ;  prolonged  and  profound  anesthesia  predisposes  to  it. 
The  bleeding  may  be  in  consecpience  of  albuminuria  or  of  hemophilia,  in  still 
other  cases  from  delicient  imis»'ular  development  of  the  uterus.  Veit"  refers, 
under  atony  of  the  uterus,  to  paralysis  of  that  portion  of  the  uterus  to  which 
the  placenta  has  been  attaclied — a  c<»ndition  which  has  been  described  by 
Kiigel,  Rokitansky,  JJurchardt,  Kiwiseh,  Chiari,  and  others.  In  this  local 
uterine  atony  there  is  found  upon  abdominal  examination  of  the  uterus  a 
depression,  while  internally,  corresponding  with  the  external  depression,  is  a 
|)r()iecting  mass. 

Fritsch  "^  observed  a  ease  of  local  atony  in  which  he  found  on  se(!tion  a 
('oinplete  varicose  degeneration  of  a  part  of  the  uterus ;  the  paralytic  portion 
was  composed  almost  entirely  of  wide  veins.  The  same  author  mentions  a 
very  dangerous  f  )rm  of  uterine  atony  the  eonsequenee  of  i'lfection  occurring 
early  in  labor,  stating  that  it  is  not  wonderful,  when  we  observe  that  paralysis 
of  the  infected  muscular  coat  of  the  bowels  leads  to  meteorism,  that  the  eon- 
tiv'i'tile  activity  of  the  uterus  should  fail  from  a  similar  cause. 

Penrose.*^  in  his  paper  upon  the  treatment  of  post-j)artum  hemorrhage, 
remarks:  "A  cause  sometimes  of  dreadful  post-partum  hemorrhage  is  the 
]>iiitial  morbid  adhesion  of  the  placenta  to  the  uterus  ;  here  there  is  often  the 
reverse  of  uterine  inertia;  the  uterus  may  be  in  a  condition  of  firm  contrac- 
tion, but  the  adherent  placental  mass,  occupying  no  little  space  in  the  cavity 
of  the  organ,  j)reveuts  and  renders  impossible  that  degree  of  shrinkage  in  si/e 
indispensable  to  the  complete  obliteration  of  the  uterine  blood-vessels,  and 
hemorrhage  is  the  inevitable  result.  To  this  cinss  of  causes  might  be  achlcd 
those  eases  where  the  hemorrhage  is  caused  by  the  presence  of  fibroids  in  the 
wall  of  the  uterus  or  of  a  jxdypus  in  the  cavity." 

Placenta  privvia  may  cause  post-partum  hemorrhage,  for  the  lower  segment 
of  the  uterus  has  not  the  contractile  power  which  belongs  to  that  portion  of 
the  uterus  in  which  the  placenta  has  its  normal  site,  hence  the  closure  of  torn 


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blood-vessels  is  not  so  prompt  and  complete,  if  the  placenta  be  attached,  in  the 
former  as  in  the  latter.  In  concluding  this  topic  we  believe  the  prevention 
of  post-partniu  hemorrhage  is  in  most  cases  secured  by  proper  management  ol' 
the  third  stage  of  labor. 

Si/mptoms. — Frequency  of  the  jmlse  is  often  a  herald  of  bleeding.  Whether 
before  or  after  the  expulsion  of  the  placenta,  the  obstetrician  finds  the  pulse 
rising  instead  of  falling,  and,  though  the  patient's  general  condition  may  appear 
favorable  and  the  uterus  appear  well  contracted,  he  will  redouble  his  watchful- 
ness, seeking  to  avert  the  threatened  ])eril  or  to  be  prepared  promptly  to  meet 
its  coming.  Possibly  the  patient  herself  may  give  the  first  danger-signal  by 
asking  if  she  is  not  "  wasting  too  much  "  or  "  flooding,"  though  frequently 
this  expression  of  fear  may  be  groundless.  Oftener  the  physician  is  advertised 
of  the  dangerous  condition  by  the  expression  of  the  patient's  face — so  deep  a 
pallor  upon  it;  probably  she  cimiplains  of  some  disorder  of  sense,  such  as 
"  ringing  in  her  ears"  or  obscurity  of  vision,  saying  that  ''the  room  is  gettiui: 
dark."  H(!r  face  is  not  only  pale,  but  also  expresses  anxiety  ;  the  pulse  is 
feeble  and  frequent ;  the  resj)irations  are  shallow,  difficult,  it  may  be  gasping ; 
the  skin  is  cold  and  bathed  in  sweat ;  in  the  hunger  for  air  she  wants  to  have 
the  window  open  and  to  be  fanned ;  she  may  in  her  great  restlessness  move 
this  way  or  that  and  toss  her  arms  about  restlessly  and  pui'posely.  Possibly 
convulsions  occur,  and  woe  to  the  patient  whose  attendant  mistakes  them  for  an 
eclamptic  attack  !  Sometimes  the  loss  of  blood  may  be  so  great  that  syncope 
occurs.  Fortunately,  however,  this  is  not  in  the  majority  of  cases  immediately 
fatal. 

The  hemorrhage  is  either  open  or  concealed — that  is,  external  or  ifiternal. 
The  Princess  Charlotte  died  five  and  a  half  hoiu's  after  a  labor  that  had  lasted 
fifty  hours,  the  child  being  stillborn.  The  hemorrhage  was  internal.  The 
autopsy  proved  a  healthy  condition  of  the  organs,  but  the  ut(>rus,  filled  with 
blood,  reached  above  the  umbilicus.  Of  course  an  external  hemorrhage 
reveals  itself,  and  an  internal  bleeding  will  be  readily  recognized  by  the 
hand  of  the  obstetrician  placed  upon  the  patient's  abdomen,  for  thereby  lie 
finds  the  uterus  greatly  enlarged,  relaxed,  and  probably  its  boundaries  not 
easily  defined.  It  ought  to  be  noted  that  a  bladder  distended  with  urine  may 
simulate  an  enlarged  uterus,  and,  even  if  it  does  not,  causes  great  ascension 
of  that  organ.     To  mention  the  possil>ility  of  the  error  is  to  avert  it. 

Post-partinn  hemorrhage  has  been  divided  into  ])rimarv  and  secondary. 
Unfortunately,  authors  differ  as  to  the  boundary-line  between  the  two,  some 
including  imder  the  latter  a  bleeding  that  begins  a  few  hours  after  labor, 
while  others  advance  the  limit  to  twenty-four  hours  or  even  some  days. 
In  the  present  di.scussion  all  hemorrhages  occtu'ring  within  the  first  twenty- 
four  hours  will  be  regarded  as  primary,  and  these  oidy  will  now  be  considered, 
secondary  hemorrhage  being  subsequently  di.scussed. 

Prof/uoNht. — The  prognosis  is  graver  the  earlier  the  bleeding  occurs,  and. 
of  course,  graver,  too,  the  greater  the  loss  of  blood.  The  character  of  the  dis- 
charge is  also  of  prognostic  significance,  for  if  the  blood  is  thin,  serum-like, 


tat'hed,  in  the 
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niul  without  clots,  the  fluid  itself  is  at  fault  and  the  danger  of  death  is  imminent. 
.S(;vere  pain  in  the  back  is  regarded  as  testifying  to  uterine  activity,  and  there- 
fore as  ground  for  encouragement.  Hippocrates  made  iiiccough  and  spasms 
(iininous  in  hemorriiage,  and  Lachapelle  counted  dilatation  of  the  pupils  a 
s;rave  prognostic  sign. 

Treatment. — It  is  of  immediate  importance  to  lessen  the  flow  of  blood  and 
to  excite  uterine  contraction.  One  step  in  the  accom])lishment  of  the  first  is 
to  lower  the  patient's  head,  taking  away  pillow  and  bolster,  and  to  raise  the 
toot  of  the  bed.  Let  tlie  obstetrician  by  his  words  and  acts  prevent  panic  on 
the  j)art  of  those  present  and  inspire  confidence  and  hope.  Instant  compres- 
sion of  the  uterus  is  made,  and  the  effort  is  exerted  to  promote  its  contraction 
liy  this  pressure  and  by  friction.  The  introduction  of  one  hand  into  the  uterus 
with  the  other  upon  the  patient's  abdomen  may  be  necessary  to  remove  the  pla- 
centa or  a  part  c»i"  it  or  coagula  or  membranes  (PI.  41 ).  It  is  important  before  this 
nianiindation  that  the  genital  canal  be  disinfected,  which  may  be  done  by 
carbolic  acid,  creolin,  or  lysol,  washing  it  out  with  hot  water  containing 
one  of  these  antiseptics ;  furthermore,  the  hot  water  has  this  advantage,  it 
stimulates  the  uterus  to  contract.  Disinfection  of  the  operator's  hand  and 
tbrcarm  is  still  more  important,  and  this  may  be  accomplished,  Fehling 
states,"  in  five  minutes  by  Fiirbringer's  method.  This  precaution  is  esj)e- 
cially  necessary  if  a  partially  free  ])lacenta  is  to  be  detached,  for,  as  Stumpf 
lias  said,  the  manual  detachment  of  the  i)lacenta  is  the  most  dangerous  obstetric 
operation.  The  introduced  hand  by  its  contact  with  the  uterine  walls  may 
evoke  the  action  of  the  organ,  and  the  removal  of  the  uterine  contents  permits 
n^iactiou.  Tn  the  removal  of  the  separated  placenta  it  is  usually  better  that 
both  hand  and  placenta  be  expelled  rather  than  withdrawn.  Meantime  ergot 
niav  be  used  hypodermatically  with  the  hope  of  stimidating  the  uterus  to  con- 
tract. If  the  patient  is  very  much  exhausted  by  hemorrhage,  stdphuric  ether, 
as  originally  advised  by  Hecker — 20  drops,  for  example — should  be  injected 
deeply  in  the  thigh,  three  such  injections  being  made. 

Among  the  older  means  of  evoking  uterine  contraction  are  striking  the 
exposed  abilomen  with  a  wet  towel,  and  the  introduction  of  a  lump  of  ice 
into  the  uterus.  The  obstetrician  now  generally  prefers  to  the  use  of  cold  the 
iiijeeting  of  hot  water  into  the  uterus.  Penrt)se  has  for  many  years  warndy 
iidvoeated  vinegar  as  an  invaluable  help  in  jiost-partum  hemorrhage.  He  lias 
given  the  following  as  his  method  of  using  it  ;•"  "I  pour  a  few  tablespoon  fills 
into  a  s'essel,  and  dip  into  it  some  clean  rag  or  a  clean  pocket-handkerchief. 
1  tlieii  carry  the  saturated  rag  with  my  hand  into  the  cavity  of  the  ntenis  and 
s(|ueoze  it ;  the  effect  of  the  vinegor  flowing  over  the  sides  of  the  uterus  and 
tiiroiigli  the  vagina  is  magical.  Tiie  relaxed  and  flabby  uterine  muscle  in- 
stantly responds.  The  organ  at  once  assiunes  what  I  will  term  its  giz/ard- 
like  feel,  shrinking  down  and  compressing  the  oj)erating  hand,  and  in  the 
vast  majority  of  cases  all  hemorrhage  ceases  instantly  ;  should  one  application 
of  vinegar  fail  to  secure  sufficient  contraction,  the  hand  can  be  withdrawn,  and 
a  second  or  even  a  third  application  can  be  made,  until  the  uterus  shall  con- 


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tract  .sufficiently  to  stop  the  flow  of  blood."  Contaniin  in  his  monograph'''^ 
states  that  "  irritant  substances  placed  in  the  uterine  cavity  act  in  the  same 
manner  as  ice,  and  are  more  readily  eni[)loyetl.  In  the  time  of  Hippocrates  a 
pomegranate  from  which  the  bark  had  been  removed  was  introduced  into  the 
uterine  cavity.  In  our  days  a  lemon  has  been  employed  (Evrat,  jNIoreau),  or  a 
sponge  saturated  with  vinegar  (liigest,  Desgrange).  iVll  these  agents  reailiK 
excite  uterine  contractions  when  they  are  immediately  in  contact  with  the  walls 
of  the  womb." 

Uterine  injections  are  as  old  as  the  time  of  Hippocrates,  but  prol?ibIy 
Pasta  in  1750  first  advised  the  introduction  of  a  solution  of  "calcined  vitriol " 
for  the  arrest  of  hemorrhage.  Dr.  Robert  Barnes  in  1857  strongly  advocatcil 
injection  of  a  solution  of  perchlorid  of  iron.  The  formula  recommended  by 
him  is  1 J  ounces  of  the  liquor  ferri  j)erchIori(li  (British  Pharmacopoeia)  and 
8^  ounces  of  water.  The  following  are  liis  directions  for  the  use  of  this  solu- 
tion :®^  (1)  "Be  sure  that  the  titerus  is  empty  of  placenta,  blood,  and  clots; 
(2)  com])ress  the  body  of  the  uterus  during  the  injection ;  (3)  have  two  basins 
at  hand,  one  containing  hot  water,  the  other  the  ferric  solution  ;  pump  water 
well  through  the  syringe  (a  good  Higginson's  will  do),  so  as  to  ex])el  air,  then 
pass  the  uterine  tube  into  the  uterus,  and  inject  first  hot  water,  so  as  to  wash 
out  the  cavitv  and  give  a  last  op|)ortunity  for  evoking  diastaliic  contraction  ; 
then  shift  the  receiving  end  of  the  syringe  into  the  ferric  solution,  and  slowly, 
gently  inject  abont  seven  or  eight  ounces,  earef  illy  keeping  up  steady  pressure 
on  the  uterus  throughout  and  afterward."  Spiegelberg®^  objects  to  the 
strength  of  the  solution  advised  by  Barnes,  and  suggests  that  half  an  ounce 
of  the  liquor  ferri  perchloridi  be  added  to  a  pint  of  water,  stating  that  "a 
high  degree  of  concentration  would  undoubtedly  corrode  the  internal  surface 
of  the  uterus,  and  might  thus  lead  to  extensive  and  deep  thnmibosis  of  the 
uterine  wall  and  to  its  setpielse ;  it  njight  also  produce  gangrenous  endometritis 
and  secondary  infection,  or  cause  the  thrombi  to  be  broken  down  and  carried 
away  by  the  veins."  Some  have  advised,  instead  of  injecting  the  uterus  with 
an  iron-salt  solution,  swabbing  the  bleeding  surface  with  a  sponge  that  has 
been  dipped  in  the  solution.  In  recent  years,  however,  the  employment  of  the 
Barnes  method  has  had  few  advocates,  not  only  because  some  fatal  cases  have 
followed  it,  but  also  because  of  the  prompt  hemostasis  usually  resulting  from 
injections  of  hot  water. 

Dr.  Attliill,*"  in  December,  1877,  in  reporting  to  the  Dublin  Obstetrical 
Society  some  cases  of  post-partum  hemorrhage  in  which  he  successfully  use<l 
h(  t-water  injections,  stated  that  he  w.s  leci  to  their  em|)lovment  because  of  a 
private  letter  from  Dr.  Whitwell  of  San  Francisco.  Dr.  Whitwell's  state- 
in;>nt  was  to  the  following  effect :  When  house-surgeon  at  the  New  York 
State  Women's  Hospital  in  1874  he  saw  the  uterus  contract  firmly  and 
instantly  upon  being  washed  out  with  hot  water  after  an  operation  by  T)r. 
Marion  Sims  ui)on  a  sarcomatous  growth  of  the  fimdiis  uteri.  The  result  led 
him  to  try  the  same  treatment  in  ])ost-]KU'tum  hemorrhage,  and  he  met  with 
perfect  success.     He  afterward  succeeded  in  having  the  treatment  tried  in  the 


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DYSTOCIA. 


605 


Lyiii{?-in  Hospital  at  Prague,  and  the  luethod  was  so  successful  that  it  was 
adopted  as  a  regular  routine  treatment.  Windelband,™  in  January,  1875, 
stated  that  by  the  recommendation  of  an  American  physician  living  in  New 
l'\)iuidland  he  had  for  a  year  employed  hot-water  inje(!tions,  vhieh  were  advised 
hy  this  physician  for  the  hemorrhage  of  abortion.  Windelband  used  them  not 
(inly  in  the  hemorrhage  in  miscarriage,  but  also  in  that  occurring  in  two  cases 
of  ])r8evial  placenta,  in  hemorrhage  from  uterine  fibroids  and  other  growths 
t'rom  the  uterine  walls,  in  bleeding  after  birth  when  the  uterus  was  relaxed, 
and  in  profuse  menstruation — in  fact,  in  all  cases  of  uterine  hemorrhage.  The 
water  should  have  a  temperature  of  112°  F.,  and  an  irrigator  or  a  fountain 
syringe  is  preferable  to  the  ordinary  instrument.  A  little  vaselin  or  cosmolin 
should  be  applieil  to  those  parts  of  the  external  sexual  organs  with  which  the 
fhiid  comes  in  contact  as  it  escapes  from  the  vagina,  for  without  this  precaution 
the  patient  will  com])lain  of  severe  burning.  The  nozzle  of  the  syringe  or 
inigator  should  not  be  passed  into  the  uterus  until  the  stream  has  begun,  thus 
guarding  against  the  possible  introduction  of  air;  it  is  gradually  carried  as 
high  in  the  uterine  cavity  as  desired,  the  escaping  stream  making  a  way,  as 
it  were,  and  facilitating  this  movement. 

Another  method  of  arresting  uterine  hemorrhage  is  bimanual  compression 
(Fig.  394).     The  patient  lies  upon  her  back  with  the  lower  limbs  drawn  up ; 


Fi(i.  ;!iM.— Bimanual  comprossidn  of  tlie  uterus. 

tlio  obstetrician  introduces  one  hand  into  tiie  vagina,  both  hand  and  vagina 
having  been  carefully  disinfected,  and  passes  two  or  three  fingers  up  to  the  pos- 
terior vaginal  vault,  so  that  he  can  exert  a  firm  pressure  upon  the  posterior 
|)art  of  the  cervix  ;  the  other  hand,  placed  upon  the  ])atient's  abdomen,  grasps 
tiio  fundus  and  the  posterior  M-all  of  the  uterus,  drawing  them  forward,  the 
vaginal  fingers  at  the  same  time  pushing  the  cervix  in  the  same  direction  ; 
tliiis  the  uterus  is  anteflexed  and  firndy  held,  so  that  hemorrhage  for  the  time 
is  impossible.  The  vaginal  fingers  may  be  ap])lied  to  the  cervix  anteriorly, 
and  the  external  hand  to  the  fundus  and  the  anterior  surface  of  the  uterus, 
and  thus  the  organ  may  be  retroflexed  and  arrest  of  bleeding  be  accomplished. 
Fritsch"  speaks  favorably  of  what  he  calls  tlie  "  rational  bandaging  "  of  the 


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abdomen,  saying  :  "  Long  prior  to  my  injection  of  iron,  and  before  Diihrsson 
recommended  the  tain|>on,  had  I  applicil  bandaging  the  abdomen  in  snitabic 
cases,  and  with  the  best  results.  It  is  especially  to  be  recommended  in  those  cases 
in  which,  some  time  post-partum,  the  uterus  is  again  distended  with  blood  and 
the  anemia  has  reache<l  the  border-line  of  imminent  danger  to  life,  as  shown  bv 
great  frequency  or  entire  absence  of  the  pidse.  In  such  a  case  it  requires  con- 
siderable self-confidence  to  apply  Diihrssen's  tampon,  as  during  its  application 
some  blo<Ml  is  lost — at  least  that  which  saturates  the  tampon.  In  these  cases 
I  recommend  and  employ  the  following  method :  The  uterus  is  pressed  for- 
ward and  antevertetl ;  behind  the  uterus  there  is  placetl  a  large  mass  of  cotton 
(one  or  two  packages,  amounting  to  250  grams)  or  large  pieces  of  muslin,  ov 
even  a  big  book  carefully  and  uniformly  wrappetl.  Now  a  roller  bandage  is 
applied  tightly,  which  not  only  compresses  the  abdomen,  but  acts  upon  the 
l)osterior  wall  of  the  uterus  so  that  the  organ  is  pushed  toward  the  pelvic  inlet. 
Additional  turns  of  the  bandage  are  made,  passing  above  the  fundus,  and  the 
uterus  is  fixed  in  its  anterior  position.  The  uterus  is  thus  compressed  in  front 
and  behind,  lying  against  the  pubic  symphysis.  By  the  abdominal  compress 
pressure  is  also  made  upon  the  aorta.  The  blood  is  pressed,  as  it  were,  out 
of  the  abdomen  and  kept  in  the  upper  part  of  the  body.  This  method,  old 
as  it  is,  still  calls  for  occasional  use,  for  it  ensiires  prompt  safety  against 
bleeding,  raj)id  recovery  of  consciousness,  and  an  improvetl  condition  of  the 
pulse.  After  such  severe  hemorrhage  patients  are  not  very  sensitive.  I  have 
often  let  the  bandage  or  compress  remain  twenty-four  hours  or  longer  with- 
out its  removal  being  requesteil.  At  all  events,  we  can  in  this  way  arrest  the 
bleeding  much  more  quickly  than  by  the  tampon,  and  at  the  same  time  we 
have  the  advantage  of  compression  of  the  aorta.  /  would  especially  adviw 
this  method  of  compremon  for  those  cases  to  which  ice  are  called  in  the  final 
star/cs — the  severest  decree  of  hemorrhaf/e.  Jf  seeing  a  case  in  the  beginning, 
such  great  anemia  may  be  averted  by  the  prophylaxis  of  Diihrssen's  tampon,'' 

Compression  of  the  abdominal  aorta  has  been  successfully  employed  in 
post-partum  bleeding.  One  of  the  recent  arguments  in  its  behalf  is  that  it 
prevents  cerebral  anemia.  Kaltenbach,^^  while  admitting  the  iisefulness  of 
this  compression,  regards  it  as  doubtful  whether  the  favorable  action  is  to  be 
attributed  to  a  lessened  l)lo()d-suj)ply  or  to  a  meohanical  irritation  of  the  ute- 
rine plexus.  The  method  Msually  pursued  is  as  follows  :  Suj)posing  the  obstet- 
rician to  be  upon  the  patient's  right  side,  the  abdominal  wall  is  depressed  with 
his  left  hand  until  the  pulsation  of  the  aorta  is  felt  just  above  the  uterus,  and 
then  slight  pressure  is  made  upon  the  vessel  with  three  fingers,  arresting  the 
flow.  An  assistant  is  needed,  for  the  fingers  become  too  tired  after  twenty  or 
thirty  minutes  to  eontimie  efficient  pressure.  Rudiger  of  Tubingen  was  prob- 
ably the  first  to  advise  this  treatment,  and  he  exerted  pressure  on  the  vessel 
through  the  jiosterior  wall  of  the  uterus.  This  method  was  rejected,  and 
Ulsamer's  method,  first  advised  in  1825,  and  previously  given,  is  that  gene- 
rally employed. 

The  tampon  is  by  no  means  a  new  way  of  treating  uterine  hemorrhage,  but 


DYSTOCIA. 


607 


its  recent  recoiniueiulation  by  Diilirssen  has  revived  its  use.     Tiie  vagiual 
tampon  is  now  never  used  except  possibly  in  tears  of  the  cervix,  and  then 
Imt  exceptionally,  and  tamponinjij  the  uterus  will  theretbre  only  be  presented. 
Lcroux  of  Dijon  and  Chevreul  of  Anj^iers  had  numerous  successes  with  the 
tampon ;  but,  as  IJaudelocqiic  has  said,  the  tampon  which  they  employed  was 
a  sponge  satiu'ated  with  vinegar,  usually  introtluced  into  the  uterus,  and  it  was 
till' action  of  the  vinegar  upon  the  walls  of  the  uterus  which  was  beneficial, 
and  not  the  barrier  which  they  supposed  the  sponge  offered  to  the  escape  of 
1)1(10(1.     Other  means  of  tamponing  the  uterus  that  have  been  recommended 
are  an  animal  bladder  or  a  rubber  sac,  either  being  introduced  empty,  and 
alter  the  introduction  filled  with  air  or  with  a  li(iuid.     Zweitei  reconimende<l 
as  a  final  resort,  other  suitable  means  having  failed,  tamponing  the  uterine 
cavity  with  cotton  that  had  been  dippwl  in  a  solution  of  chlorid  of  iron.     He 
preferred  this  method  to  injecting  the  uterus  with  the  solution,  for  a  patient 
of  his  perished  after  such  injection,  while  another  recovered  when  this  tampon 
was  applied.    In  recent  years  the  preference  for  gauze  (usually  iodoform  gauze 
is  selected,  though  some  advise  that  which  has  been  made  antiseptic  with  cre- 
olin)  has  been  decided.     In  tamponing  the  uterus  three  strips  of  gauze  about 
the  width  of  three  fingers,  each  strip  nearly  10  feet  long,  will  be  provided.* 
The  strips  have  been  dipped  in  a  20  i)er  cent,  solution  of  iodoform,  and  iodo- 
form is  sprinkled  upon  them  just  before  they  are  used.      The  patient  lies 
upon  her  back  across  the  bed,  and  two  tenaculum  forceps  are  used,  one  to 
seize  the  anterior,  the  other  the  posterior,  lip  of  the  uterus,  and  by  them  the 
organ  is  tlrawn  toward  the  vulva.     An  assistant  holds  these  forceps.     A  long 
uterine  dressing-forceps  grasps  one  end  of  a  strip  of  gauze,  and  is  used  to  carry 
this  up  to  the  fundus  of  the  uterus ;  at  the  same  time  the  oj)erator  has  his 
hand  upon  the  patient's  abdomen  over  the  uterus.     One  fold  after  another  is 
laid  upon  that  first  introduced,  and  thus  successive  layers  are  disposed  like  the 
folds  of  a  closed  fan  until  the  strips  are  all  in.troduced  and  the  cavity  is  cora- 
|)letoly  filled.     The  uterus  contracts,  it  is  claimed,  because  of  the  contact  of  a 
foreign  body  with   its  walls.     The  tampon  does  not  cause  suffering,  and  it  is 
removed  at  the  end  of  twenty-four  hours,  and  the  uterus  is  washed  otit  with  an 
antiseptic  solution.     No  matter  what  tampon  is    used,  it   caiuiot  succeed  if 
fragments  of  placenta  are  left  in  the  uterus ;  they  therefore  must  be  removed 
before  its  introduction. 

Schauta,  in  his  paper,  Die  Behandhmg  der  Blutunf/cv  post-partum ,  after 
referring  to  his  own  successfid  employment  of  the  gauze  tampon,  states  that 
failures  have  been  reported  by  Diilirssen  himself  and  by  Fritsch  and  OIs- 
liausen,  and  advises,  if  the  hemorrhage  continues  after  the  tampon  has  been 
introduced,  that  the  strips  be  removed  and  fresh  tamponing  made  after 
washing  out  the  uterus,  the  gauze  being  packed  more  thoroughly.  The  tiim- 
pon  will  be  a  failure,  he  says,  in  case  the  bleeding  results  from  large  arterial 
vessels  that  have  undergone  atheromatous  degeneration,  or  even  a  single  such 

*  Playfair  l>as  said  that  the  puerperal  uterus  will  hold  two  ball-dresses  I  This  being  true, 
one  need  not  be  astonished  at  the  quantity  of  gauze  required. 


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vossc'l  at  tlic  jdiKTiital  ssitc.  He  adds  tiiat  in  such  cases  the  removal  of  tin 
uterus  by  supravaginal  amputation  may  be  considered  in  a  well-c(»n(hiet((l 
clinic,  but  in  private  practice  wouhl  not  as  a  rule  be  thought  of.  The  prop.,- 
siti(m  of  Kocks  he  rcf^awls  as  worthy  of  consideration.  This  sugjicstion  i- 
to  invert  the  uterus,  anil  after  thi>  orjian  has  been  brouj^ht  down  it  is  to  !»• 
encircled  by  a  piece  of  rubber  tubing  or  by  a  firm  bandage,  best  of  a  strip 
of  iodoform  gauze,  so  placed  that  the  placental  site  shall  be  below  it.  Ncco- 
sarily  the  bleeding  will  be  thus  immediately  arrested,  and  at  the  end  of  six 
hours  the  bandage  is  removed,  and,  the  hemorrhage  not  reappearing,  the  uteni> 
is  restored,  this  restoration,  according  to  the  communication  of  Kocks,  being 
accomplishetl  without  difficulty. 

Kaltenbach  states  that  the  introduction  of  a  gauze  tampon  is  very  difficult 
in  case  of  a  flaccid  uterus,  and  often  it  is  incompletely  done,  and  thus  tlic 
bleeding  remains  internal.  He  fiu'ther  states,  after  referring  to  the  dangerous 
embolism  which  may  result  from  injecting  an  iron  solution,  that  the  gaii/c 
tamp(m  is  especially  applicable  in  eases  of  deficient  coagulability  of  the  blo(Ml. 
Herman,"  in  criticising  the  gauze  treatment,  remarks  that  we  must  judge 
the  effi^ct  of  treatment  of  post-partum  hemorrhage  rather  by  the  fewness  of 
the  failures  than  by  the  number  of  apparent  successes.  Fritsch  has  reeord((d 
a  case  in  which  death  occurred  from  atonic  hemorrhage  notwithstatiding  the 
tampon  •  and  other  cases,  in  which  the  cause  of  death  was  not  clear,  have  been 
published.  One  ease  of  fatal  air-embolism,  occiu-ring  while  the  tampon  was 
being  introduced,  has  been  reported.  To  the  assertion  that  the  treatment  is 
neither  certain  nor  eafe  he  adds  that  it  is  imphysiological,  for  the  uterus  camiot 
bo  completely  contracted  while  the  gauze  is  in  it.  (.'ertaiidy  the  eases  are  very 
rare  in  which  this  treatment  will  be  required. 

(iuite  exceptional,  too,  are  those  cases  in  which  a  departure  from  the  rule, 
long  established  and  almost  universally  held,  that  the  uterus  must  be  emptied 
of  clots,  is  justifiable.  "  Tiu'u  out  that  clot!"  has  been  the  injunction  of 
obstetric  teachers  for  a  century  or  more ;  yet  it  may  be  that  in  some  very  rare 
instances  the  direction  shoidd  be,  "  Do  not  turn  out  that  clot."  In  Containiu's 
paper  the  following  case  is  narrated  :  "  There  are,  nevertheless,  cases  in  which 
clots  seem  to  oppose  a  barrier  to  the  flow  of  blood.  In  one  of  his  patients 
Professor  Bouehacourt  three  times  emptied  the  uterus  of  clots.  After  each 
evacuation  the  hemorrhage  rectu'red  and  clots  were  again  formed  in  the  uterine 
cavity.  The  patient  was  exhausted  and  syncope  was  imminent.  As  the  si/.c 
of  the  uterus  was  not  very  great  and  did  not  seem  to  increase,  this  fact  indi- 
cating that  the  hemorrhage  was  suspended,  the  clots  were  left  in  the  uterus. 
"  The  hemorrhage  did  not  recur,  and  the  following  day  the  clots  were  spon- 
taneously expelled.  In  this  case  the  clots  had  the  fvle  of  an  obstacle  to  tlic 
flow  of  blood,  and  it  might  be  asked.  What  woidd  have  happened  if  the  nh- 
sti^trician  had  determined  at  all  hazards  to  empty  the  uterus?  In  exceptional 
cases  only  can  this  practice  be  followed.  Xcvertheless,  we  are  justified  in  tem- 
porizing when  the  hemorrhage  seems  arrested,  and  especially  if  the  firmness 
of  the  uterus  indicates  return  of  its  contractions."     To  this  case  mav  be  addcil 


DYSTOCIA. 


000 


(die  recorded  hy  Dr.  James  F.  Ilibbertl/*  in  whicii  a  similar  practice  was 
siiccessrully  followed.  There  was  this  ditferencc,  however :  Dr.  Ilibberd's 
patient  fainte<l  twice  from  the  loss  of  blood. 

The  means  Ibr  compensating  the  loss  of  blocnl  are  transfnsion,  atitotransfu- 
.-ion,  subcutaneons  and  intravenous  infusion  of  a  sterilize<l  solution  of  ddorid 
of  sodium — the  so-called  "normal  salt-solution'' — and  rectal  injections  of  this 
xthition.  Transfusion,  in  which  the  blood  from  another  person  is  introduced 
into  the  venous  circulation,  is  now  scarcely  ever  employctl.  In  autotransfiision 
tlic  limbs  are  bandaged  so  that  the  great  mass  of  bhxxl  which  they  contain  is 
t'orccd  toward  vital  organs,  especially  the  heart.  In  this  operation  flannel 
baiidtigcs  are  used,  those  of  rubber  being  objected  to  because  by  their  great 
compression  thromboses,  and  later  embolism,  may  be  produced.  For  hypo- 
dermatic or  intravenous  use,  and  also  for  injections  in  the  rectum,  the  physio- 
logical or  normal  salt-solntion  is  prepared  by  adding  6  grams  of  chlorid  of 
sodium  to  1  liter  of  water  free  iVoni  germs.  Winckel  advises  1  drop  of  caus- 
tic solution  of  sodium  to  be  added  to  the  mixture.  The  hypodermatic  appli- 
cation is  made  with  Minichmeyer's  apj)aratus,  which  consists  of  a  fumiel,  a 
rubber  tube,  three  needles,  and  a  thermometer.  Some  select  the  upper  portion 
of  the  thigh  for  the  introduction  of  the  fluid,  and  the  quantity  used  in  a  case 
reported  by  Ziemssen  was  1  liter :  usually  a  much  smaller  amount  will  be 
sutKcient.  The  method  is  fully  presented  in  the  treatment  of  Eclampsia 
(page  637),  and  therefore  further  details  are  not  here  given. 

Before  describing  intravenous  introduction  of  normal  salt-solution  it  should 
be  mentioned  that  much  may  be  accomplished  to  prevent  the  injurious  conse- 
([iiences  of  loss  of  blood  by  having 
the  patient  drink  the  fluid  as  freely 
as  she  can  without  catising  irritabil- 
ity of  the  stomach,  and  also  by  in- 
jecting as  much  of  it  in  the  rectum 
from  time  to  time  as  will  be  toler- 
ated. 

Intravenous  injection  of  normal 
salt-solution,  approximately  one  tea- 
s|VK)nftd  of  salt  to  a  pint  of  water 
that  has  been  boiled  and  has  a  tem- 
perature of  100°  F.,  may  be  made 
with  a  glass  funnel,  a  rubber  tnhe, 
and  a  cannula.  Horrocks,"  from 
whose  paper  the  accompanying  illus- 
tration (Fig.  395)  is  taken,  describes 
the  operation  as  follows :  "  Make  an  incision  about  one  inch  long  and  expose 
the  median  basilic  or  any  other  vein  of  not  less  calibre.  In  some  cases 
it  is  found  useful  to  cause  filling  of  the  vein  by  tying  a  pocket-handker- 
chief or  bandage  round  the  arm.     With  a  needle  pass  a  silk,  gut,  or  other 

ligature  under  the  vein,  cutting  it  so  as  to  leave  two  ligatures.     Draw  one  to 

;<9 


Fio.  395.— Intravenous  injection. 


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AMEIilCAX    TEXT-noOK   OF   OBSTETRICS. 


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the  lower  angle  of  tlu;  wound,  and  tie  it  round  the  vein  by  a  double  knol, 
cutting  the  ends  short.  With  the  disseeting-fbreeps  pineh  up  the  vein  and 
make  a  small  nick  in  't  with  scissors,  taking  care  not  to  sever  tlic  vein  com- 
pletely. Introduce  the  cannula  (silver  or  glas.s)  into  the  vein,  and  tie  it  in  by 
means  of  the  upper  ligature,  leaving  the  ends  long  as  in  the  Figure.  Tli. 
blood  will  How  down  the  camuda,  and  when  it  is  full  the  rublK«r  tubing,  pre- 
viously attached  to  the  glass  funnel  and  tilled  with  the  saline  solution,  is  tixcd 
on  the  end.  The  funnel  is  now  raised,  and  as  the  water  flows  it  ia  replaccij 
by  pouring  in  more  of  the  saline  solution  from  a  jug  (pitcher)  held  close  to 
the  rim  to  prevent  air-bubbles  being  formed.  As  long  as  the  funnel  is  kept 
above  the  level  of  the  camuda,  air-bubbles  will  always  rise  to  the  surface  and 
escape.  Another  method  of  introduction,  and  one  recommended  in  severe 
cases,  is  to  fix  the  funnel  and  the  cannula  in  the  tubing,  fill  the  apparatus  with 
salt-solution  till  it  runs  out  warm,  and  then  to  introduce  tiie  cannula  into  the 
vein,  the  funnel  being  held  by  an  assistant  slightly  higher  than  the  cannula,  so 
as  to  keep  up  a  gentle  flow  which  washes  away  the  oozing  blood  and  ensures 
the  absence  of  air.  The  speed  at  wliich  the  fluid  is  injected  can  be  regulated 
bv  raisintr  or  lowering  the  funnel.  In  most  cases  a  distance  of  about  .'{ 
feet  is  sutticient,  and  the  flow  is  found  to  be  about  a  pint  every  four  minutes. 
When  enough  has  been  injected,  remove  the  canntda  from  the  vein.  Cut  the 
latter  completely  across,  and  tie  the  upper  end  with  the  long  ends  of  the  ligii- 
ture.  Sew  up  the  wound  with  a  continuous  or  interrupted  fine  silk  or  other 
suture,  and  fix  a  clean  pad  with  a  bandage." 

Horroeks  states  that  enough  fluid  should  be  injected  to  cause  the  pulse  to 
be  perceptible  at  the  wrist,  and  that  the  worst  cases  require  about  six  pints. 
Further,  in  the  treatment  of  the  ))rostratc  condition  Kaltenbach  commends  a 
rectal  injection  of  red  wine  and  the  whites  of  two  eggs  with  from  20  to  30 
drops  of  tincture  of  opium.  lie  also  sjieaks  favorably  of  an  injection  once  or 
oftener,  in  the  up])er  ])art  of  the  thigh,  of  ether,  tincture  of  musk,  or  cani- 
])horated  oil  (1  :  9). 

Convalescence  from  the  anemia  resulting  from  severe  bleeding  will  he 
best  prouKjted  by  keeping  the  patient  in  a  horizontal  position,  not  even 
permitting  her  to  sit  up  to  nurse  her  child  or  to  urinate.  Milk,  eggs,  and 
animal  broths  should  constitute  the  thief  part  of  the  diet,  and  alcoholic 
.stimulants  may  be  advisable  in  some  eases.  If  the  hemorrhage  has  been 
from  the  placental  site,  and  esi)ecially  if  the  flow  is  profuse  and  its  bloody 
character  is  prolonged,  ergot  or  fluid  extract  of  hydrastis  is  indicated.  The 
first  getting  out  of  bed  will  be  delayed  several  days  after  the  usual  time 
in  patients  who  have  suflered  from  post-partum  bleeding.  Many  patients 
will  require  the  early  administration  of  tonics — quinin  and  iron,  for  exani- 
])Ie,  or  the  elixir  of  phosphate  of  iron,  quinin,  and  strychnin,  or  the  eoiii- 
jiound  of  **  beef,  wine,  and  iron." 

Lacerations  and  Rupture  of  the  Uterus. — These  lesions  are  found 
almost  exclusively  in  the  lower  segment  of  the  uterus;  most  of  them  con- 
sist in  tears  of  the  uterine  wall   that  run   more  or  less   transversely  (Fig. 


DVSTOC/A. 


Gil 


.?9G).  Tlioy  nro  callod  "  complete  "  rnptnroa  of  the  utoruH  wlion  tlir  wouimI 
|>('iiotrnte.s  all  throt-  fonts  of  that  organ,  and  "  incomplete  "  when  cither  the 
serous  or  the  nmcoiis  lining  of  the  womb  remains  nnimpaired.  Laccrutions 
in  the  upper  portion  of  the  uterus  are  exceeilingly  rare. 

CdHncs. — Sliarp  ridges  projecting  from  the  pcjlvic  hones  have  sometimes 
Iteen  known  to  sever  the  vails  of  the  uterus.  These  projections  are  most  likely 
(c>  be  found  at  the  promontory  and  along  the  ilio-pectineal  line,  ff  there  is 
any  mechanical  disproportion  between  the  inlet  of  the  pelvis  and  the  fetal 


I'lc.  3%.— Trnnsverso  rupture  of  lower  set;-  Fii!.;i>J7.—IrapeniliiiK  rupture  of  utcnis  in  iishoul- 

iiicut  of  uterus  (Spiejjelbern) :  a,  probe  inserted       der  iiresentiition  (niueli  ruoililieil  from  Scliroeiier): 

or,   external    os;   oi,  internul   os ;    r,\  eontraetion- 
ring. 


miller  the  peritoneum. 


head,  the  latter  in  its  descent  will  press  the  lower  segment  of  the  womb  against 
these  sharp  ridges  with  so  mucli  force  that  they  may  grind  their  way  into  the 
uterine  tissues.  Any  attempt  to  pull  the  head  into  the  j)elvis  with  forceps 
will  under  these  conditions  only  help  to  increase  the  amount  of  injury  to  the 
uterus.  Incomplete  rupture  of  the  uterus,  with  the  inner  portion  of  the  wall 
entire,  can  have  originated  only  in  this  manner. 

By  far  the  greatest  number  of  ruptures  of  the  uterus,  however,  are  caused 
ill  an  entirely  different  way.  They  are  the  direct  result  of  the  uterine  con- 
tractions and  of  over-distention  of  the  lower  segnjent  of  the  uterus.  This 
mode  of  origin  \\as  first  jwinted  out  in  1875  by  Bandl,  and  since  then  his 
statements  have  generally  been  accepted  as  correct.  During  labor  the  upper 
|i(ii-tion  only  of  the  uterus  contracts,  while  the  entire  cervix  and  that  portion 
of  tlie  body  immediately  above  the  inner  os  are  subjected  to  a  stretching  process 
until  they  form  one  wide  cylindrical  canal.  While  this  dilatation  is  going  on 
we  find  that  the  wall  of  the  lower  segment  gets  thinner  during  each  labor- 
|)aiii,  whereas  the  wall  of  the  contracting  portion  of  the  uterus  thickens  and 
iiardons.  The  border-line  between  the  upper  and  the  lower  segment  of  the 
womb  is  marked  by  a  ring-shaped  projection  of  the  contracting  portion,  the 
so-called  "contraction-ring,"  which  is  found  at  a  variable  distance  above  the 
inner  os.     During  the  contractions  the  uterus  has  a  tendency  to  move  upward 


.     ' 

1 

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612 


AMERICAN    TEXT-nOOK   OE    OBSTETRICS. 


toward  tho  diaphragm  and  to  pull  the  dilated  lower  segment  upward  and  awa\ 
from  the  presenting  part,  the  latter  usually  deseending  at  the  same  time,  thi- 
partial  evacuation  of  the  iiterus  preventing  an  undue  stretehing  of  the  lowoi- 
segment.  If,  however,  a  malpresentation  or  some  other  mechanical  impcdinieni 
])revents  the  fetus  from  descending,  tlie  stretching  of  the  lower  segment  con- 
tinues. The  uterus,  as  a  rule,  tries  to  overcome  the  obstacle  by  an  increase  iii 
the  intensity  and  duration  of  the  contractions,  thereby  augmenting  the  chances 
for  a  ru|)ture.  When  there  is  unequal  dilatation — as,  for  instance,  in  shoulder 
prescntalion,  in  which  the  greatest  stretching  of  the  lower  uterus  takes  jihuc 
on  that  side  to  which  the  fetal  head  has  escaped — the  rupture  becomes  still 
more  imminent  (Fig.  .'J97). 

The  administration  of  ergot  during  labor  is  at  times  directly  responsible 
for  uterine  ruptures.  The  writer  remembers  a  case  of  a  multipara  with  eentril 
placenta  pra>via  in  which  the  attending  physician  had  plugged  the  vagina 
very  effectively,  and  at  the  same  time  had  given  the  patient  a  teasp^onful 
of  ergotol.  The  tampons  together  with  the  mass  of  the  placenta  nuulc  it 
impossible  for  the  presenting  head  to  enter  the  pelvis;  it  escaped  to  the  left 
iliac  fossa,  ami  when  the  writer  saw  the  patient  two  hours  later  he  found  a 
transverse  laceration  on  the  left  side  of  the  uterus  a  little  above  the  inner  os, 
through  which  the  head  had  entered  the  abdominal  cavity. 

From  what  has  been  said  above  it  is  evident  that  these  ruptures  nnist 
always  originate  in  the  lower  segsiient  of  the  uterus;  which  fact,  however, 
does  not  preclude  the  possibility  of  the  tear  extending  upwanl  into  and  above 
the  contraction-ring. 

Si/mpfoinx. — In  a  minor  number  of  cases  the  rupture  takes  place  without 
premonitory  symptoms,  but  usually  these  symptoms  are  well  marked.  The 
parturient  wt>man  does  not  rest  between  the  uterine  contractions  ;  she  complains 
of  constant  and  severe  pain  in  the  lower  abdomen  on  account  of  the  intense 
stretching  to  which  the  lower  segment  of  the  uterus  and  the  uterine  ligaments 
is  being  sul)jecte<l.  The  rupture  itself  always  takes  place  during  a  uterine 
contraction,  and  it  is  usually  accompanied  by  an  intense  penetrating  pain.  At 
the  same  moment  the  parturient  woman  feels  that  the  child  has  turned  or  lias 
shifted  its  position.  The  labor-pains  suddenly  cease ;  there  may  be  a  free 
hemorrhage;  the  patient's  skin  gets  cold  and  clammy;  the  pulse  becomes  very 
frequent  and  thread-like  in  volume.  Some  or  all  of  these  symj>toms  may  bo 
missing,  with  the  exception  of  a  change  in  the  character  of  the  pulse.  The 
abrupt  cessation  of  the  uterine  activity  is  also  very  constant. 

On  examination  the  presenting  part  will  ije  found  to  have  receded,  or  it 
may  have  entirely  disappeared.  Part  or  all  of  the  chihl  has  escaped  throuiili 
the  rent,  and  it  can  (Nearly  be  outlined  through  the  abdominal  wall.  If  the 
tear  does  not  extend  through  the  peritoneum,  then  this  membrane  is  detacheil 
so  as  to  form  a  large  cavity  which  contains  the  escaped  fetus  and  a  greater  or 
lesser  quantity  of  blood. 

Frcqunu'i/  of  the  Accidait. — No  reliable  statistics  as  to  the  frequency  »l' 
rupture  of  tlie  uterus  can  be  procured,  as  in  maternity  hospitals,  to  which  com- 


ho  tVeqiioncv  of 
,  to  which  coin- 


BYSTOCIA. 

|)licat(xl  oas^os  arc  constantly  forwarded,  there  will  naturally  he  found  a  greater 
[icrcentagc  of  sncli  accidents  than  if  all  labor  cases  from  a  large  territory 
were  collected  for  statistical  purposes.  In  countries  in  which  osteomalacia 
;ind  rickets  are  common  the  frequency  of  pelvic  contractions  must  necessarily 
increase  the  number  of  ruptures  of  the  uterus.  The  ireijuency  of  this  awi- 
(lont  will  vary  also  with  tlie  greater  or  lesser  ability  of  the  obstetrician. 
IJandl  found  one  case  of  rupttn-cd  uterus  among  1200  continements,  while 
(Jarrigucs  states  the  frequenev  as  1  in  from  3000  to  5000;  the  latter  statement 
seems  to  be  apj)roximately  correct  for  the  Uniteil  States 

Frog)WHis. — Rupture  of  the  uterus  is  one  of  the  gravest  complications  of 
l;il)(>r.  Over  90  per  cent,  of  the  children  are  born  dead,  and  of  the  mothers 
liiliy  60  per  cent,  succumb  to  the  accident.  Many  women  bleed  to  death  before 
help  can  reach  them  ;  others  die  within  the  next  few  days  from  septic  infection 
or  from  secondary  hemorrhage. 

Before  antiseptic  times  the  outlook  was  even  more  gloomy,  but  it  has  greatly 
iini)rovcd  within  recent  years,  and  we  may  hope  that  in  the  future  a  still  greater 
percentage  of  mothers  will  be  saved.  According  to  statistics  published  by 
Sciiultz  and  quoted  by  Winckel  in  his  text-book,  the  following  percentage  of 
cures  was  effected  in  the  11)3  cases  collected  from  modern  literature: 

Complete  ruptures  without  treatment,  20.2  jier  cent. 

Complete  ruptures  treated  with  drainage  oidy,  36  per  cent. 

Complete  rupuires  treated  by  laparotomy,  44.7  per  cent. 

Treat  incut. — Whenever  during  labor  the  over-distention  of  the  lower  seg- 
ment of  the  uterus  can  be  diagnosticated,  an  attempt  must  be  nuule  to  deliver 
at  once  and  to  accomplish  this  without  increasing  the  distention  of  the  parts. 
Tlie  patient  should  be  anesthetized,  as  the  narcosis  will  lessen  the  intensity 
ol' the  uterine  C()ntra<'tions.  The  mode  of  delivery  nuist  be  clu)sen  according 
to  the  nature  of  the  case.  Tn  shoulder  presentations  version  carefully  executed 
is  the  proper  procedure,  providing  the  child  's  living.  IShould  the  child  be 
(lead,  then  embryotomy  would  bo  itrefoiablc,  as  i'  does  not  increase  the  tension 
of  the  uterine  walls,  an<l  consequently  the  danger  .f  a  ruptur<>,  while  version, 
no  matter  how  skilfuUy  performed,  will  cause  some  additional  distention.  In 
licail  presentations  a  gentle  attempt  with  the  forceps  should  be  made,  always 
taking  it  for  granted  I'lat  the  child  is  living.  Failing  with  the  forceps,  the 
onlv  choice  lies  between  Cesarean  section  and  craniotomv  ol'  he  livins;  child. 
N'ersion  in  these  cases  is  out  of  the  question,  because  t'le  stretching  of  the 
uterus  in  a  transverse  direction  is  very  nuieh  greater  ^\hon  the  operation  is 
|i('rformed  in  head  presentation  than  when  it  is  resorteil  to  in  shouhh'r  pres- 
ciilation,  where  the  child  lies  already  with  its  long  axii  more  or  less  trans- 
versely in  the  uterus.  U«ider  favorable  surroimdini^s  Cesarean  section  should 
always  be  the  operation  for  treating  this  emcr}^  .ic; \  and  craniotomy  should  be 
performed  in  those  eases  in  which  the  «.  hild  has  censed  to  live. 

After  the  rupture  has  taken  ])lace  a  spoci^  delivery  is  also  called  for. 
1 1'  a  part  of  the  child  '"■^  retained  in  !  le  .  ^^nis,  delivery  through  the  natural 
passages  shoidd  at  once  be  attempted.    Usually  w.  are  able  to  extract  the  child 


;.v| 


i. 


.Z  . 


•l^J"      ij, 


*  I  ■' 


1m 


^' ' 


I'     ', 


>u  . 


•    !    ^ 


,, 


'  i 


I ; 


31' 


614 


AMEBICAN    TEXT-liOOK    OF   OBSTETRICS. 


by  the  feet.  The  placenta  is  removed  next,  and  the  parts  are  then  cleaned 
and  examined.  Hemorrhage  may  not  be  very  great,  as  the  uterus  gcnoi- 
ally  contracts  well  as  soon  as  it  is  completely  emptied.  The  patient  should  lie 
allowed  to  rest,  and  she  may  be  stimulated  with  hypodermatic  injections  ol' 
ether,  brandy,  and  like  agents.  If  she  rallies,  the  further  treatment  must  lie 
decided  upon.  The  question  will  be  :  Shall  the  abdomen  be  opened,  the  rupture 
be  closed  by  sutures,  and  the  peritoneal  cavity  be  cleansed  of  the  blood  ami 
meconium  that  have  entered  it,  or  shall  the  treatment  be  confined  simply  to 
cleansing  the  vagina  with  disinfecting  irrigations  and  introducing  a  glass  tuho 
or  a  roll  of  iodoform  gauze  into  the  rent  in  the  uterine  wall  to  provide  drain- 
age for  the  infected  peritoneum  ?  When  the  accident  has  happened  amid  sur- 
roundings that  would  not  be  objectionable  to  laparotomies  for  other  causes, 
there  is  no  good  reason  why  the  patient,  provided  she  has  rallied,  should  nut 
be  given  the  full  benefit  of  the  modern  advance  in  abdominal  surgery. 
Laparotomy  performed  under  these  conditions  cannot  expose  the  patient 
to  any  additional  danger,  but  it  can  greatly  improve  her  chances  fur 
recovery. 

AVhen  the  child  has  entirely  escaped  from  the  uterus  or  when  it  cannot  be 
extracted  through  the  v'las  naturales  without  greatly  increasing  the  laceration, 
there  is  no  choice  in  the  mode  of  treatment.  The  abdomen  must  be  opened 
and  the  child  be  taken  away  after  ligating  the  umbilical  cord ;  the  placenta  is 
best  removed  by  compressing  the  uterus,  when  the  after-birth  usually  glides 
down  into  the  vagina,  whence  it  can  be  extracted  by  the  hand.  The  tear  is 
now  repaired  by  suturing,  care  being  first  taken  to  unite  the  muscular  coat 
of  the  uterus,  and  then  to  close  the  peritoneum  separately  with  the  edges  folded 
in,  so  as  to  ensure  a  good  and  speedy  union. 

Incomplete  ruptures,  with  the  peritoneum  detached  from  the  uterus,  do  not 
necessitate  laparotomy.  The  newly-formed  cavity  is  washed  out  through  the 
rent  and  a  drainage-tube  or  a  roll  of  iodoform  gauze  is  inserted  to  give  escape 
to  the  secretions.  The  same  treatment  is  pursued  in  complete  ruptures,  as 
already  stated,  whenever  laparotomy  is  decided  against.  In  the  latter  ease 
no  attempt  should  be  made  to  wash  out  the  abdominal  cavity  through  such 
a  tube :  the  tube  should  serve  only  for  drainage. 

Iryuries  to  the  Infra  vaginal  Portion  of  the  Uterus. — Physiologically 
there  is  a  laceration  of  the  vaginal  portion  of  the  cervix  in  all  primipane  and 
also  in  some  nuiltipara;.  This  laceration,  wliich  is  usually  bilateral,  runs  in  a 
transverse  direction,  so  that  in  women  who  have  borne  children  the  external 
OH  is  no  longer  a  small  round  opening  surrounded  by  a  perfect  ring  of  tissue, 
but  is  a  more  or  less  funnel-shaped  aperture  placed  transversely  between  two 
well-marked  lips. 

It  is  only  when  these  tears  arc  excessive  that  they  gain  pathological  im- 
portance.    This  is  the  case  when  the  laceration  extends  upward  to  the  vaginul 
vault  and  above  it,  or  when  it  is  accompanied  by  considerable  li'>  iior»!i!i^";'. 
In  some  cases  the  anterior  lip  oi  the  cervix  is  wedged  in  bet^i  een  the  tU'-' 
head  and  the  pubic  arch,  and  it  may  be  torn  off  more  or  less  ccnplLtely,     By 


DYSTOCTA. 


615 


aiiiuilar  lacerations  of  the  cervix  (Figs.  398-408^  are  meant  those  very  rare 
cases  iu  which  the  external  os  is  unyielding  and  in  which  the  whole  lower  sec- 
tion of  the  vaginal  portion  has  by  the  descending  head  been  forced  off  in  the 
>liape  of  a  circular  flap  containing  the  external  os  in  its  centre  (Fig.  404). 

Cuuses. — The  nioie  extensive  lacerations  of  the  cervix  arc  almost  always 
caused  by  obstetrical  operations  at  a  time  when  the  cervix  uteri  is  not  suf- 
liciently  dilated  to  allow  an  easy  passage  of  the  fetus.  In  some  few  instances 
))athological  ciianges  in  the  tissues  of  the  cervix  are  to  blame  for  these  injuries. 


Fici.  ;>1)8.— Cervix  of  virgin 
(Keitzmann). 


Fig.  399.— Another  form  of 
exteriiul  os  in  tlie  virf,'in  (Ueitz- 
mann). 


Kl<;.-1(K).— Cervix  iifler  niiseiir- 
riuge  (Ueitzmiinn). 


At  limes  the  uterine  contractions  are  so  severe  and  frequent  that  they  force 
tlie  presenting  ])art  through  the  cervix  before  the  latter  has  had  time  to  dilate. 
Not  unfrequently  the  administration  of  ergot  during  the  first  stage  of  labor, 
or  rupture  of  the  bag  of  waters  before  the  os  is  fully  dilated,  has  provoked 
these  dangerous  labor-pains.     It  is  stated   that  prolonged   labors  are  more 


K''  .   .1.-- Cervix  of  mnltipara  Via.  WJ.— HllHteral  Iiieeration  Vm.  -103.— Kxtensivelnecrnticpu 

(Heitzmunn).  to  vaginnl   walls  with   eversion       involvinfj    sii)ira-vaKinal    cervix 

(Heitzmann).  and  vaginal  wall  (Ueitzmaun). 


Klj 


fertile  ciiuses  of  cervical  injury  than  rapid  labors,  ou  account  of  the  long- 
continued  compression  of  the  cervical  tissues. 

iSipnptoms. — It  is  only  in  a  minority  of  cases  that  there  are  symptoms 
])resent  of  sufficient  gravity  to  lead  to  immediate  discovery  of  the  excessive 
laceration  of  the  cervix  at  the  time  of  its  occurrence.  Intcnst;  pain  is  somc- 
iiues  present,  more  particularly  in  those  cases  in  which  the  rent  extends  uj)- 
ward  through  the  vault  of  tiie  vagina  to  the  neigliboriiood  of  the  peritoneum. 
TIk^  hoMiorrhage,  usually  trifling,  is  now  and  then  so  sevens  as  directly  to 
endanger  the  life  of  the  patient.  When  a  post-])artum  hemorrhage  is  noticed 
while  the  uterus  is  firmly  contracted  a  close  examination  nmst  l)e  made  of  the 


.^  . 


H  i.; 


'  .! 


vm:,\/fil 


I'  'i-i  ill  \h 


1  !■ 


(  < 


1^ 


I  i, 


I  ^ 


I    I 


i     ' 


616 


AM/'JIilCAiV    TEXT-BOOK    OF    OBSTETRICS. 


lower  portion  of  the  genital  canal ;  if  it  is  foiind  that  there  is  no  lesion  of  tlir 
vulva  or  of  the  vagina  that  could  cause  the  bleeding,  it  will  l)e  an  eas\ 
matter  to  trace  its  origin  to  an  injury  of  the  cervix.  If  needs  be  the  cervix- 
may  be  pulled  down  into  the  vaginal 
orifice  to  allow  of  inspection.  During- 
the  puerperal  state  an  extensive  lacera- 
tion of  the  cervix  increases  the  danger 
of  ])uerpt'ral  septicemia  and,  at  a  lat(!i' 
period,  it  may  lead  to  chronic  uteriuf 
disease. 

Treatment. — The  prophylactic  treat- 
ment necessitates  deferring  all  obstetric 
operations  until  the  cervix  is  fully 
dilated.  This  waiting  is  not  always 
practicable,  and  we  often  have  lo 
choose  the  lesser  to  anticipate  the 
greater  evil,  but  we  should  never  ope- 
rate under  these  conditions  without  tlie 
most  urgent  indications.  The  administration  of  ergot  dui'ing  labor  at  any 
time  before  the  birth  of  the  child  is  accompanied  by  so  many  dangers  to  both 
mother  and  offspring  that  no  terms  are  too  strong  to  denounce  this  nefarious 
practice. 

Profuse  hemorrhage  from  a  tear  in  tiie  cervix  will  sometimes  be  arrested 
by  hot-water  injections  or  by  direct  compression  of  the  parts  either  by  the 


Fui.  404.— External  os  aiul  a  |)i.' 
rorvix   liiulitT  ii|>,  which    have    been 
(luring  delivery  (Winekel). 


i)f  the 
irn  oil' 


Fl(i.  lO.'i.— l.iici'nitiDU  throuiih  the  left  side  of 
the  cervix  intcitlie  hroad  lijranienl  to  the  ischial 
Rjiine  and  along  the  vagina  through  the  perineal 
pyramid. 


Fiii.  4fX'i.— The  two  lower  corners  of  the  latciiil 
laceration  of  the  cervix  seized  hy  a  double  teiiiu - 
nlnni  and  drawn  down  to  make  ready  forsuturini,' 
(Dickinson). 


finger  or  by  a  tampon  ])laced  against  the  bleeding  surface.  In  most  cases, 
however,  it  is  j)referable  to  unite  the  torn  ti.ssuos  by  sutiu'cs.  The  vagina  is 
held  open  l)y  vaginal  specula  or  holders  and  the  cervix  is  ])ulled  down  with  a 
volsella  or  with  a  pair  of  Muzeaux  forceps  until  it  appears  in  the  vulva,  when 
the  sutures  can  usually  be  applied  without  nuich  difficulty  (Figs.  405,  400). 

Inversion  of  the  Uterus. — Wy  complete  inversion  of  the  uterus  is  meant 
that  cliange  of  position  and  form  in  which  the  fundus  is  the  lowest  and  the 
cervix  the  highest  i)art  of  the  organ,  and  the  external  surface  is  the  internal ; 


DYSTOCIA. 


(317 


*!  ,  I         el 


osion  of  tlic 
be  au  easy 
e  the  cervix 
the  vaginal 
jn.     Duriii- 
nsive  laceni- 
s  the  (hui<;(  r 
lul,  at  a  lat(!r 
ronic  uterine 

lylactic  troat- 
r  all  obstetric 
•vix  is  fully 
i  not  always 
ten  have  in 
nticipate  the 
Id  never  opc- 
is  without  till' 

labor  at  any 
anirers  to  both 

this  nefarious 


es  be  arrested 
either  by  the 


liriicrsol'tlif  liiUval 
l)y  11  (Imililc  toiim- 
:  ready  iDrsuturiiij; 


[n  most  oases, 

I  The  vagina  is 

II  down  with  a 
[e  vulva,  wilt  11 

405,  400). 
Items  is  nionnt 
lowest  and  tlic 

the  internal ; 


the  shortest  definition  of  uterine  inversion  is,  the  uterus  upside  down  and 
inside  out. 

Varieties. — We  have  here  to  consider  only  what  is  known  as  puerperal 
inversion,  and  of  it  there  are  two  or  three  varieties,  according  to  the  degree 
of  the  displacement  of  the  organ.  The  first  degree,  constituting  one  of  the 
I'orins  of  incomplete  inversion,  consists  in  cupping  or  depression  of  the  fundus 
(if  the  uterus.  Should  the  fundus  descend  so  that  it  is  at,  or  partially  projects 
tVoin,  the  OS,  the  inversion  is  still  incomplete ;  but  if  the  fundus  and  the  body 
of  the  uterus  have  passetl  through  the  os,  the  inversion  is  complete.  If  the 
inverted  organ  is  external,  the  vagina  also  being  inverted,  the  greatest  displace- 
ment is  present,  and  it  is  complete  inversion  with  prolapse.  Into  the  funnel- 
slia])ed  cavity  formed  by  the  organ  internally,  and  lined  with  peritoneum,  the 
Falloj)ian  tubes,  the  ovarian  ligaments,  rouuu  and  broad,  the  ovaries  in  part, 
or  a  portion  of  intestine  or  of  omentum,  may  enter  (Figs.  407,  408). 


Kic.  40"  iviTsiim  "f  utoriis :  (liiiwiiiK  from  an 
nlil  [ipi'cimi'ii  in  alciiliol.  Tlio  iitonic  cliief  site  of 
|iliic(  iitiil  iittiiclnnoiit  ((')  is  slirunkcn  liy  the  alco- 
liol.anil  llms  its  lessenint;  is  explained  ;  li.eoiitrue- 
linii-riu);;  ((.external  os  nteri  (alter  .1.  Veit). 


Flfi.  40«.— Inversion  of  tlie  nteriis.  The  Ininen 
of  the  reetuni  is  seen,  and  also  the  inversion  fun- 
nel in  whieh  are  the  tubes  and  an  ovary  (after  J. 
Veit). 


Frequcnci/, — We  have  no  conclusive  stati.stics  as  to  the  frequency  of  this 
accident.  Winckel  ^^  in  more  than  20,000  labors  has  not  seen  a  case  of  com- 
plete inversion,  nor  had  Braun  one  in  '200,000.  Denham  in  100,000  cases  of 
labor  in  the  Rotunda  Hospital,  Dublin,  found  one  ca.se  of  inversion.  Kehrer" 
states  that  the  accident  is  thought  to  occur  once  in  2000  labors.  Probablv 
uterine  inversion  is  more  frequent  than  published  reports  of  cases  would  lead 


f^^m^^ 


1 


% 


■fiw 


I ;  \ ! 


If '  ' 


>  <' 


,«•'      i 


618 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


one  to  believe.  It  may  be  that  in  some  cases  if  the  displacement  was  recog- 
nized the  fact  was  concealed  ;  in  other  instances  the  accident  was  not  dis- 
co veretl. 

Etiology. — Relaxation  of  the  nterus  necessarily  precedes  inversion.  Mat- 
thews Duncan  has  stated  :  ^*  **  Four  kinds  of  uterine  inversion  occur  after 
delivery : 

1.  Spontaneous  passive  uterine  inversion  ; 

2.  Artificial  passive  uterine  inversion; 

3.  Spontaneous  active  uterine  inversion  ; 

4.  Artificial  active  uterine  inversion. 

The  only  uterine  condition  essential  to  the  production  of  all  these  kinds  is 
paralysis  or  inertia  or  complete  inaction." 

Without  entering  into  the  various  explanations  of  uterine  inversion  given 
by  Duncan,  this  accident  may  originate  in  three  ways : 

1.  There  may  be  spontaneous  inversion.  Paralysis  of  the  uterus  at  the 
placental  site  existing,  simply  the  weight  of  the  placenta  may  cause  sinking 
of  that  portion  of  thd  uterus  in  the  cavity.  Such  ot<3urrence  is  more  liable  to 
happen  if  the  placenta  is  attached  at  the  fundus;  then,  the  remaining  portion 
of  the  uterus  being  a(  tivo,  t'  >  introcedent  part  becoties  a  foreign  body,  and 
by  peristaltic  action  is  forced  farther  down,  just  as  happens  in  intussusception 
of  the  bowels.  So,  too,  in  complete  paralysis  of  the  uterus  the  organ  may  be 
inverted  by  the  \veight  of  the  placenta.  Each  of  these  forms  of  spontaneous 
inversion  is  rare :  some,  indeed,  regard  them  as  doubtful. 

2.  The  inversion  may  be  caused  by  abdominal  pressure  or  by  the  pressure 
of  the  hand  upon  the  uterus.  Kaltenbach  states  that  he  saw  an  inversion 
produced  by  the  practitioner,  in  endeavoring  to  express  the  placenta,  con- 
tinuing to  press  after  the  uterine  contraction  had  ceased.*  Denuce^'  quotes 
a  passage  from  Galen  showing  that  this  great  physician  knew  uterine  inversion 
could  be  caused  by  spontaneous  abdominal  pressure. 

3.  Inversion  is  most  frequently  produced  by  pulling  upon  the  cord,  and 
this  may  occur  in  spontaneous  expulsion  or  in  extraction  of  the  child,  there 
being  absolute  or  relative  shortening  of  the  funis.  Again,  it  may  hapi^en  if 
the  child  is  expelle<l  when  the  mother  is  standing,  the  sudden  strain  of  the 
child's  weight  in  falling,  acting  upon  the  attached  placenta  through  the  cord, 
producing  inversion. 

Much  oftener,  however,  the  uterus  is  inverted  by  improper  or  untimely 
traction  upon  the  cord  in  an  effort  to  remove  the  placenta,  this  traction  being 
made  soon  after  the  birth  of  the  child.  The  uterus  may  then  be  in  a  relaxed 
condition,  and  especially  at  this  time  its  lower  segment  and  the  os,  having 
been  recently  stretched  to  the  utmost  in  the  passage  of  the  child,  can  oppose 
only  slight  resistance  to  the  descent  of  the  inverted  part.  It  has  been  asserted 
that  if  jiulling  upon  the  cord  was  liable  to  cause  such  result,  the  accident 
would  be  very  much  more  frequent,  because  so  many  obstetric  attendants, 

■*  A  (liiniliircnse  has  been  previously  reported  by  Johnston  (Johnston  and  Sinclair's  Practicul 
Midwifery). 


i  ;- 


ersion  given 


DYSTOCIA. 


fcl9 


liclair's  Praciiod 


especially  midwives,  resort  to  it  for  the  removal  of  the  placenta.  But  the 
•answer  to  this  is  that  such  employment  of  traction  is  not  usually  made  almost 
immediately  after  birth,  and  therefore  the  condition  of  the  uterus,  contractions 
Iiaving  returned,  cannot  promote  the  accident.  There  are  too  many  histories 
of  inversion  being  caused  by  untimely  or  excessive  pulling  upon  the  co  d  for 
one  to  doubt  that  this  is  the  most  frequent  cause  of  the  accident. 

"\niile  in  the  great  majority  of  cases  inversion  occurs  during  the  third 
stage  of  labor,  it  may  exceptionally  happen  hours  or  days  after  delivery. 
Pcnuce,  in  describing  tardy  inversions,  inversions  tardives,  assumes  a  semi- 
])aralysis  of  the  placental  portion  of  the  uterine  wall,  which  becomes  there- 
i'ore  depressed,  and  the  depression  furnishes  a  receptacle  inviting  intestinal 
pressure.  He  observes :  "  Such  pressure,  acting  as  in  hernias,  increases  the 
cxtc!it  and  depth  of  the  inverted  portion  and  thus  causes  true  secondary 
inversion."  Again :  **  These  late  inversions  may  happen  in  different  ways. 
Sometimes  the  intestinal  pressure,  acting  in  a  continuous  i;^!Uiner,  gradually 
produces  the  inversion ;  sometimes,  on  the  other  hand,  suddenly  nnd  under 
tlie  influence  of  an  abrupt  and  accidental  effort  or  successive  efforts  the  inver- 
sion results." 

We  have  thus  explained  the  fact  that  in  rare  instances  competent  obstetri- 
cians have  met  with  cases  of  inversion  when  the  labor  was  properly  conducted, 
and  at  its  end  the  uterus  occupied  its  normal  position,  the  displacement  occur- 
ring hours  or  even  days  after.  Of  course  in  such  cases  no  blame  can  be 
attached  to  the  practitioner.  TV,it  an  inversion  may  begin  at  the  ce.  vix,  as 
has  been  taught  by  some  celebrated  obstetricians,  this  part  becoming  everted 
and  then  drawing  down  the  rest  of  the  uterus,  is  in  the  highest  degree  improb- 
able ;  especially  is  the  apparent  improbability  great  since  we  have  learned  in 
recent  years  more  of  the  passive  character  in  labor  of  the  lower  uterine 
segment. 

Symptoms. — The  most  important  symptoms  of  this  accident  are  shock  and 
hemorrhage.  The  hemorrhage  is  inevitable  if  the  placenta  be  partially  or 
completely  detached.  There  may  be  vomiting  in  consequence  of  the  stretch- 
ing of  the  nerves  in  the  lower  part  of  the  abdomen  and  of  the  pelvis,  and 
syncope ;  there  may  be  reflex  paralysis  of  the  heart ;  anemia  of  the  brain  from 
the  sudden  decrease  in  the  intra-abdominal  pressure  may  occur.  Kehrer 
speaks  of  the  collapse  as  being  anemic-nervous.  If  there  be  complete  inver- 
sion with  prolapse,  there  is  in  front  of  the  vulva  a  large  ovoidal  body  as 
ropresentetl  in  the  illustration  (Fig.  409).  In  quite  exceptional  cases  inversion 
may  occur,  as  asserted  by  Reeve,*'  "  without  sufficient  symptoms  to  attract 
attention  or  to  indicate  that  anything  has  gone  wrong."  In  support  of  this 
statement  Reeve,  unsurpassed  in  obstetric  knowledge  and  learning,  adduced 
only  two  cases,  both  in  the  practice  of  the  same  obstetrician ;  therefore  the 
accident  thus  occurring  must  be  exceedingly  rare. 

J>i<ig)iosis. — If  the  obstetrician  is  ])resent  at  the  time  of  the  accident,  and 
if  the  placenta  is  still  attached,  wholly  or  partially,  to  the  inverted  organ,  a 
mistake  is  impossible.     In  other  cases  the  history  points  to  inversion,  and  the 


||h 

M 

m 

% 

■  '^l^l:■ 


620 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


f 


symptoms  presented  assist  the  diagnosis,  wliieh  finally  must  rest  upon  a  direct 
examination.  This  examination  must  be  made  with  the  greatest  care,  for, 
though  in  the  nuijority  of  cases  a  correct  conclusion  can  be  reached  with  abso- 
lute certaintv,  vet  mistakes  have  been  made  even  bv  men  illustrious  in  the 
profession,  though  these  errors  have  usually  been  in  the  diagnosis  of  chronic 
inversion. 

One  of  the  fii-st  things  for  the  examiner  to  do  is  to  pass  a  catheter  in  the 
bladder,  for  this  organ  distended  with  urine — as  it  probably  will  be  if  some 
hours  have  elapsed  since  the  accident — may  be  mistaken   for  the  uterus. 


Fi(i.  409.— Complete  inversion  with  prolapse  (Boivin  and  DurOs):  A,  raons  veneris;  li,  laliia  majorn; 
r,  labia  miimra  ;  P,  clitoris;  K,  urinary  meatus  ;  /',  exteriuil  anterior  border  of  the  vagina;  G,  external 
bonier  of  tlie  os  uteri ;  //,  the  internal  surface  of  the  uterus,  now  external. 


il 


1    I 


Moreover,  the  bladder  must  be  e^iipty  in  order  that  abdominal  palpation 
I  .  be  made.  No  matter,  then,  what  oral  information  may  be  given  that 
the  patient  has  recently  urinated  freely,  let  the  physician  know  for  himsell', 
and  this  knowle<lge  can  be  best  obtainetl  by  the  catheter.  If  the  uterus  is 
extra-vaginal,  its  general  appearance  is  fairly  given  in  the  illustration  (Fijr. 
409).  More  frequently,  especially  if  the  examination  is  made  some  hours 
or  a  day  or  two  after  the  inversion  occurretl,  the  uterus  is  intra-vaginal,  and 
by  no  means  the  size  represented  in  the  illustration.  If  the  vagina  is  of 
normal  dimensions,  the  hand  can  bo  readily  introduced,  notwithstanding  the 
presence  of  the  uterus.     Thereby  the  examiner  feels  a  soft,  probably  sensitive, 


DYSTOCIA. 


621 


possibly  contracting,  pear-shaped  tumor,  the  larger  end  below.  By  means  of 
line  or  two  fingers  introduced  into  the  rectum  and  directed  forward  the  funnel- 
sliapcd  o{)ening  of  the  uterus  is  felt.  If  a  sound  should  be  passed  into  the 
bladder  while  two  fingers  are  in  the  rectum,  the  ends  of  the  latter  may  be 
lirought  in  close  approximation  with  the  knob  of  the  sound  above  the  vaginal 
tumor.  By  abdominal  examination  the  body  of  the  uterus  cannot  be  felt,  but 
il"  the  abdominal  wall  is  not  very  thick  and  not  sensitive — and  the  rule  is  that 
ill  great  loss  of  \>  lod  sensibility  to  pain  is  much  lessened — the  depression 
tormetl  by  the  entrance  to  the  new  uterine  cavity  can  be  recognizetl. 
Denuce  gives  the  following  diagnostic  marks  of  inversion  and  polypus : 

1.  The  circular,  not  lateral,  implantation  of  the  pedicle; 

2.  The  openings  of  the  tubes  upon  the  inferior  portion  of  the  tumor ; 

3.  The  special  sensibility,  sometimes  acconpanied  by  special  contractility, 
that  it  otters  to  pressure  and  to  acupuncture  • 

4.  The  half  reduction  which  can  always  be  made  in  inversions,  never  with 
polypi ; 

5.  The  absence  of  the  uterus  from  its  ordinary  place,  ascertained  by  rectal 
and  vesical  examination. 

Now,  we  have  to  say  as  to  these  diagnostic  marks,  first,  that  finding  the 
ojionings  of  the  oviducts  is  not  always  easy  under  the  circumstances,  and  that 
we  know  that  an  invertetl  uterus  may  reveal  no  contractility,  and  that 
it  may  be  insensitive,  possibly  in  consequence  of  the  utter  prostration 
of  the  subject,  to  pressure  and  to  acupuncture,  so  that  the  absence  of  these 
])articular  signs  does  not  prove  that  the  suspected  tumor  is  other  than  an 
invertetl  uterus. 

Prognoms. — x4ccording  to  Crosse,*'  one-third  of  the  women  with  puerperal 
inversion  of  the  uterus  die  either  immediately  or  within  a  month.  In  seventy- 
two  of  109  fatal  cases  collected  by  him  death  occurral  within  seventy-two 
hours,  usually  within  half  an  hour.  Crampton*'^  in  1885  collected  120  cases; 
there  were  eighty-seven  recoveries,  thirty-two  deaths,  and  one  remained  unre- 
lieved. Winckel,  after  quoting  Crosse's  statistics,  states  that  in  54  recent  cases 
only  twelve  died.  But  even  this  comparatively  low  mortality  proves  that  in- 
version of  the  uterus  is  one  of  the  gravest  accidents  of  labor.  Patients  may 
die  from  shock  or  from  bleeding;  the  death  may  not  be  immediate,  and  then 
it  may  occur  from  incarceration  of  a  loop  of  intestine  in  the  inverted  uterus, 
from  jieritonitis,  from  puerperal  infection,  or  from  gangrenous  inflammation 
of  the  uterus.  In  very  rare  instances  recovery  has  followetl  the  separation  by 
sloughing  of  this  organ.  Spontaneous  restoration  of  the  uterus  has  occasion- 
ally taken  place.  Schiitz '^  states  that  ten  such  cases  are  known.  Sometimes 
this  has  occurred  after  the  failure  of  artificial  means. 

Treatment. — Of  course  the  prophylaxis  is  of  primary  importance.  Ijct  the 
rooiimbeut  position  be  insisted  upon  in  delivery.  If  brevity  of  the  funis  be 
ivcognizwl,  promptly  dividing  the  cord  is  indicated.  In  removing  the  placenta 
let  no  traction  be  made  upon  the  cord,  or  at  least  no  traction  except  during  a 
pain.     If  compression  of  the  uterus  is  made  in  efforts  to  express  the  placenta, 


S-  ,**«7 


•i: 


I   > 


.'I  i 


I  i! 


■I  ^^M 


InKi''.^ 


p 


1.    I 


ei 


11 


■liki 


622 


AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 


let  the  obstetrician  be  assiirod  that  his  hand  is  so  applied  to  the  organ  that  im 
depression  of  a  part  of  its  wall  is  possible. 

The  accident  having  occurred,  restoration  of  the  inverted  organ  is  to  Ijo 
made :  this  restoration  will  be  more  readily  effected  the  sooner  it  follows  the 
accident.  If  the  ])lacenta  is  undetache<l,  and  especially  if  partially  attached, 
it  should  be  removed.  The  opinion  of  the  majority  of  obstetric  authorities  is  in 
favor  of  first  removing  the  placenta  before  attempting  reposition.  Craniptoti 
remarks:  "  Firm  and  continued  pressure  upon  any  part  of  the  inverteil  organ, 
the  patient,  if  possible,  under  the  influence  of  ether,  will  suffice  in  the  great 
majority  of  csises  to  reposit  a  recently-invertetl  uterus.  Thus  in  92  instances 
of  recent  inversion  retluction  was  eflf'ected  in  from  five  minutes  to  eight  and  a 
half  hours."  He  gives  the  mortality  as  20  per  cent.,  whatever  the  treatment. 
The  restoration  of  the  inverted  uterus  is  best  made  with  the  hands.  Of 
course  the  hands,  as  well  as  the  vagina  and  the  projecting  uterus,  must  fii-st  he 
carefully  disinfected.  Then  one  hand  is  placed  in  the  vagina,  grasping,  com- 
pressing, and  pushing  the  organ  upward,  while  the  other  hand  is  placetl  upon 
thealxlomen,  in  part  to  make  counter-pressure  and  in  part  to  dilate  the  ring  at 
the  mouth  of  "the  inversion  funnel."  In  this  effort  the  operator  seeks  to 
restore  first  that  part  of  the  uterus  which  cnrae  out  last.  According  to  Kaltcn- 
bach,  the  restoration  is,  as  a  rule,  easily  accomplished,  even  without  narcosis. 

The  objection  to  beginning  the  reduction  at  the  fundus,  depressing  it,  and 
thus  restoring  first  that  which  came  out  first,  is  that  thereby  a  greater  thick- 
ness of  uterine  walls  must  be  passed  through  the  constriction-ring.  M'CMin- 
tock  **  has  said,  in  criticism  of  this  method  :  "  By  proceeding  after  this  manner 
we  should  give  the  uterine  walls  a  second  inflection,  and  we  should  necessarily 
require  a  greater  dilatation  of  the  constriction  to  admit 
of  reposition.  The  accompanying  diagram  (Fig.  410)  will 
help  to  bring  out  my  meaning.  Here  a  is  the  angle  of 
inflection  caused  by  the  inversion  ;  b  indicates  the  position 
of  the  OS  uteri ;  and  c  shows  how  the  second  angle  of 
inflection  would  be  produced  by  depressing  the  fundus, 
which  the  dotted  line  represents.  It  would  ajipear,  there- 
fore, that  in  the  attempt  to  re-invert  the  uterus  we  should 
aim  at  replao''^g  the  part  that  has  last  come  down,  and 
so  changing  the  angle  of  inflection  according  as  each  suc- 
cessive circle  of  the  cervix  and  body  is  pushed  uj)."  TIio 
Fio.  4io.-invorsion  of    same  objection  holds  if  the  indentation  be  made  at  one 

uterus:  improper  method     ^,f  j,,p   ^,,1,^^    [nsiaSiA    of  at   the   fuudus. 
of  restoration. 

After  the  reduction  uterine  retraction  is  .sought  by 
irrigating  the  cavity  with  hot  water  and  by  the  administration  of  ergot ;  pack- 
ing the  uterus  with  iodoform  gauze,  as  some  have  reconmiended,  is  unnecessarv. 
If  reduction  be  impossible  without  too  prolonged  or  violent  manipulation,  it  is 
better  to  wait  until  the  puerperal  period  has  passed.  A  restoration  immediately 
followed  by  the  death  of  the  patient  can  hardly  be  counted  an  ob.stetric  triumpli. 
Delay,  too,  is  advisable  if  the  patient  is  not  seen  until  a  few  days  after  the 


DYSTOCIA. 


623 


acoidont :  iniuiediate  peril  has  passed,  and  new  peril  may  arise  from  active 
efforts  at  reduction  made  during  the  lochial  flow.  After  tliis  flow  has  ceased 
reposition  may  be  attempted  by  continuetl  elastic  pressure — as,  for  example, 
i)y  a  colpeurynter  filled  with  warm  water. 

li  returning  the  uterus  is  impossible — and  the  reduction  of  an  inversion  is 
literally  rc-turning — it  is  generally  advised  to  control  hemorrhage  by  ergot  and 
by  local  application  of  astringents  and  refrigerants.  Denuce  commends  lacta- 
tion if  the  patient's  strength  permits,  stating  that  the  hemorrhages  are  almost 
completely  suppressed  wliile  she  nurses. 

3.  Dystocia  due  to  Diseases  of  the  Mother. 

Eclampsia. — Eclampsia  {exXa/jtrrai:;,  a  shining  forth,  from  exXa/mo,  to 
flash)  is  now  commonly  used  as  a  synonym  for  puerj)eral  convulsions.  It 
may  occur  in  pregnancy,  in  labor,  or  in  childbed.  It  is  characterized  by 
a  series  of  convulsive  nu)vements  and  loss  of  consciousness,  and  coma  fol- 
lows. Martin's  definition  is,  "  Convulsions  of  the  entire  body  with  loss  of 
consciousness."  ^ 

Desormeaux  **  stated  that  Hippocrates  and  the  ancient  physicians  employed 
the  word  exlan-at;:  metaphoricidly  to  ex|)ress  the  exaltation  of  tiie  vital  proj)- 
ertics,  the  scintillation  of  the  fire  of  life,  according  to  the  expression  of  com- 
inontators,  that  occurs  at  the  epoch  of  puberty.  "  Some  modern  writers  have 
called  eclampsia  the  epileptiform  convulsions  which  are  transiently  developed, 
aiul  as  the  effect  of  an  appreciable  cause,  in  certain  individuals,  and  more  espe- 
cially the  convulsions  that  occur  in  infants  during  dentition  and  in  women  in 
])regnancy  or  labor.  It  is  this  last  variet\ ,  designated  by  Sauvages  eclampsia 
pariurientium,  to  which  the  term  eclampsia  is  now  usually  restricted." 

The  disease  presents  a  strong  resemblance  to  epilepsy,  with  which  it 
has  sometimes  been  confounded.  Eclampsia  is  not  rare ;  its  danger  to  the 
mother,  and  especially  to  her  unborn  child,  is  great,  and  even  if  the  former 
should  escape  imme<liate  death,  she  is  liable  to  septic  infection  or  to  chronic 
nephritis,  and  sequelae  involving  the  psycho-motor  or  psycho-sensorial  centres 
are  not  uncommon.  Moreover,  its  essential  etiology  is  not  settled  beyond  all 
controversy,  nor  is  there  j)erfect  professional  agreement  in  all  things  concern- 
ing the  medical  and  obstetrical  treatment.  For  these  reasons  ^h  refore,  the 
subjoct  is  of  great  in^portance,  and  it  demands  careful  consideration. 

Frequency. — T'.e  statements  of  authorities  differ  in  regard  to  the  ])roportion 
of  those  attacked.  Auvard^"  gives  3  in  1000;  Martin  and  Kaltenbach,*^ 
1  in  500 ;  Vinay,**  1  in  250  or  260 :  the  last  statement  we  believe  is  at  least 
approximately  correct.  The  reports  of  the  Philadelphia  Board  of  Health 
show  that  in  the  five  years  beginning  with  1868  and  ending  with  1872  there 
wore  47,191  children  born,  and  in  that  period  132  women  died  from  eclampsia. 
Assuming  that  the  disease  was  mortal  in  25  per  cent,  of  cases,  that  is,  three 
recovered  for  one  that  died — we  believe  that  this  is  a  fair  estimate  of  the 
mortality — the  entire  number  of  cases  of  eclampsia  occurring  in  the  five  years 
was  525,  or  1  in  170  labors.     From   1888   to   1892,   inclusive,  there  were 


■'«  ¥,.  ^^ 


()2i 


AMNIill'Ay    TKXr-IUKtK    OF    OliSTKTniCS. 


141,2;i5  births,  and  99  cases  of  deatlis  from  cflanipsia.  Ap|)roximatcl\, 
then,  tlicn;  wtMV  WMy  cases  of  tlic  diseast;  in  tliat  period,  or  1  to  .'581  labors. 
It  appears,  therefore,  tliat  \.\w  disease  was  more  than  twice  as  frecpieiit  in 
the  first  period  as  it  was  in  the  second  :  the  partial  interpretation  of  tliis  Ijut 
will  appear  in  a  moment. 

Absolute  accuracy  is  not  clainie<l  for  these  statistics,  for  some  of  the  births 
were  plural ;  hence  the  entire  nundwr  of  children  born  must  be  jj;reater  than 
the  actual  mnnber  of  labors.  Further,  errors  may  arise  as  to  the  cause  oi 
death  jfiven  by  the  physician,  and  thus  the  patient  sut!'erin<i^  from  eclampsia 
may  have  perished  from  sej)tic  or  from  renal  disease,  and  the  death  have  been 
thus  reported.  It  cannot  justly  bo  asserted  that  there  has  been  such  advamc 
in  the  treatment  of  the  disease  that  the  mortality  has  been  lessened  more  tliiiii 
one-half.  A  [)artial  explanation  of  the  ditt'ereuce  is  j^iveu  by  the  fact  that 
eclaujpsia  is  more  fretiuent  at  certain  times  than  at  others.  Kaltcnbadi 
directs  attention  not  oidy  to  this  fact,  but  also  to  these :  the  disease  occurs 
more  frcnpiently  in  certain  places,  and  likewise  varies  in  its  severity.  In 
illustration  of  the  variation  in  frccpiency  of  eclampsia  at,  certain  times,  the 
statistics  from  whi«'h  we  have  (piot(Hl  show,  estimatiuj;  the  actual  number 
from  the  number  that  died,  that  in  1891  there  were  l.'JG  cases,  or  1  in  213 
labors;  but  in  1890  and  18*^ .i  the  proportion  was  only  1  in  49G  labors — not 
half  so  many  in  the  two  years  as  in  the  interveninjij  year. 

Periods  and  T'uiw  when  J'Jehnnpnia  most  Frequenfli/  Occurs, — We  have  not 
merely  to  consider  the  several  periods  in  which  the  disease  is  manifested,  but 
also  the  time  in  each  of  those  periods.  Kalteubach's  statement  is  that  while 
the  disease  may  apjiear  toward  the  end  of  pregnancy,  it  is  most  frequent  in 
labor,  most  seldom  after  it.  Pajot  has  given  the  following:  During  labor, 
100;  before,  60 ;  and  after,  40.  The  recent  studies  of  Goldberg,^^  includintr 
1120  cases,  show  that  in  21.07  |)er  cent,  the  disease  appeared  in  pregnancy  ;  in 
labor,  o(].34  per  cent.;  and  after,  in  22.59  per  cent.  Bailly,*^  in  his  admirable 
article  upon  EcUunjtsia,  has  taken  the  ])osition  that  the  order  in  frequency  is 
pregnancy,  labor,  and  the  lying-in,  and  he  has  attributed,  as  wo  believe  justly, 
the  discrepancy  so  common  among  authorities  in  part  to  the  fact  that,  as  the 
disease  so  generally  induces  labor,  cases  that  really  begin  in  pregnancy  have 
been  included  in  those  that  belong  to  labor,  sufficient  care  not  having  been 
taken  to  observe  the  actual  time  when  the  attacks  commeucal.  N(!vertheless, 
the  statistics  of  Goldberg  cannot  be  .set  aside,  and  wo  accept  the  results  as  at 
least  approxinuitiug  the  truth,  though  doubting  the  absolute  correctness  as  to 
the  very  It.rgc  percentag-  of  cases  occurring  during  and  after  labor,  while  we 
believe  that  the  percentage  of  those  that  happen  before  labor  is  too  small.* 

If  eclampsia  occurs  in  labor,  it  is  usually  in  the  first  stage.  If  after  labor, 
in  the  great  majority  of  ca.ses  within  a  few  hours,  though  a  few  or  several  days 
may  intervene  in  others :  even  twenty-eight  days  have  passed  in  a  patient  ob- 
served by  Bailly,  and  fifty-eight  in  a  case  of  Sir  James  Y.  Simpson's.     Wv 

*  In  IIe^nl!ln'^s  12  cases,  nine  be)j;an  before  labor,  two  during,  and  one  after  labor  {London 
Obstetrical  Sociely'n  I'ranmctioni!,  vol.  xxxiii,  18'J2). 


Iter  labor  (loii''')!' 


DYSTOVIA. 


625 


limy,  with  Viiiay,  qiieHtioii  wlicthcr  attacks  (irst  oa-iirriiij;  niorotlian  two  nvpoUh 
alter  lal)or  should  jii>tly  he  iiichuh'd  imdcr  puerperal  eehimpsia.  In  the  ^reat 
majority  of  eases  in  which  the  disease  iiappens  in  prej^nancy  the  time  (Votu 
Hcvon  to  nine  inontiis  oilers  tiu!  jjjreatest  liability  ;  nevertheless,  eases  have 
been  observed  at  the  sixth,  the  tifth,  or  the  fourth  month,  even  at  the  sixth 
week,  and  Tissier  re|M»rted  a  case  at  the  seventeenth  day,  and  Prestiit  one  in 
the  se(!ond  week. 

I'reinonilori/  Si/inp(ovi». — The  first  atta(tk  may  oeenr  without  warninj;,  the 
patient  appanaitly  having  been  up  to  the  seizure  in  good  health.  IVit  usually 
there  are  precursory  phenomena,  lasting  only  a  few  hours  or  begimiing  a  few 
(lays  before.  These  phenomena  are  nausea  iuul  vomiting,  restlessness,  weariness 
upon  exertion,  mental  irritability,  headache,  disturbance  of  vision,  dizziness, 
iiiiiscular  tremors,  ringing  in  the  ears,  and  severe  epigastric  pain.  Delore  calls 
attention  to  lumbago  as  a  premonitory  sym|)tom  observed  in  some  eases,  this 
symptom  being  the  expression  of  renal  changes.  Special  importance  is,  prob- 
ably with  justice,  to  be  attached  to  three  of  these — namely,  the  epigastric^  pain, 
tlie  headache,  and  the  disturbance  of  vision — and  therefore  fidler  consideration 
must  1)C  given  them.  The  cpif/dntric  suffering  is  I'v  no  means  a  constant  nuin- 
ili-tation  ;  but  if  it  occurs,  it  is  (piite  significant :  according  to  liailly,  it  rarely 
lasts  more  than  a  few  hours,  and  when  it  becomes  very  severe  and  continuous 
one  may  almost  be  certain  that  the  convulsive  attack  is  imminent.  Dyspnea 
is  connected  with  epigastric  pain,  antl  is  attributed  to  the  poison  in  the  blotxl, 
which,  as  will  presently  be  seen,  seems  the  essential  cause  of  eclampsia.  The 
hcadaclm  is  usually  frontal,  occupying  the  entire  forehead,  or  it  may  be  upon 
the  one  or  the  other  side;  rarely  is  it  occipital.  The  dixturbatice  of  vixixm 
may  be  simply  asthenopia  or  amblyopia  or  diplopia,  or  even  absolute  blind- 
ness ;  in  one  case  we  have  seen  loss  of  vision  twenty-four  hours  before  fatal 
eclampsia  at  the  fourth  month  of  pregnancy,  and  v/v  have  had  a  patient  who 
became  amaurotic  during  labor — it  was  a  plural  pregnancy,  and  she  had  had 
for  some  weeks  albuminuria;  the  amaurosis  continued  several  days  after  the 
delivery  of  living  twins,  and  then  spontaneously  disappeared. 

According  to  Vinay,  if  headache  is  accomj>anied  by  flashes  of  light,  by 
ringing  in  the  ears,  by  tingling  and  numbness  of  the  lower  limbs,  the  attack 
is  at  hand.  In  some  cases,  rare,  however,  ati  aura  immediately  precedes 
eclampsia.  A  patient  of  Olshausen's  uttered  her  husband's  name,  and  in- 
stantly the  convulsions  came.  Another  may  have  the  sensation  of  falling, 
still  another  may  utter  a  cry  of  terror,  and  others  have  been  known  to  raise 
the  arm  before  the  face  as  if  to  protect  it  from  a  threatened  blow. 

If  some  of  the  premonitory  symptoms  that  have  been  mentional,  such 
as  disturbance  of  stomach,  of  vision  or  hearing,  headache,  numbness  of  the 
lower  limbs,  be  observed  in  a  woman  who  is  edematous,  if  she  has  scanty 
urine,  and,  above  all,  if  this  contains  albumin  and  casts,  convulsions  will 
surely  come  unless  proper  means  arc  promptly  usetl  to  avert  them. 

Phenomena  of  Eclampsia. — The  patient  lies  fixed  in  position,  while  her 
eyes  are  apparently  directed  to  some  distant  object ;  she  has  become  nncon- 

40 


!  ] 


llsw 


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AMERICAX  TEXT-BOOK  OF  OBSTETRICS. 


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scions,  and  gives  no  attention  to  what  may  be  said  or  done;  in  a  few  seconds 
the  eyeballs  move  in  various  directions,  soon  become  still,  generally  turned 
upward  and  to  the  left;  the  head,  changing  from  side  to  side,  finally  remains 
directed  to  the  right ;  the  eyelids  open  and  shut,  the  muscles  of  the  nostrils 
and  of  the  face  move  spasmodically,  then  the  mouth  is  drawn  toward  one 
side;  the  trembling  tongue  maybe  thrust  between  the  teeth;  brief  jerkiiii; 
movements  of  the  lind)s  (jccur,  the  arms  are  pronated,  the  forearm  flexed,  the 
thumb  firmly  applied  to  the  palm,  and  the  fingers  over  it ;  the  jaw;  becoiiio 
rigid,  and  if  the  tongue  has  protruded,  it  is  bitten;  resj)iration  is  arrested  liv 
tonic  contractions  of  the  muscles  of  the  chest,  and  rigidity  of  the  entire  bodv 
and  limbs  is  present.  In  from  a  third  to  half  a  second  clonic  convulsions 
ensue,  the  rigid  state  ceases,  these  convulsions  involving  the  muscles  of  aniintil 
life,  wave  of  disordered  movetiient  swiftly  following  wave  ;  respiration  returns, 
but  it  is  stertorous,  and  moist  bi'onchial  rd/cs  are  heard  ;  tlu?  swollen  face,  which 
became  "  violet,  livid,  even  black"  (Jacquemier)  din'ing  the  tonic  stage,  gradu- 
ally takes  a  less  unnatiu'al  color;  the  noisy  expirations  drive  out  frothy  saliva, 
often  tinged  or  deej)ly  colored  with  blood.  The  clonic  convulsions,  after  lasting 
from  one  to  five  minutes,  cease,  their  cessation  being  nuirked  by  an  unusually 
deep  inspiration.  Coma  concludes  the  drama,  the  patient  remaining  imcmi- 
scious,  and  also  iur^onsible.  The  coma  is  the  consequence  of  cerebral  conges- 
tion, and  the  congestion  is  caused  by  jn'cssure  on  the  jugular  veins  by  the  con- 
vulsed muscles  of  the  neck,  and  especially  by  the  arrest  of  respiration  diu'ing 
the  tonic  stage.  The  comatose  condition  may  last  from  ten  to  twenty  mimites, 
or  even  a  longer  time.  i 

During  the  onvulsions  ex])ulsion  of  feces  sometimes  occurs — more  rarelv 
of  urine  and  of  the  contents  of  the  stomach.  The  body  is  covered  with  :iii 
abundant  viscid  persj)iration.  The  pulse,  which  at  the  beginning  of  tin 
attack  was  jirobably  full  and  strong,  is  feeble  and  frequent  during  it,  but  be- 
comes more  natural  in  the  coma.  The  clonic  convidsions,  while  rarely  lasting 
so  long  as  five  mimites,  continued  in  a  pati(>nt  observed  by  Tarnier  for  twenty 
mimites.  The  return  of  the  patient  to  consciousness  is  only  gradual,  and  the 
time  intervening  between  the  first  onset  of  the  convulsions  and  the  end  of  the 
coma  is  a  complete  blank  in  her  memory. 

Very  rarely  there  is  but  a  single  attack,  and  the  jiatient  is  restored  to  ))er- 
feet  health.  Still  more  rarely  death  results  from  this  attack  ;  such  a  case  li:i< 
been  recently  reported  :"'  the  ])atient  was  delivered  just  at  the  beginning  of  a 
broncho-pneumonia ;  at  the  end  of  nine  days  she  had  eclampsia,  and  died  in 
fortv-eijiht  hours  after  the  attack. 

In  almost  all  cases  after  an  interval  of  half  an  hour,  or  even  of  several 
hours,  the  eclampsia  recurs,  and  attack  may  follow  attack  with  no  restoni- 
tion  to  consciousness — indeed,  in  grave  cases  the  consciousness  may  imt 
return  after  the  first  attack.  The  number  of  seizures  may  be  very  great  ; 
Kaltenbach  refers  to  eighty  in  some  cases,  and  A'^inay  says  there  may  l>r 
more  than  a  hundred.  Winckcl  has  seen  but  one  ease  of  recovery  al'ti  i' 
eighteen  attacks;  but  \  inay  states  that  a  patient  recovered  after  twenty-six, 


If    ^ 


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erally  tvinud 
niilly  remains 
)f  tlie  nostril> 
II  toward   oiu' 

brief  jerkiiii: 
nil  Hexed,  the 
■i  jaw;  beeoinc 

is  arrested  hy 
he  entire  body 
ie  eonvnlsioii- 
seles  ot'aniiiiiil 
iration  returns, 
lien  faee,  wliidi 
ic  stage,  gradn- 
it  frothy  saliva, 
ns,  after  lastiii;j; 
)v  an  nnusnally 
naining  uncon- 
[•erebral  conges- 
cins  by  the  con- 
spiration during 
twenty  minutes, 

rs — more  rarely 
•overed  with  an 
■ginning  of  tlic 
iring  it,  but  bc- 
ie  rarely  lastinir 
[nier  for  twenty 
radual,  and  the 
|l  the  end  of  tlii' 

restored  to  per- 

sueh  a  ease  lia* 

I'  beginning  of  a 

[iia,  and  died  in 

even  of  several 

,'itli   no  restor:i- 

lisness    may    n^t 

be  very  gre:ii  ; 

|s  there  may  !"' 

recovery   al'ti  i' 

ifter  twenty-i^i-^, 


DYSTOCIA. 


^627 


and  Olshaiisen  had  six  patients,  having  from  twenty-two  to  thirty-six,  who 
irot  well. 

It  is  rare  for  the  attacks  to  continue  longer  than  forty-eight  hours ;  indeed, 
the  fate  of  the  j)atient  is  usually  determined  within  the  tirst  twenty-four 
iK)urs,  for  if  there  are  several  attacks  during  this  time,  unmitigated  in  severity 
;ind  undiminished  in  frequency,  a  fatal  result  is  almost  inevitable.  Winckel 
lii'st  called  attention  to  the  progressive  elevation  of  temperature  with  suceessive 
attacks,  so  that  it  may  reach  102°  or  10-4°  F.,  and  after  death  the  thermom- 
oter  marks  a  still  higher  degree.  Investigations  by  others,  especially  by  Bom-- 
neville,  followed  those  of  Winckel.  Bourneville  claimed  that  not  only  did 
the  thermometer  lurnish  important  ground  for  prognosis,  but  by  it  only  could 
puerperal  eclampsia  be  dilferentiated  from  uremia.  If  the  temperature  of 
till'  eclamptic  continued  to  increase,  reaching  a  high  degree,*  the  prognosis 
would  be  unfavorable,  while  a  {)rogressive  diminution  pointed  in  an  opposite 
direction.  The  results  of  experience  do  not  give  absolute  contirmation  of  this 
view,  for  though  usually  the  temperature  increases  during  the  continuance  of 
the  eclamptic  attacks,  yet  in  some  instances  the  danger  may  be  imminent, 
(liaili  at  hand,  witiiout  such  increase,!  or  the  temperature  may  even  be  sub- 
normal. So  too  in  regard  to  the  diagnosis  between  eclampsia  and  uremia : 
wliile  it  is  true  that  there  is  in  the  latter  a  lessened  temperature,  there  are 
exceptions  %  to  the  rule. 

The  urine  of  the  eclamjitic  is  usually  scanty,  contains  albumin  in  large 
|)i'(t|)oftion,  various  casts,  epithelium  from  the  urinary  tract,  and  blood-eel h; : 
ill  somc^  cases  there  is  com])lete  anitria.  Nevertheless,  all  albuminurics  are  not 
(■('huii])tics ;  Hubert  makes  the  number  only  2G  per  cent.,  and  Charpentier 
has  collected  141  cases  of  eclampsia  without  albuminuria.  The  writer,  a  few 
years  ago,  had  under  his  care  a  primipara  who  was  attacked  with  eclamjisia  a 
lew  hours  after  labor,  and  the  quantity  of  urine  was  not  lessened,  and  showeil 
only  a  faint  trace  of  albumin. 

The  Iiijfuence  of  Ju'/((iii}tsia  upon  the  IIcvuh  and  ujion  the  Fctut^. — In  case 
eclamptic;  attacks  occur  in  pregnancy,  more  especially  in  the  latter  weeks,  in 
tlie  majority  of  cas(>s  action  of  the  uterus  is  excited  and  its  contents  are 
<\pelled  after  the  fetus  is  death  The  death  of  the  fetus  may  be  followed 
by  a  disappearance  of  the  eclampsia,  and  in  case  no  uterine  action  has 
Ix'gnii,  the  pregnancy  may  continue  for  a  time,  or  even  until  term  ;  meantime, 
if  alijumiiiuria  has  been  jiresent,  this  gradually  ceases.  In  still  other  cases, 
by  IK!  ineanv   numerous,  the  fetus  lives,  the  patient   recovers,  and  the  preg- 

lUack  stall's  thiit  in  <nw  cuso,  untreated  until  tiie  ])atient  was  inoriiiund,  lie  had  IouikI  tlie 
U'iii|n'iature  as  liigli  as  110°  F.  (  TntiiKdfliinis  Luiidnii  < lliMttrical  Soriitji,  vol.  xxxii.l. 

t  Kiviere,  referring  to  ISourneville's  statement,  remarks:  "In  several  of  our  ohservatious 
llii"  teinjierature,  earel'ully  taken  either  duriiiu'  the  attacks  or  in  the  intervals,  was  not  elevated 
alinve  the  normal,  or  so  slightly  that  it  should  not  he  considered"  ( f'tllnKiniii'  'I  Intili'infiit  de 
I'liiiliiiiidxriciilinn  fcl<impti(iiii;  1 SSS ). 

t  Hiviere  {op.  ril.),  ret'errini;  to  this  view,  states  that  Honehard  ascertained  tlial  while  uremia 
cinises,  in  the  majority  of  cases,  slowiny;  of  calorilication  sutlicieiil  to  iiroduce  ii  suhno'.-mnl 
temperature,  this  sometimes  tails,  luid  there  may  he  increase  of  teiiiporatiiro. 


Ji ;  ■■  V 


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k'.JiJ 


i^: 


d» 


628 


AMERICAN   TEXT-BOOK   OF   OBSTETBICS. 


nancy  is  completed.  Should  eclampsia  appear  in  labor,  this  is  accelerated,  and 
delivery  may  occur  without  the  patient  being  conscious  of  it.  The  attacks 
are  frequently  excited  by  uterine  contractions  ;  the  escape  of  the  amnial  liquor 
may  be  followcfl  by  at  least  a  temporary  cessation  of  the  paroxysms. 

The  death  of  the  fetus  probably  occurs  in  about  50  per  cent,  of  cases  as 
the  consequence  of  maternal  eclampsia.  This  death  may  result  from  the  fact 
that  the  pregnancy  ends  before  the  child  is  viable,  or  be  caused  by  placental 
hemorrhages,  peculiarly  liable  to  occur  in  albuminurics,  or  from  asphyxia 
resulting  from  the  deficient  oxygenation  of  the  mother's  blood,  or  from  the 
same  poison  that  causes  the  convulsions  of  the  mother.  In  several  cases  the 
child  has  been  expelled  dead  and  rigid :  the  writer  met  with  a»'  example  of 
this  kind  more  than  thirty  years  ago,  the  mother  attacked  witi  jlampsia  at 
the  end  of  her  pregnancy,  and  dying  twenty-four  hours  after  delivery ;  tiie 
rigidity  was  well  marked  ;  it  seemed  almost  as  if  the  chief  joints  of  the  fetal 
members  were  ankylosed.  Some  of  the  children  are  born  hemiplegic ;  others, 
apparently  in  good  condition  at  birth,  are  soon  attacked  with  convulsions 
similar  to  those  of  the  mother,  and  (juickly  perish,  and  the  lesions  arc- 
often  those  of  eclamptic  women  (Vinay).  A  case  of  fatal  encephalitis  in 
the  infant  of  an  eclamptic  woman,  coming  on  soon  after  birth,  has  recently 
been  reported.'^ 

Terminations  of  Eclampsia. — Eclampsia  may  end  in  death  or  in  partial 
or  complete  recovery.  A  fatal  result  rarely  occurs  during  the  eclamptic 
attack  from  the  long  arrest  of  breathing — an  acute  asphyxia— caused  l)y 
tetanic  contractioii  of  the  respiratory  mus(;les.  More  frequently  the  patient 
dies  from  gradual  asphyxia,  caused  by  pulmonary  edema  or  congestion. 
Cerebral  apoplexy  is  the  cause  of  death  in  some  cases :  Olshausen's  statis- 
tics,**  embracing  200  cases,  the  general  mortality  being  25  per  cent., 
include  five  deaths  from  this  cause,  while  there  were  two  other  fatal  cases 
presenting  hematomata  of  the  pia  mater,  and  five  with  notable  hyperemia  of 
the  brain  and  its  membranes.  Pneumonia  is  not  an  infrequent  cause  of 
death ;  and  so,  too,  puerperal  infection.  It  has  been  suggested  that  tlic 
occurrence  of  the  latter  is  to  be  attributed  to  "  a  special  receptivity  for 
infectious  germs ;"  but  it  seems  to  the  writer  more  rational  to  regard  this 
frequency  as  explained  by  the  interference  on  the  part  of  the  obstetriciau  with 
the  labor,  either  to  induce  or  hasten  it,  and  the  local  treatment  employed 
for  the  arrest  of  post-partum  hemorrhage,  an  accident  to  which  the  albu- 
minuric eclamptic  is  peculiarly  liable.  Another  cause  of  death  is  acute  yel- 
low atrophy  of  the  liver.  Finally,  the  profound  toxemia,  regardless  of  ectni- 
plications  or  consequences  of  the  eclampsia,  is  the  cause  of  death  in  some 
cases. 

Mental  defect  and  disorder  may  appear  as  consequences  of  eclampsia, 
making  the  recovery  incomplete :  anniesia  represents  the  former,  and  insanity 
the  latter.  The  amnesia  may  be  temporary,  or  last  for  many  weeks  or 
months,  and  in  some  cases  it  relates  only  to  recent  events;  in  others  the 
knowledge  of  years  may  be  blotted  out.     Insanity  occurred  in  6  per  cent. 


DYSTOCIA. 


629 


of  Olshausen's  cases.  In  the  majority  of  cases  the  albuniinuria  disappears 
ill  a  few  weeks,  especially  if  it  resulted  from  the  kidney  of  pregnancy,  but 
in  others  grave  renal  disease  is  manifested.  Hemiplegia  sometimes  follows 
eclampsia,  and  is  usually  incurable.  Disorders  of  vision  may  I'cmain  for 
pome  weeks,  but,  as  a  rule,  are  not  permanent.  Fortunately,  comj)lete  recov- 
ery is  the  rule  in  eclampsia.  The  signs  which  indicate  this  happy  result  will 
!)('  considered  under  the  head  of  Prognosis. 

Diagnosis. — Epilepsy  presents  the  most  striking  resemblance  to  eclamp- 
sia— the  same  loss  of  consciousness  and  of  sensation,  the  same  series  of  tonic 
and  clonic  convulsions,  succeeded  by  coma.  But  then  the  fact  of  preg- 
nancy, the  prodromata  of  eclampsia,  the  number  of  attacks,  the  condition  of 
tlio  urine,  not  albuminous  ®r  only  slightly  so  in  the  case  wf  the  epileptic, 
abundant  and  not  containing  casts,  and  above  all  the  previous  history,  would 
prevent  doubt  or  confusion  in  diagnosis.  The  thermometer,  too,  may  assist 
in  the  diagnosis,  for  the  epileptic  does  not  present  a  constantly  rising  tempera- 
tni'o,  while  the  eclamptic  generally  does. 

Winckel  states  that  a  confusion  of  eclamptic  convulsions  with  those  caused 
by  meningitis  occurred  to  him  once  in  a  pregnant  woman.  He  states  that  in 
the  latter  disease  the  attacks  are  seldom  so  general,  do  not  return  so  regidarly; 
they  constitute  gradually  increasing  irregular  contractions  of  some  groups  of 
muscles.  Moreover,  fever  usually  precedes  the  attacks  for  some  time ;  the 
])!»lients  have  i)reviously  been  forgetful  and  sonuiolent ;  yet  the  difference  is 
by  no  means  always  marked.  Hysteria  belongs  to  one  who  has  an  hysterical 
history,  and  can  only  momentarily  counterfeit  eclampsia,*  for  there  is  often  to 
be  discovered  "  a  method  in  the  madness,"  the  evidence  of  feigning  ;  no  pro- 
fi)iind  loss  of  consciousness,  if  loss  at  all ;  there  may  be  grotesque  attitudes 
ant'  expressions,  but  not  the  horrible  grimaces  of  eclampsia ;  coma  does  not 
come,  and  the  secretion  of  urine  is  not  scanty  nor  does  this  fluid  contain 
albumin. 

Prognosis. — In  general  the  eclamptic  attacks  that  occur  before  labor  are 
attended  with  the  greatest,  those  after  labor,  the  least,  mortality.  So,  too,  if  the 
uterus  can  be  emptied  without  violence  and  soon,  the  prognosis  is  improved. 
Diihrssen  '*  claims  that  if  the  uterus  is  relievetl  of  its  contents  during  pro- 
fntind  narcosis,  in  93.75  per  cent,  the  eclampsia  ceases.  Charpentier,  taking 
tile  statistics  of  German  authors,^'  has  shown  that  the  mortality  in  171  cases 
of  eelarapsia  coming  on  after  labor  was  12.5  per  cent.  These  facts  will  be 
osjieeially  considered  in  presenting  the  treatment.  Referring  to  an  individual 
case,  if  the  attacks  have  been  less  than  fifteen,  if  neither  violent  nor  close 
together,  if  the  coma  is  brief,  if  the  temperature  is  not  high,  the  pulso  not 
fVefjuent,  if  the  secretion  of  urine  be  not  greatly  lessened,  only  slightly  or 
not  at  all  albuminous,  there  are  good  grounds  for  expecting  a  favorable  issue. 
Opposite  conditions  indicate  a  doubtful  or  fatal  result.  "  Of  very  unfavor- 
al)le  prognostic  significance  are  complete  anuria,   profound   stupor,   loss  of 

*  One  of  the  nciite  obscrviitions  of  ColeridKe  was ;  "  Hysteria  may  well  be  called  viimoaa^ 
from  Its  counterfeiting  so  many  diseases— even  death  itself." 


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630 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


reflex  irritability,  paralysis,  small  frequent  pulse,  great  elevation  (»f  tempera- 
ture, jaundice"  (Kaltenbaeh). 

The  mortality  is  certainly  less  than  that  given  by  Pajot,  50  per  cent.,  but 
even  Bailly  has  made  it  42  per  cent.,  and  in  some  recent  statistics  the  lowest 
percentage  given  is  19.38,  and  the  highest  36.50:  Kaltenbaeh  gives  30  pi  r 
cent,  of  deaths. 

Post-mortem  Appearances. — The  brain  in  many  cases  presents  no  material 
lesion,  but  in  other  instances  there  is  great  anemia  with  edema,  and  flattening 
of  the  cerebral  convolutions ;  less  frcciuent  is  hyperemia,  though  sometimes 
this  may  be  so  great  that  rupture  of  the  vessels  occurs  and  apoplectic  clots 
are  found.  In  rare  cases  the  kidneys  have  been  found  absolutely  normal,  but 
oftener  present  those  changes  characteristic  of  the  kidney  of  pregnancy,  and 
next  of  parenchymatous  nephritis.  Kaltenbaeh  observes,  on  the  one  hand,  that 
frequently  the  changes  in  the  kidney  are  not  significant,  and  are  not  at  all  in 
])roportion  to  the  gravity  of  the  disease,  as  has  recently  been  pointed  out  by 
Virchow  ;  and,  on  the  other  hand,  there  may  be  grave  alterations,  chronic  pa- 
renchymatous and  interstitial  nephritis,  without  eclampsia  having  occurred. 
But  it  would  not  be  rational  to  conclude,  from  the  fact  that  the  kidneys  show 
slight  or  no  changes,  that  their  function  may  not  be  seriously  disturbed. 

Edema  of  the  lungs  is  frequently  found,  less  often  congestion,  with  apoplec- 
tic centres,  and  finally  the  evidences  of  j)neumonia — deglutition-pneumonia — mav 
occur.  Vinay  regards  lesions  of  the  liver  as  presenting  as  great  an  import- 
ance as  those  of  the  kidney,  and  considers  them  as  more  frequent  and  mo'-e 
churacteristic.  The  liver  may  be  completely  disorganized,  and  present  the 
lesions  of  acute  yellow  atrophy  in  some  cases,  while  in  others  it  is  increased 
in  size.  It  presents,  under  these  circumstances,  capillary  ectasije  and  hemor- 
rhagic centres  at  the  jieriphery ;  sometimes  necrosis  is  found,  and,  again, 
hemorrhages  beneath  the  capsule.  It  is  quite  rational  to  admit,  as  several 
authors  have  done,  that  in  some  cases  the  eclampsia  should  be  recognized  as 
cholemic  rather  than  renal.* 

Etiology. — It  is  proper  to  divide  the  causes  of  eclampsia  into  (1)  Predis- 
posing, (2)  Exciting,  and  (3)  Essential. 

1.  Predisposing  Causes. — Primiparity  holds  an  important  ])lace  among  pre- 
disposing causes.  The  statistics  of  the  Philadelphia  Hospital  from  1874  to 
1889  include  2G55  deliveries  with  nine  cases  of  eclampsia,  and  all  the  nine 
were  primipanc.  Other  statistics  make  the  disease  from  three  to  seven  times 
more  frequent  in  primipara?  than  in  multipara\  This  increased  liability  has 
been  attributed  to  the  more  frequent  occurrence  of  albuminuria  in  a  first 
pregnancy,  the  greater  intra-abdominal  pressure,  and  excessive  nervous  exci- 

*  Massen  makes  the  following  statement  as  to  post-mortem  ajipearances  in  women  (lend 
of  eclampsia:  In  19  cases  there  was  acute  interstitial  or  parenchymatous  nepliritis,  sotiic- 
times  with  destruction  of  the  ej)itlielium  of  the  tubes  in  the  cortical  substances;  in  5  cases 
interstitial  hepatitis;  in  3  necrosis  centres  in  the  hepatic  parenchyma;  the  uterus  and  tubes 
jiresented  interstitial  lesions;  the  brain,  dilatation  of  capillaries;  the  heart,  a  parenchymatous 
myocarditis  ("  Proceedings  of  the  St.  Petersburg  Obstetrical  Society,"  Annules  de  Gynccottyit; 
1893). 


of  tcnipcra- 

)oi'  cent.,  but 
H  the  lowest 
gives  30  jKT 

s  no  material 
nd  flatteniiit;' 
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eguancy,  aud 
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not  at  all  in 
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iturbed. 
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it  is  increased 
e  and  hemor- 

,  and,  again, 
[lit,  as  several 

recognized  as 

ko  (1)  Predis- 

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Ifrom  1874  to 
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to  seven  tini(>s 
Id  liability  has 
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nervous  exei- 

in  women  ili'inl 
I  nephritis,  soiiu'- 
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DYSTOCIA. 


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tability  :  the  longer  labor  is  also  a  cause.  If  the  priniipara  be  old,  the 
liability  is  increased. 

Plnri[)arity  predisposes  to  eclampsia.  In  Olshausen's  statistics  sixteen  out 
lit"  two  hundred  gave  birth  to  twins.  Here,  again,  we  have  similar  or  rather 
the  same  factors  which  are  present  in  primipanc  and  have  been  mentioned. 
Tliere  must  also  be  borne  in  mind  that  in  plural  i)regnancy  additional  work 
is  thrown  upon  the  eliminating  organs  of  the  mother,  but  this  will  be  pre- 
sented in  considering  the  essential  etiology  of  the  disorder.  When  the  pelvis 
is  narrow  or  the  child's  head  of  unusual  size,  the  eclamptic  attacks  are  more 
likely  to  occiu"  than  in  oj)posite  conditions.  Eclampsia  is  more  frequent,  too, 
i)etween  the  ages  of  twenty  and  thirty :  here,  probably,  the  true  factor  is 
priniiparity. 

Hereditary  influence  has  rarely  been  observed.  One  of  the  most  striking 
eases  of  this  influence  has  been  recorded  by  the  late  Dr.  George  T.  Elliot:^* 
The  jjatient's  mother  had  given  birth  to  four  daughters,  and  then  died  of 
ei'lam])sia  at  the  birth  of  a  son.  Of  these  daughters  one  died  of  eclampsia 
at  the  sixth  month  of  her  first  pregnancy,  a  second,  after  having  two  miscar- 
riages, died  of  eclampsia  in  her  third  pregnancy,  the  tliird  had  eclampsia 
about  the  sixth  month,  and  recovered  ;  while  the  foiu'th  was  attacked  in  the 
(Mglith  month,  and  perished  after  artificial  delivery.  Lohlcin  states  that  a 
jxitient  in  Schroeder's  clinic  died  of  eclampsia,  and  her  two  sisters  had  con- 
vulsions in  their  first  labors. 

Independently  of  heredity,  as  manifested  in  the  cases  quoted  from  Elliot, 
and  also  independently  of  the  mental  distress  referred  to,  as  predisposing 
causes,  it  will  readily  be  admitted  that  the  susceptibility  of  the  nervous  system 
jrreatly  varies  in  diflcn-nt  subjects,  and  that  some  from  excessive  irritability 
may  have  an  eclampsia  liability.  Of  course  such  condition  alone  cannot  pro- 
duce the  disease,  but  it  may  greatly  assist  in  'ts  production.  Kaltcnbach  has 
said  that  a  generally-contracted  pelvis  corresponds  usually  with  an  infantile 
liobifux,  which  is  shown  in  an  increased  irritability  of  the  nervous  centres; 
yet,  according  to  Wiedow,  such  pelvis  must  sometimes  be  looked  upon  as 
indicating  degeneration.    Thus  predisposing  causes  may  be  combined  in  action. 

The  mental  condition  may  be  a  predisposing  cause,  and  thus  unmarried 
women,  sutFering  with  shame  and  anxiety,  are  more  liable. 

What  shall  be  said  of  the  opinion  expressed  some  years  ago  by  Johns  of 
Dublin,  tiiat  indcss  the  vertex  presented  there  was  little  liability  to  eclampsia? 
When  it  is  proved  that  there  is  in  proportion  to  the  entire  nund)er  of  the 
various  presentations  an  undue  predominance  of  eclamptic  cases  in  which  the 
vertex  descends  first,  the  action  of  this  alleged  cause  would  be  Justly  considered. 
It  may  be  of  interest,  in  comicction  with  this  view  of  Johns  as  to  the  etiology 
uf  eclampsia,  to  quote  a  sentence  from  Denman's  "Introduction  to  Midwifery," 
as  showing  the  possible  first  inspiration  of  the  view  :  "  I  was  for  many  years 
persuaded  that  convulsions  oidy  happened  when  the  head  presented  ;  but 
experience  has  proved  that  they  sometimes  occur  in  preternatural  presentation 
of  the  chihl." 


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AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


2.  ExcMlng  CauHcu. — When  essential  and  predisposing  causes  combine,  tlie 
exciting  cause  of  the  convulsive  paroxysm  may  be  in  itself  a  very  slight  one, 
just  as  the  electric  spark  or  a  lighted  match  causes  explosion  of  a  powder 
magazine,  or  careless  handling  that  of  dynamite.  Thus  the  outbreak  ol" 
eclampsia  may  occur  from  touching  the  os  uteri,  from  pressure  of  the  hand 
upon  the  abdomen,  from  distended  rectum  or  bladder,  from  a  uterine  con- 
traction, or  from  movements  of  the  child. 

3.  Essential  Etiology. — Various  theories  as  to  eclampsia  which  once  pre- 
vailed— the  nervous  theory,  that  which  made  the  disease  the  result  of  cerebro- 
spinal congestion,  the  uremic  theory  and  its  derivatives — have  passed  away. 
True,  Herff  *^  contends  for  the  disease  resulting  from  the  physiological  irritations 
of  pregnancy,  but  this  is  given  by  him  as  oidy  one  of  the  causes.  True,  too, 
that  the  term  uremic  is  still  applied  by  some  to  these  convulsions,  but  no 
intelligent  physician  now  claims,  as  was  done  by  Wilson  and  others,  that  urea 
retained  in  the  blood  is  the  cause  of  spasms :  it  is  probably  unfortunate  that 
any  continue  the  use  of  the  word  in  this  connection,  for  etymological ly  and  as 
originally  employed  it  is  now  misleading. 

The  theory  which  makes  the  essential  cause  toxemia — not  one,  but  several 
different  poisons,  it  may  be,  concerned — is  now  generally  upheld.  So,  too, 
the  toxemia,  while  usually  associated  with  renal  failure,  and  dependent  uj)tm 
it,  does  not  in  all  cases  have  such  association  and  dependence,  for  the  disease 
caused  by  the  toxemia  may  occur  without  renal  disorder ;  moreover,  it  is  a 
question  in  some  cases  whether  this  disorder  is  not  the  consequence  ratlior 
than  the  cause  of  the  toxic  condition.  Admitting  the  microbian  theory  of  the 
origin  of  the  disease,  now  Jiei(i  by  a  few — a  most  improbable  supposition — it 
could  only  explain  the  toxic  condition  of  the  blood,  and  could  not  invalidate 
the  opinion  that  the  innnediatc  cause  of  the  convulsions  is  such  condition. 

As  stated  by  Kaltenbach,  the  theory  of  blood-poisoning  is  sustained  by  tiio 
clinical  history  ofthe  disease  and  by  post-mortem  appearances.  "  The  prodro- 
mata — gastric  and  cerebral  symptoms — the  rapid  occurrence  of  serious  disturb- 
ances in  the  action  of  the  brain,  the  post-mortal  increase  of  temperature,  tlio 
nature  and  frequency  of  nervous  disorders  that  follow,  and  which  find  their 
analogy  in  the  neuroses  consequent  upon  typhus  and  diphtheria,  probably  causetl 
by  toxalbiuuins,  are  scarcely  to  be  oxi)lained  unless  by  the  theory  of  blood- 
poisoning.  The  nature  as  well  as  the  extent  of  the  anatomical  lesions  also 
corresponds  with  such  theory."  Admitting  the  toxemia,  the  (juestion  naturally 
arises.  What  is  the  source  of  the  toxic  agent  or  agents  ?  Are  we  to  concede 
the  truth  of  the  position  taken  by  Riviere,  for  example,  that  autointoxication 
is  the  true  answer  ?  Bouchard  has  said  ^  that  man  is  constantly  menaced 
by  poisoning ;  he  labors  each  instant  for  his  own  destruction,  makes  incessant 
attempts  at  suicide;  nevertheless,  this  intoxication  is  not  realized,  for  the 
organism  has  multiple  resources  to  escape  it.  The  liver  plays  an  important 
part  in  the  destruction  of  poisons,  and  elimination  by  the  skin,  by  the  lungs, 
by  the  kidneys,  and  by  the  intestines  assists  in  the  protection  of  life  from 
poisoning :  the  most  important  agents  in  elimination  are  the  kidneys. 


DYSTOCIA. 


033 


The  urine,  according  to  Bouchard's  investigation,  contains  several  toxic 
]irincij)les.  Further,  it  has  been  found  by  experiment  that  tlie  toxicity  of 
tills  secretion  is  greatly  lessened  in  the  eclamptic,  while  that  of  the  blood- 
serum  of  the  ^ame  subject  is  notably  increased.  It  is  not  the  failure  of  the 
kidneys  to  eliminate  urea  that  determines  the  convulsions,  for  the  non-jjregnant 
woman  may  have  anuria  for  several  days  without  eclampsia,  and  while  the 
nmount  of  urea  eliminated  by  the  woman  in  gestation  each  twenty-four  hours 
is  increased  nearly  one-third,  there  must  be  arrest  of  elimination  for  more  than 
ten  days  in  order  that  intoxication  become  j)ossible.  We  can  readily  under- 
stand that  if  the  poison  or  poisons  which  jiroduce  eclampsia  are  retained  in  tiie 
blood,  renal  inefficiency  or  failure  may  add  to  the  gravity  of  the  condition,  in 
tiiat  were  the  kidneys  healthy  they  would  cast  out  the  offending  matter.  Ac- 
cording to  Bouchard,  the  kidneys  are  ca})al)le,  when  sound,  of  eliminating 
infinitely  more  toxic  material  than  they  habitually  do ;  nevertheless,  there  are 
limits,  and  if  the  quantity  of  poison  is  such,  notwithstanding  their  integrity, 
that  they  cannot  accomplish  their  task,  accumulation  is  produced  and  intoxi- 
cation results.  Thus  in  the  etiology  of  eclampsia  the  non-elimination  by  the 
several  emunctories  mentioned  must  be  placed  at  the  very  beginning  of  the 
trouble — and  the  toxic  matter  may  l)e  maternal  in  origin.  Yet  may  not  the 
fetus,  and  even  the  placenta,  have  a  part  in  the  etiology  of  the  poisoning? 
Tiie  non-pregnant  woman  may  have  her  abdomen  as  greatly  distended  by  an 
ovarian  tumor  as  from  plural  pregnancy  at  terra,  and  she  does  not  suffer  from 
eclampsia.  Often  if  the  fetus  dies  the  eclauipsia  ends.  So,  too,  the  eclamptic 
attacks  are  more  frequent  as  the  labor  occurs  and  progresses ;  uterine  contrac- 
tions may  cause  now  poison  to  pass  into  the  maternal  blood  from  the  fetus 
and  placenta.  It  seems,  therefore,  at  least  not  improbable  that  from  the 
latter  source  a  part  of  the  poison  ])roducing  eclampsia  is  derived. 

The  microbian  theory  recognizes  infection,  attributing,  however,  the  poison- 
ing, not  to  maternal  life-processes,  pois  m-producing,  and  failure  of  poison- 
eiiinination,  but  to  the  action  of  microbes,  toxins  being  formed  by  these. 
This  theory  was  first  suggested  *  by  Delore  ten  years  ago.  A  few  have,  from 
experimental  studies,  sustained  the  theory,  but  the  majority  of  investigators 
liavc  rejected  it.  Moreover,  in  order  to  explain  the  entrance  of  microbes,  the 
hypothesis  of  a  previous  endometritis  has  been  assumed.  But  as  the  eclamptics 
are,  in  the  great  majority  of  cases,  primiparse,  who  rarely  are  subjects  of  endo- 
metritis, while  multiparse,  in  whom  the  disease  is  not  infrequent,  are  compar- 
atively seldom  eclamptic,  the  microbian  theory  must  be  regarde<l  as  very 
improbable. 

It  may  readily  be  admitted,  as  Kaltenbach  has  said,  that  the  ))athogenesis 
of  eclampsia  is  by  no  means  perfectly  clear.  Winckel,  while  accepting  the 
toxemic  theory,  remarks  that  there  are  different  degrees  of  this  condition, 
j)robal)ly  different   poisons,  or   a   ])oison  originating   from   different   causes. 

*  Corre,  when  the  hypothesis  was  first  presented,  pleasantly  remarked  (Manuel  (rnceouchcment 
rl  (h  pdlhologic  pnerpiralc )  :  "  We  have  the  niicrnhe  of  tetanus,  that  of  eclampsia,  and  soon, 
doubtless,  will  have  those  of  hysteria,  of  epilepsy,  of  meningitis,  etc." 


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Halbcrtsma  attributes  the  eeiampsia  chiefly  to  K'ssened  excretion  of  uriiK 
resulting  from  eompresi<ion  of  the  ureters.  Stunipf*'^  believes  that  in  sonic 
cases  juuler  abnormal  decomposition  u  non-nitrogenous  substance,  probablv 
acetone,  is  produced,  and  this  in  its  elimination  causes  irritation  ;  intlannuatioii 
of  the  Ividneys  has  a  destructive  effect  upon  the  coloring  matter  of  the  blood  ; 
diabetes  mellitus  and  acute  yellow  atrophy  of  the  liver,  with  the  formation 
of  tyrosin  and  leucin,  follow,  and  coma  and  convulsions.  Herrgott '•'"•'  hiis 
recently  contributed  an  elaborate  paper  upholding  the  microbian  theory. 
C'hambrelent  '"*'  observes  that  eclam})sia  appears  to  be  due  to  a  poisoning  by  a 
toxin,  but  investigations  so  far  fail  to  prove  the  presence  of  a  really  path- 
ogenic bacillus.  Von  Herff  regards  eclampsia  as  a  complex  of  symptoms 
which  may  be  produced  by  various  causes,  but  the  origin  is  especially  in  the; 
])sycho-!notor  cerebral  centre  and  in  the  subcortical  gangliou-cu'lls  :  a  change  f)l" 
irritability  of  this  cerebral  centre  is  assantln],  ^' cklamtii^c/u' Ldbilitdt,"  and  is 
either  inherited  or  is  acquired  through  intoxication,  infection,  pathological 
conditions  etc.,  or,  finally,  it  is  the  consequence  of  physiological  gestation- 
irritation.  Diihrssen  finds  the  cause  of  eclampsia  in  retention  of  creatin  and 
croatinin  in  the  kidneys ;  sometimes  there  is  a  nephritis  resulting  from  accu- 
midation  of  urine  residting  from  pressure  upon  ureters.  The  ereatiu  and 
creatinin  accumulate  in  the  vessels  of  the  cerebral  cortex,  causing  (convulsions 
and  coma.  The  disease  may  alst)  be  caused  by  bacterial  products,  and  in  a 
few  cases  it  is  purely  reflex,  resulting  from  great  distention  of  the  uterus  or 
other  violent  irritation  of  nerves  of  the  genital   tract. 

In  regard  to  some  of  these  views  one  is  tempted  to  repeat  tlie  remark  of 
Pr.  Samuel  Johnson  :  In  the  arena  of  conjecture  all  men  are  equal  whose 
ojiportunitios  for  information  are  equal. 

Treatment. — Vinay  justly  observes  that  there  are  malignant  cases  of 
eclampsia  in  which  death  is  inevitable,  all  means  of  cure  failing.  This  fact 
should  be  borne  in  mind  in  considering  not  oidy  the  value  of  therapeutic 
agents,  but  also  the  results  of  personal  experience.  There  are  no  specific 
remedies  in  this  disease,  and  no  one  plan  of  treatment  to  be  constantly 
pursued. 

Prophi/la.ris. — The  first  points  in  prophylactic  treatment  are  the  avoidance 
of  constipation  and  securing  free  action  of  the  skin  and  kidneys.  The  tir>t 
is  accomplished,  as  advised  by  Winckcl  when  there  is  any  notable  albumi- 
nuria, by  the  administration  each  morning  of  a  pill  composed  of  extract  nf 
aloes  and  extract  of  colocynth,  in  sufficient  cpiatitity  to  cause  free,  watery 
evacuations.  The  hot  bath  is  the  best  means  for  producing  activity  of  the 
skin ;  this  bath  should  have  a  temperature  of  100°  F.,  the  patient  to  remain 
in  it  at  least  fifteen  minutes,  and  upon  coming  out  of  it  be  wrapped  in  warm 
blankets,  drink  a  glass  of  hot  milk,  and  remain  in  a  warm  room  for  two 
hours :  abundant  perspiration  will  thus  result.  If  an  absolute  milk  diet  is 
not  directed,  at  least  milk  should  be  the  chief  food  ;  Winckel  allows  the  spar- 
ing use  of  meat  and  vegetables.  The  diuretic  action  of  the  milk  may  be  pni- 
moted  bv  alkaline  mineral  waters.     For  the  albuniimiria  Duff""  recommends 


1 


DYSTOCIA. 


G35 


one  drop  of  nitrof^Iyoerin  tliroe  times  daily,  and  Vinay  speaks  hiplily  of 
cliloral.  The  latter  refers  to  a  patient,  a  primigravida,  haviiif]f  at  the  end  of 
the  eighth  month  22  j^rams  of  dried  albumin  in  the  iirine  in  twenty-four 
liours,  who  took  duriiij!;  the  ninth  month  120  grams  of  chloral,  or  4  grams 
per  day,  and  was  delivered  at  term  of  a  living  ehild,  no  eonvulsions  oceur- 
ling:  in  most  eases  he  advises  3  grams  daily,  or  4o  grains,  lie  also  states 
that  when  the  albumin  is  al)un(lant,  and  headaehe,  irritability,  restlessness, 
vertigo,  disturbance  of  vision,  etc.  are  present,  chlorali/ation  of  parturients  is 
(if  the  greatest  value;  from  the  beginning  of  the  pains  from  4  to  G  grams 
(if  chloral  arc  given  by  the  mouth,  and  the  patient  soon  sinks  into  a  profound 
sleep,  uninterrupted  but  at  the  moment  of  contractions. 

In  grave  and  persistent  albuminuria,  no  benefit  having  been  obtained  by 
hygienic  and  medical  means,  and  eclampsia  threatened,  the  artificial  interrup- 
tion of  the  pregnancy  may  be  clearly  indicated.  In  case  the  convidsive 
attack  occurs,  the  immediate  duty  of  the  ])ractitioner  is  to  prevent  the  patient 
from  injuring  herself;  the  greatest  liability  is  that  she  may  bite  her  partially 
prdtruded  tongue,  which,  therefore,  should  be  held  back  by  means  of  a  napkin 
stretched  between  i\w  teeth  and  grasped  on  each  side.  Kaltenbach  advises, 
for  this  purpose,  inserting  between  the  jaws  the  handle  of  a  spoon  wrai>ped 
with  gauze. 

Of  course  the  patient  is  jireventcd  from  injuring  herself  by  striking 
against  hard  objects,  or  even  falling  out  of  bed  during  clonic  convulsions — a 
possibility,  but  not  a  probability.  If  after  a  convulsion  the  tongue  falls  back, 
iirrcsting  respiration,  it  must  be  drawn  forward.  Kaltenbach  emphasizes  the 
imiiortance  of  cleansing  the  pharynx  by  means  of  small  sponges  with  a  handle, 
t(i  prevent  the  entrance  of  the  secretions  from  the  mouth  and  pharynx,  mixed 
with  bloody  slime,  into  the  lungs,  stating  that  many  patients  die,  after  recovery 
fioin  the  convtdsions,  in  consequence  of  SvhluckpnvHmonicn,  or  deglutition- 
pneumonia. 

Is  she  to  be  bled?  Doubtless  oiu*  fathers  were  wrong  in  making  vene- 
section the  common  remedy  in  eclampsia,  but  their  sons  are  equally  wrong 
in  entirely  rejecting  it.  Though  Winckel  and  jNIartin  condemn  it,  though 
indeed  it  has  little  professional  support  from  great  authorities  in  general,  yet 
we  find  Kaltenbach  wisely,  as  we  believe,  saying  that  in  strong,  plethoric 
women,  with  great  cyanosis,  bleeding  has  undoubtedly  a  favorable  effect. 
Tills  bleeding  removes  a  certain  amount  of  poison  from  the  circulation  ;  the 
removal,  too,  is  instant,  and  it  further  removes  from  the  convidsive  centres 
tlio  [loisoned  blood  by  restoring  contraction  of  the  small  vessels  as  claimetl 
l)y  Peter.  We  believe,  therefore,  that  bleeding  in  some  cases  of  eclampsia  is 
rational,  and  rests  upon  a  sound  clinical  basis.  (See  especially  the  st;itistics  of 
Charpentier  upon  this  jioint.)  Of  course  it  is  only  in  exceptional  cases  that 
this  treatment  is  indicated. 

The  administration  of  chloral  by  the  rectum  is  generally  adopted  ;  Winckel 
oinploys  1  to  2  grams  of  chloral  thus,  repeating  the  dose  after  each  attack 
until   12  grams  or  more  are  administered  in  twenty-four  hours;  Plant  suc- 


.^•■^'■ 


i  't ' 


.i-S' 


^^'': 


! .  ■  i  ■ 


)  ' 


636 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


■r, 


1 


!  I 


f''l 


'A 


I 


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cessfully  used  150  grains,  or  about  15  grams,  in  the  same  period.  Clark 
ill  America  (Oswego,  N.  Y.)  and  G.  Veit  in  (Jermany  arc  the  most  promi- 
nent advocates  of  morphia  hypmlennatically,  and  each  uses  what  many  would 
regard  as  heroic  doses.  Olshausen  employs  one-third  of  a  grain,  increasing  to 
nine-tenths,  and  only  resorts  to  chloral  when  morphia  cannot  be  emj)l(tye(l : 
he  has  given  11  to  12  grains  of  morphia  in  four  days.  But  all  have  not  been 
as  successful  in  using  the  morphia  treatment  as  Veit,  only  two  deaths  in 
sixty  cases ;  and  moreover  a  fatal  narcosis  of  the  infant,  if  not  of  the  mothei-, 
has  sometimes  been  observed. 

Anesthetic  inhalation,  chiefly  of  chloroform,  is  generally  recommended, 
though  Olshausen  reserves  it  for  exceptional  cases,  and  Kaltenbach  objects  t«i 
the  protracted  narcosis  with  chloroform,  for,  on  the  one  hand,  it  readily  leads 
to  fatty  degeneration  of  the  heart  and  other  organs,  and,  on  the  other  hand, 
impairs  the  activity  of  the  kidneys;  on  the  contrary,  Vinay  refers  to  patients 
having  Ix^n  kept  under  its  influence  six,  ten,  or  even  twenty-four  hours. 
The  potassic  bromid  may  be  rejectetl  because  requiring  large  doses,  slow, 
uncertain,  and  feeble  in  its  action ;  moreover,  according  to  Bouchard,  the 
potash  is  the  most  toxic  of  mineral  salts.  Pilocar]>in  is  a  remedy  condemned 
by  Braun,  Fordyce  Barker,  and,  more  recently,  by  Winckel,  Kaltenbach,  and 
Vinay.  Purgatives  are  generally  recognized  both  from  theoretical  reasons  and 
from  experience  as  important.  In  addition  to  those  previously  mentioned,  el:i- 
teriuin  and  croton  oil,  administered  by  the  mouth,  and  infusion  of  senna,  witii 
the  sulphate  of  soda  or  of  magnesia,  by  the  rectum,  are  frequently  employed. 

Professional  evidence  seems  conclusive  as  to  the  great  value  of  tinctiu'c  of 
veratrum  viride,  first  used  in  1859  by  Dr.  Baker '"^  of  Eufaula,  Alabama,  and 
long  a  favorite  remedy  with  practitioners  of  the  South  and  West  of  the  United 
States.  The  method  of  administering  is  hypodermatic,  and  the  dose,  accord- 
ing to  Jewett,"^  is  from  10  to  20  minims  ;  the  smaller  dose  rejieated  in  half 
an  hour  will  doubtless  suffice  in  the  majority  of  cases.  Dr.  Jewett  asserts 
that  experience  seems  to  justify  the  statement  that  no  convulsion  will  occur 
while  the  i)atient  is  sufficiently  under  veratrum  to  hold  the  cardiac  pulsations 
below  sixty  to  the  minute.  If  the  pulse  is  not  sufficiently  reduced  by  the 
first  injection,  a  second  is  given  in  thirty  minutes :  five-minim  doses  at  longer 
intervals  are  used  to  keep  up  this  lessened  frequency  of  the  pulse. 

The  Cesarean  operation  performed  after  the  mother's  death  has  in  a  very 
few  instances  saved  the  life  of  the  child,  but  Halbertsma""  has  proposed, 
and  several  times  done  the  operation,  to  save  not  only  the  life  of  the  child, 
but  also  that  of  the  mother,  in  grave  cases  of  eclampsia.  The  entire  number 
of  operations  by  him  and  by  others  is  14,  but  as  two  of  the  patients  wen- 
dying,  the  number  is  reduced  to  twelve ;  of  these  four  dietl ;  that  is,  the 
operation  gives  a  mortality  of  a  little  more  than  36  per  cent.  Recogniziui: 
that  the  subjects  operated  upon  were  in  imminent  danger  of  death,  the  result 
does  not  seem  discouraging. 

Maygrier^  has  reported  the  case  of  a  primipara  who  had  eighteen  attacks 
of  convulsions;  she  was  treated  by  venesection,  and  then,  by  a  sound  passed 


DYSTOCIA. 


637 


into  the  stomach  throii}]fh  the  nose,  150  firams  of  milk  were  introduced 
every  hour ;  anuria,  whi<'h  was  present,  was  almost  irametliately  relieved,  and 
tlic  patient  recovered. 

Porak  and  Bernheim  '"*  advise  in  every  case  in  which  the  urine  is  sup- 
])rossed  or  is  scanty  and  dark  colored  that  salt  water  shoidd  he  used  hypoder- 
iiiatically,  to  promote  diuresis  and  thus  elimination.  A  liter  of  sterilized  warm 
water  containiiifr  7  to  7.-5  grams  of  chlorid  of  sodium  is  introduced  into  one 
of  the  huttocks,  the  skin  hih'ing  been  first  disinfetJted,  and  either  a  needle 
or  a  siphon  employed  :  twenty  minutes  is  required  for  the  operation  ;  the  fluid 
injected  has  a  tenijKjrature  of  88°  to  90°  F. ;  the  results  have  been  (piite  satis- 
iiu'tory. 

There  is  a  general  agreeni'^nt  of  the  profession  that  if  eclampsia  occur  in 
labor  or  labor  come  on  during  it,  delivery  should  be  effected  as  soon  as  possi- 
ble without  violence.  So,  too,  the  majority  agree  that  eclamptic  attacks  that  do 
not  yield  to  appropriate  treatment  furnish  an  indication  for  ending  the  ])reg- 
iiancy.  Diihrssen  ®*  has  gone  further,  reviving  accouchement  force,  which  in 
tiiis  day  of  antiseptics  and  anesthetics  is  by  no  means  the  perilous  proceeding 
it  once  was ;  he  does  not  shrink  from  ending  the  pregnancy,  even  when  the 
child  is  not  viable,  in  eclampsia  and  in  the  pri.nigravida  when  no  efforts  at 
labor  are  made,  overcoming  obstacles  presentetl  by  the  cervix  or  by  the  peri- 
neum and  vulva  with  incisions,  so  as  to  ensure  rapid  delivery.  This  method 
has  not  met  with  the  approval  of  Olshausen,  for  example  ;  it  has  received  from 
Oliarpentier  a  searching  and  severe  criti(;ism,"'*  and  he  declares  it  dangerous  and 
that  it  ought  to  be  absolutely  proscribed.  In  his  conclusions  Charpentier  states 
that  the  induction  of  premature  labor  should  be  reserved  for  some  exceptional 
oases  in  which  the  medical  treatment  has  entirely  failed.  He  also  gives  the 
following  statistics  of  mortality  in  eclampsia  :  After  spontaneous  labor,  18.96  ; 
after  artificial  labor,  30.04  ;  and  after  accouchement  force,  40.74.  Goldberg 
gives  the  following  statistics  in  eclampsia :  5  times  labor  was  induced,  4 
deaths ;  6  dilatations  of  os  by  incisions,  4  deaths. 

Haultain'"^  reported  three  cases  of  eclampsia  successfully  treated  by  the 
iiKhiction  of  premature  labor;  he  dilatetl  the  cervix  with  the  fingers,  dilatation 
sufficient  to  apply  the  forceps  being  accomplished  in  from  sixty-five  minutes 
to  an  hour  and  a  half,  and  then  the  gentlest  traction  is  sufficient  to  cause  the 
head  to  act  as  a  most  efficient  dilator.  All  the  patients  recovered,  and  two  of 
the  children  lived.  Should  eclampsia  come  on  after  labor,  chloral  is  the  most 
important  remedy ;  in  many  cases,  however,  veratrum  viride  has  proved  suc- 
cessful.    Milk  diet  is  important  in  all  cases  during  convalescence. 

Hyperemesis. — Excessive  vomiting  in  labor  is  very  rarely  seen.  Should 
it  occur,  however,  its  injurious  effect  is  shown  by  weakened  uterine  contrac- 
tions and  by  early  exhaustion  of  the  patient. 

Etiology. — Naegele  and  Grenser,'^^  who  find  the  immediate  cause  of  hyper- 
emesis in  extraordinary  sympathetic  excitement  of  the  nerves  of  the  stomach, 
state  that  it  is  most  likely  to  occur  in  nervous,  feeble  persons,  in  the  chlorotic, 
and  in  those  who  have  previously  been  subject  to  gastralgia  and  to  hyperesthesia 


*;' 


■V-      i' 


638 


A.VKIt/rAX    TF.XT-IiOOK   OF   OliSTKTlilCS. 


\  •'! 


.1  ? 


I  I 


Ji     I 


e  '! 


I      ■ 


of  the  gustric  norvos.  Ilypt'roniortis  may  rosult  from  excessive  distention  nt 
the  stomneh  by  fo(Ml  o'-  by  tlnids.  Tliesc  observers  refer  also  to  a  nioi-al 
impression  as  sometimes  a  cause. 

Treat iiii'iit. — Usual  means  slionld  be  employed  to  arrest  the  vomitinj? :  if  it 
results  i'rom  irritatinji;  matter  in  the  ttomach,  whether  foinl  or  secretions,  cojiiuiis 
draughts  of  warm  water  should  be  given.  Sinapisnis  or  the  application  of  etlifi- 
spray  to  the  epigastrium,  and  the  hypodennatic  injection  of  morphia,  will  lie 
employed;  carbonic-acid  water  or  champagne  may  be  useful.  But  it  is  ol" 
the  greatest  importance  that  the  delivery,  whether  manual  or  instrumental, 
shall  take  place  as  soon  as  practicable. 

Hemorrhagres. — Discharge  of  blood  outside  the  genital  sphere,  such  as 
epistaxis,  hematamesis,  hemoptysis,  is  occasionally  seen  in  labor.  Epistaxis, 
unless  excessive,  is  to  be  regarded  not  as  a  conipiication  of  labor,  but  ratiicr 
as  a  salutary  condition  relieving  congestit)n  of  the  head.  If  pulmonary  Dr 
gastric  hemorrhage  occurs,  it  has  been  recomnjcndcd  that  the  jiaticut  should 
sit  rather  than  lie  upon  the  betl.  Ice,  cold  acid  drinks,  muriated  tincture  of 
iron,  and  in  pulmonary  hemorrhage  small  doses  of  ipecacuanha,  as  advised  by 
Graves,  may  be  useful.  In  either  form  of  the  disease,  if  grave,  ])ronipt 
delivery  is  indicated.  If  the  os  is  not  sufficiently  dilated  to  permit  delivery 
with  the  forceps  or  by  podalic  version,  acconcheinoU  forcC  has  been  recom- 
mended. A  ease  of  rapidly  fiital  pulmonary  hemorrhage  in  a  woman  at  term 
has  been  reportctl  by  Budin.'""  The  labor  had  not  begun,  and  soon  after  death 
the  Cesarean  operation  was  performetl  and  a  child  extracted  that  lived  a  few 
hours,  and  then  perished  with  trismus. 

Hernia. — Several  instances  of  hernia  causing  dystocia  are  recorded.  For 
example,  Smellie's*"  case.  No.  G3,  was  one  of  crural  hernia  on  the  left  side,  the 
patient  suffering  from  it  during  her  entire  pregnancy.  In  labor  the  hernia  was 
forcwl  down  during  every  pain  and  gave  her  great  uneasiness.  Smellie  says: 
"  The  labor  being  pretty  far  advanced  when  I  arrived,  I  took  the  opportunity 
of  reducing  the  hernia  upon  the  cessation  of  the  pain,  pressing  my  fingers 
upon  the  part,  and  directing  her  to  lie  on  her  left  side  with  her  left  tliigli 
close  up  to  the  abdomen — a  position  which  favored  its  keeping  up  ami 
prevented  the  anguish  which  I'ctarded  the  labor.  She  was  accordingly  saf<  'y 
delivered." 

Winckel  published  a  case  in  which  there  was  a  left  labial  ho  ■  size 

of  a  man's  fist.  In  the  second  stage  of  labor,  while  an  assistan  lil  l)ack 
the  mass,  the  forceps  was  applied.  Reposition  was  madj  after  the  lai  <\\  iwA 
retention  was  secured  by  a  truss.  He  also  saw  a  congenital  left  ovari  ,11 
hernia  in  a  parturient.  The  ovary,  the  size  of  a  walnut,  was  irreducible,  was 
not  especially  painfid,  and  presented  no  obstacle  to  birth. 

Smellie  narrates  two  cases  of  perineal  hernia.  Of  the  one  of  these  (:i?es 
seen  during  labor  he  states  :  "  The  hernia  was,  however,  reduced  by  opening 
the  OS  externum,  introducing  my  hand  into  the  vagina,  and  i)ushing  the  intes- 
tine above  the  os  sacrum."  Spiegelborg,  in  describing  vaginal  enterocclo, 
states  that  the  hernia  is  almost  always  found  at  the  posterior  vaginal  wall,  and  its 


DYSrOVJA. 


(j.jy 


cdiitcuts  are  iiHiinlly  formed  In*  loops  of  small  intestine,  rarely  hy  loops  of  the 
l;irfj;e  intestine.  Smellie  reporteil  a  case,  oectirring  in  the  practice  of  Mr. 
Stiibhs,  in  which  tiie  vaj^ina  and  the  pelvis  were  filknl  by  a  tnmor  which 
probably  procetHUnl  from  the  intestines  beinjj;  pnshed  down  at  the  back  part  of 
tlic  vagina.  The  tnmor  was  rednced  by  pressnro,  and  the  head  immediately 
descended  into  the  ju'lvis,  the  forceps  then  being  applied.  Dr.  Hirst"  col- 
lected 27  cases  of  vaginal  enterocele  complicating  prcgnainy  and  labor.  The 
lieriiia  was  posterior  in  all  except  two  cases.  Such  a  hernia  existing,  uterine 
contractions  niay  cause  it  to  descend  so  lo\v  that  it  partially  protrudes  from 
the  vnlva  and  presents  a  serious  hin<1erancc  to  birth.  The  tumor  is  soft  and 
(•(impressible  at  the  beginning  of  labor,  and  the  percussion  sound,  according  to 
iNriillcr,'^  plainly  indicates  its  character.  Heposition,  as  successfidly  performed 
ill  the  case  reported  by  Smellie,  is  still  the  essential  in  treatment,  the  labor 
being  ended  by  the  forceps  or,  in  case  of  pelvic  presentation,  by  manual 
extraction. 

Eventration. — ^^hen  diastasis  of  the  recti  muscles  occurs  in  an  abdomen 
greatly  distended  by  pregnancy,  ])art  of  the  uterus  protrudes  in  the  interval. 
This  condition  gives  rise  to  inefficiency  in  the  action  of  the  abdominal  muscles 
in  the  second  stage  of  labor.  The  remedy  will  be  found  in  a  )iroperly-ap])lie<l 
bandage  and  in  keeping  the  ])atient  upon  her  back  during  the  expidsive  period. 

Displaced  Kidney. — Winckel  "■  collected  six  cases  of  displaced  kidney  in 
pnrtiu'ient  women.  He  refers  to  the  fact  that  in  this  condition  hinderance  to 
lal)()r  may  result  from  the  organ  entering  the  pelvis,  thus  materially  lessening 
the  size  of  the  pelvic  cavity.  He  advises,  after  replacement,  as  the  best  means 
of  retention,  having  the  ])atient  lie  up(m  the  opposite  side. 

Tumors  of  the  Rectum. — Jacijuemier  "'  states  that  in  some  cases  hard- 
ened feces,  resulting  from  long  constipatit)n  or  from  foreign  bodies  such  as 
the  seeds  of  cherries,  have  been  an  obstacle  to  expulsion  of  the  fetus. 
AViiickel  says  that  hard  fecal  masses  presseil  into  a  small  pelvis  may  hinder 
tiie  entrance  of  the  head,  cause  an  unfavorable  jMisition  or  ])rolapse  of  a 
member,  render  the  examination  difficult,  and  produce  anomalies  of  the  pains. 
He  quotes  the  case  of  Madurowicz-Rosner,  in  which,  the  child  being  trans- 
verse, the  examination,  because  of  the  fecal  mass,  was  very  difficult  and  turn- 
ing was  impossible,  decapitation  being  employed. 

Such  an  accumulation  should  be  washed  out,  its  removal  being  assisted  by 
mechanical  means  such  as  the  handle  of  a  spoon.  McClintock,  in  one  of  his 
notes  to  the  Sydenham  edition  of  Smellie's  Midirifcrjf,  says:  "I  have  seen  the 
rectum  distended  with  such  a  mass  of  hardened  feces  that  supjiositories  and 
e;  iiata  were  utterly  useless  to  effect  their  renioval,  the  anus  being  dilated  to 
the  size  of  a  florin  by  the  fecal  accumulation  within.  Here  direct  mechanical 
means  must  be  employed  to  dislodge  and  extract  the  scybala  with  which  the 
gnt  is  blocked  up.  This  having  been  accomplished,  then  enemata  of  turpcn- 
ne,  soap,  and  water  may  advantageously  be  employed  to  clear  out  the  lower 
portion  of  the  colon  and  to  stimulate  its  peristaltic  action."  Cruveilhier, 
according  to  Jacquemicr,  publishwl  a  case  in  which  the  expulsion  of  the  fetus 


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AMERICAN  TEXT- BO  OK  OF  OBSTETRICS. 


was  prevented  by  a  cancerous  tumor  of  the  rectum.  He  successfully  ended 
the  hibor  by  the  forceps. 

Relaxation  and  Rupture  of  the  Pelvic  Articulations. — In  pregnancy 
the  pelvic  symphyses  are  swelled  and  softened,  especially  in  the  latter  months 
of  gestation.  Budin  has  shown  that  at  this  time  motion  may  be  detected 
between  the  pubic  bones.  The  physiological  condition  of  softening  may  bv 
excess  become  what  is  known  as  "relaxation  of  the  joints,"  manifesting  itself 
by  pain  at  the  articulation  concerned  and  by  more  or  less  interference  witli 
locomotion.  In  rare  instances  occurring  in  labor  there  is  an  actual  separation 
of  the  bones,  a  diastasis  known  as  "rupture  of  the  joint,"  the  previous  relaxa- 
tion predisposing  to  this  accident.  Vinay '"  believes  that  in  cases  of  great  re- 
laxation of  these  articulations  articular  or  periarticular  inflammations  (arthritos) 
complicate  the  condition.  Schauta '"^  quotes  the  case  observed  by  Gmelin,  in 
which  the  autopsy  showed  (death  having  followed  Cesarean  section)  that  the 
pubic  bones  were  separatetl  1.5  centimeters  by  an  accumulation  of  yellowish 
serum  at  the  place  of  the  .synovial  cavity.  In  some  cases  there  has  been  found 
inflammation  of  the  cartilage,  causing  abnormal  softening  of  the  joint.  Osteo- 
malacia predisposes  to  rupture  of  the  joints,  this  accident  being  very  rare  in 
the  rachitic  pelvis.  Trousseau,"^  who  met  with  several  cases  of  this  disorder, 
and  who  has  admirably  described  it,  refers  to  one  patient  in  whom  the  separa- 
tion of  the  pubic  bones  was  so  great  that  the  end  of  the  index  finger  could  bo 
interposed.  The  late  Fordyce  Barker  "'^  presented  the  subject  in  his  usual  clear 
and  scholarly  manner.  Snelling's  monograph  "**  is  oi  course  valuable.  In  the 
American  edition  of  Denman,'"  edited  by  Francis,  two  cases  of  this  accident 
are  reported  by  its  author  and  two  by  its  editor. 

Pelvic  contraction,  great  size  and  solidity  of  the  fetal  head,  and  unfavor- 
able position  have  been  mentioned  as  causes  of  rupture  of  the  pelvic  articula- 
tions. In  one  instance  this  accident  seems  to  have  resulted  from  the  I'emarkable 
development  of  the  trunk  of  the  child,  thus  preventing  its  entering  the  pelvis, 
the  forceps  being  required  for  delivery.  In  many  cases  the  lesion  has  been 
attributed  to  the  forceps,  but  it  would  seem  more  rational  to  regard  the  con- 
dition requiring  instrumental  deliveiy  as  the  more  important  factor.  Havaje- 
wicz  '^'  found  that  in  23  cases  of  separation  of  the  symphysis  forceps  had  been 
used  in  sixteen.  In  one  of  three  cases  reported  by  Remy  '^'  the  forceps  was 
used,  but  in  the  other  two  the  delivery  was  spontaneous.  The  direction  in 
which  traction  is  made  with  the  forceps  may  be  a  cause,  as  when  a  part  of 
the  force  is  exerted  in  the  axis  of  the  birth-canal,  while  the  rest  of  the  force 
acts  upon  the  pelvic  girdle,  especially  at  the  pubic  joint :  nevertheless,  tlie 
accident  has  occurred  when  Tarnier's  axis-traction  forceps  was  employed. 

Ulsamer  '^^  believed  that  rupture  of  the  pelvic  articulations  from  the  for- 
ceps was  much  more  frequent  than  was  reported.  He  states  that  sometimes 
these  ruptures  are  undiscovered,  and  sometimes  they  are  ke})t  secret,  for  tlie 
public  is  disposal  to  attribute  the  injury  to  the  exercise  of  great  force,  althoti^Ii 
it  has  been  proved  that  separation  of  the  pelvic  joints  has  followc<l  the  skilful 
use  of  the  instrument,  moderate  force  oidy  being  exerted ;  it  may  occur  also 


DYSTOCIA. 


641 


ill  spontaneous  dolivorv.  Alilfekl  in  1875  colloctcd  100  cases  of  lesions  of  the 
)){'lvic  joints,  and  in  1888  Schauta'"  added  13  cases.  Diihrssen '-''  has  given 
3.'}  casts  in  which  suppuration  in  the  joint  foUowed  the  injury.  The  23  cases 
of  Havajewicz  and  the  3  cases  of  lleniy  have  been  mentioned  above. 

When  rupture  of  a  pelvic  joint  occurs  in  labor,  it  is  accompanied  by  sudden 
and  violent  pain  in  the  joint,  tlic  patient  being  conscious,  it  may  be,  of  a  serious 
tear  at  the  painful  part,  and  the  instant  yielding  of  resistance,  so  that  the  pre- 
senting part  rapidly  advances.  Moreover,  a  "crack"  is  heard  not  seldom  by 
those  near  the  patient.  Sometimes,  as  in  a  case  (jf  Remy's,  the  labor  ends  with- 
out any  indication  of  the  injury,  which  is  made  known  in  some  movements  of 
the  patient  a  short  time  afterward,  there  having  been  a  silent  rupture.  Accord- 
ing to  Schauta,  the  accident  most  frequently  involves  the  pubic  and  the  right 
sacro-iliac  articulation ;  then  the  pubic  and  the  left  sacro-iliac  articulation. 
Rarely  are  the  two  sacro-iliac  articulations  affected  without  the  })iibic. 

Direct  examination  of  the  pubic  joint  with  two  fingers  or  with  the  thumb  and 
finger,  one  external  and  the  other  internal,  will  detect  the  injury.  Further,  the 
lower  limbs,  the  patient  being  recumbent,  will  be  everted.  Trousseau  called  atten- 
tion to  the  fact  that  "  loosening  of  the  pelvic  symphyses  "  may  be  mistaken 
for  disease  of  the  spinal  cord  ;  and  Remy  remarks  that  "  relaxation  of  the 
symphyses  may  involve  functional  impotence  of  the  inferior  members  so  ]>ro- 
noiiiiced  that  it  may  be  believed  there  is  a  real  paraplegia."  Should  the 
injury  not  be  detected  at  the  time  of  its  occurrence  or  while  the  patient  is 
in  bed,  it  is  recognized  when  she  gets  up  and  attempts  to  walk  ;  if  she 
succeeds,  she,  as  Trousseau  states,  waddles,  dragging  one  leg  after  the  other 
and  leaning  greatly  to  the  right  or  the  left  according  to  the  foot  she  advances. 
Barker  found  that  one  of  his  patients  could  stand  with  comparative  ease  rest- 
ing iipon  either  leg,  but  could  not  balance  herself  upon  both  legs  at  once.  If 
this  accident  occurs  in  labor,  it  is  imjiortant  to  redouble  antiseptic  precautions, 
so  that  all  danger  of  infection  shall  be  averted  so  far  as  possible.  Tf  suppu- 
ration follows  the  injury,  it  is  essential,  as  urged  by  Diihrssen,  that  the  purulent 
(•ullcction  shall  promptly  be  evacuated. 

In  one  of  the  13  cases  given  by  Schauta  the  urethra  was  torn,  and  in 
lotiier  the  bladder  and  the  vagina.  Four  of  the  women  died,  but  perfect 
recovery  occurred  in  the  others,  save  one  who  was  bedridden,  at  the  end  of 
twelve  months.  The  period  of  recovery  varied  from  a  few  weeks  to  several 
iiKiiiths.  In  the  case  occurring  to  Havajewicz  deatii  followed  on  the  nine- 
teenth (h\y,  delivery  having  been  made  with  forceps.  The  child,  which  was 
iiiiiisiially  large,  perished  half  an  hour  after  birth.  In  Diihrssen 's  33  cases  of 
suppuration  following  rupture  only  seven  recovered  of  twenty-four  treated 
without  incision,  while  of  nine  in  which  tiiis  treatment  was  employed  all 
recovered. 

'flic  essential  treatment  of  rupture  or  o''  great  relaxation  of  the  pelvic 
artieiilations  is  a  Hrin]y-a])plied  bandage  encircling  the  pelvis.  "  A  girdle 
re(niires  to  be  placed  around  a  pelvis  which  has  its  staves  separated.  It  is 
iKHossary  to  supply   the  temporary  deficiency  of  intrinsic  contention  by  an 

41 


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AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


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extrinsic  contention — tiiat  is  to  say,  by  the  tight  a])i)lication  of  a  bandage  in 
such  a  way  as  to  bring  into  contact  the  separated  surfaces  of  the  symphyses" 
(Trousseau).  Most  authorities*  agree  that  a  towel  answers  well  for  a  pelvic 
girdle.  Tho  union  of  the  joint  may  take  place  in  from  ten  to  fourteen  davs, 
but  sometimes  several  weeks  or  even  months  are  required. 

Diseases  of  the  Heart. — Cardiac  disease  is  not  uncommon  in  pregnant 
women,  the  most  frequent  form  being  valvular,  the  mitral  valve  being  often- 
est  involved.  The  longer  the  lesion  has  existed  and  the  more  incomplete  \\\c 
compensation,  the  greater  tlie  liability  to  premature  arrest  of  the  pregnancy. 
This  accident  was  observed  (Vinay)  in  ninety-two  of  220  eases,  according  to 
the  statistics  of  Courrejol  united  with  those  of  Porak. 

The  question  of  the  interruption  of  pregnancy  is  determinetl  by  the  con- 
dition of  the  patient.  Fehling"''  includes  among  the  indications  for  inducing 
premature  labor  chronic  bronchitis  with  great  pulmonary  emphysema  and 
insufficiently  compensated  cardiac  disease.  Kaltenbach,  too,  makes  uncompen- 
sated valvular  disease  of  the  heart  an  indication.  Vinay  '"  states  that  in  the 
severe  forms  marked  by  gravido-eardiac  accidents,  when  bronchitis  is  united 
with  pulmonary  congestion  and  edema,  and  there  often  supervene  visceral  con- 
gestions, anasarca,  and  ascites,  and  the  dyspnea  is  constant,  ]>reventing  nourish- 
ment and  sleep,  energetic  intervention  becomes  necessary.  "  Peter  insists  upon 
the  good  effects  of  bleeding,  whicli  is  immediately  useful  in  calming  the  dis- 
tress and  dyspnea.  There  may  be  added  inhalations  of  oxygen,  subcutaneous 
injections  of  caffeine  and  ether,  infusion  of  digitalis  or  digitalin.  But  it 
often  happens  that  the  disorders  of  compensation  camiot  bo  ameliorated  l)y 
medical  treatment,  and  the  life  of  the  patient  is  in  peril  from  increasing 
dyspnea  and  the  cardiac  astiienia;  it  is  then  necessary  to  induce  labor." 
In  a  recent  valuable  monograph  by  Allyn  '^*  the  author  states  that  labor 
should  be  induced  when  dangerous  pulmonary  symptoms  j)ersist  in  spite  of 
suitable  treatment;  he  further  advises  bleeding  before  labor  is  induced. 
Winekel  regards  induction  of  labor  as  uncertain  in  its  effect  upon  the  diseaso 
of  the  mother,  and  says  that  it  ouglit  to  be  restricted  to  the  severest  cases. 

When  labtn*  occurs  it  is  agreed  that  anesthesia  may  properly  be  employed, 
chloroform  being  preferable  to  ether,  and  that  the  travail  should  be  ended  with 
as  little  exertion  on  tlie  ])art  of  the  mother  as  possible.  If  the  forcejis  is  used, 
it  is  advised  that  extraction  be  made  slowly,  to  avoid  sudden  lowering  of  tlic^ 
intra-abdominal  pressure.  To  compensate  for  this  lessened  pressure  foUowinL^ 
birth,  Lahs  and  Fritsch  '"  recommend  bags  of  sand  upon  the  alxlomen. 

Dr.  AVebster '"''  advocates  chloroform  as //«^  anesthetic  in  labor;  he  stato 
that  occasional  lii/podcnnicn  of  ether  may  be  required,  and  especially  recom- 
mends nitrite  of  amyl  as  first  tried  by  Frascr  Wright,  capsules  eontaim'ng  4 
or  5  minims  being  broken  and  the  drug  being  held  to  the  ])atient's  nose.     "  It 

*It  is  rt-markiible  tli.it  Meigs  should  liave  fi)uii(l  "every  iiltenji-.t  iit  l):ini1aKii)g  a  I'liliire.  "ii 
acromit  (if  the  impossibility  of  well  adjiistiiiLr  aii<l  imiperly  retaininir  ii  hauiluK''  in  jilaoe  in  ilii< 
particular  part  of  the  hoily,  so  that  I  am  ohlimed  to  concliule  that  the  best  tiling  that  cnii  lie 
done  is  to  go  to  a  protracted  rest  in  bed." 


DYSTOCIA. 


643 


etrnaiK'v. 


is  also  useful  in  opposing  the  tendency  to  cliloroform  syncope."  "  As  the  child 
is  delivered  the  nitrite  of  amyl  is  of  great  value  in  neutralizing  the  increasing 
strain  on  the  heart  <lue  to  the  additional  blood  thrown  out  of  the  uterine  circu- 
lation as  a  result  of  the  uterine  retraction  which  follows  delivery."  He  further 
advises  that  during  the  third  stag,  of  labor  artificial  detachment  of  the  i)la- 
cciita  be  made  by  a  hand  passed  into  the  uterus,  securing  a  certain  amount  of 
hemorrhage,  and  warns  against  the  delivery  of  the  placenta  by  the  Cred6 
method,  and  also  against  the  administration  of  ergot. 

Diseases  of  the  Brain. — Winckel  states,  referring  to  meningitis  in  preg- 
nauev,  that  when  labor  begins  the  condition  is  aggravated  and  the  severe 
headaches  may  end  in  convulsions,  but  the  lu'ine  is  free  from  albumin.  He 
refers  to  Hecker's  case  of  tubercular  meningitis,  the  restlessness  of  the  uncon- 
scious patient  bccoining  so  great  with  the  occurrence  of  labor-pains  that  the 
labor  was  artificially  ended.  Of  the  35  eases  of  paralysis  collecte<l  by 
Clnn-chill,'^"  in  twenty-three  the  attack  occurred  during  pregnancy,  and  in 
twelve  eitlier  during  or  after  labor.  In  this  inunber  there  were  thirteen  cases 
of  hemiplegia,  partial  or  complete,  occurring  before  or  during  labor:  those 
cases  were  obtained  from  Lever  Stokes,  Crosse,  Simpson,  and  M'Clintock. 
linbert-Gourbeyre  in  his  well-known  monograph  reports  several  cases  of 
hemiplegia  occurring  in  pregnancy,  and  he  states  that  in  more  than  half  the 
cases  des  paralyses  obstrtricales  the  paralyses  are  nianifested  during  pregnancy, 
and  that  in  two-thirds  the  patients  are  hemlplegic.  In  1872,  Charpentier '^ 
collected  172  cases  of  puerperal  paralysis,  and  of  these  there  were  fifty-seven 
lieiniplegias  to  forty-five  paraplegias.  The  causes  of  hemiplegia  were  chiefly 
cerebral  lesions  and  failure  of  renal  action. 

In  quite  a  large  ])roportion  of  eases,  if  the  hemijilegia  occurs  during  ju'eg- 
nancy,  either  premature  labor  or,  in  some  cases,  abortion  occurs.  In  these 
patients  there  is  usuallv  albuminuria.  In  verv  manv  of  the  cases  a  fatal 
result  occurs,  tw^enty  t>ut  of  fifty-seven  dying,  according  to  Charpentier's  sta- 
tistics. It  is  only  exceptionally  that  the  labor  is  protracted  in  the  hemiplegic. 
La  Motte  (Observation  CCXIX.)'^''  gives,  in  his  usual  graphic  manner,  the 
history  of  a  woman  attacked  with  convulsive  movements  three  days  befi)re 
laltor;  they  were  followe<l  by  loss  of  speech  and  almost  entire  loss  of  eon- 
scioiisiiess.  Wiien  the  labor  began  he  recjognized  it  by  some  contractions  of 
the  lips  and  slight  movements  of  the  pelvis  during  a  pain.  Tiie  woman  was 
siit'ciy  delivered,  but  there  was  complete  paralysis  of  the  right  side;  the 
j)atiei)t  slowly  convalesced,  so  that  at  the  end  of  six  months  she  was  able 
to  go  to  the  waters  of  liourbon,  where  the  cure  was  completed.  The  chief 
argUMient  of  La  Motte  that  the  j)atient  had  not  true  convulsions,  though  she 
iiad  convulsive  movements,  was  the  fact  that  the  child  lived,  whereas  in  true 
ciinviilsions  it  would  have  been  d(>ad  when  so  long  a  time  passed  before  labor. 
He  regarded  the  disease  simply  as  apoplexy.  I  lemiplegia  occiu'ring  during  labor 
will  most  probably  result  from  cerebral  hemorrhage  in  connection  with  eclam|)- 
sia,  and  it  then  presents  an  additional  argument  for  ))rompt  artificial  delivery. 

Paraplegia. — In  paraplegic  women  the  anesthesia  of  the  abdominal  wall 


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may  bo  so  complete  that  the  subject  is  never  conscious  of  the  movements  of 
the  fetus  and  does  not  fool  any  pain  in  labor  (Vinay).  "  In  a  patient  of  Beni- 
luird's  atfeoted  with  progressive  locomotor  ataxia  labor  passed  almost  entinlv 
without  the  j)atient's  knowledge,  suffering  being  felt  only  when  the  head  win 
disengaged.  In  a  case  published  by  F.  Benicke  the  patient  had  Pott's  disease 
wilh  compression  of  the  cord.  The  accouchement  took  place  at  term  withtnit 
suffering,  and  so  unexpected  was  it  that  the  woman  was  first  advised  of  the 
labor  by  the  crying  of  the  child."  A  patient  of  Bernays,'^"  a  victim  of 
syphilis,  was  *'  totally  paralyzed  in  her  lower  limbs  and  in  all  the  muscles  of 
her  trunk  which  are  supplied  by  nerves  originating  from  the  cord  below  tlic 
seventh  cervical  vertebra."  The  entire  labor  lasted  only  about  thirty  minutes, 
and  its  "peculiarity  was,  that  in  place  of  the  usual  interrupted  labor-pains, 
there  was  but  one  continued  contraction  of  the  uterus,  which  resulted  in  the 
expulsion  of  a  large,  well-formed,  healthy  child."  In  Epley's  patient"" 
delivery  was  effected  by  forceps  after  labor  had  lasted  a  day.  In  the  case 
reported  by  I^itsckus,''^'  the  woman  suffering  from  progressive  locomotor 
ataxia,  the  labor  was  very  slow,  lasting  five  days.  Garnet,  quoted  by  Vinay, 
states  that  the  final  period  in  lal)or  may  be  long  in  overcoming  the  resistance 
of  the  ])erineum — not  from  the  muscles  which  are  paralyzed,  but  of  the 
aponeurotic  and  fibrous  paits. 

Shock. — If  sliock  occurs  to  a  woman  in  labor,  it  is  most  frequently  the 
result  of  a  grave  accident — for  example,  rupture  of  the  uterus.  Apart  fVoin 
the  causal  treatment  of  the  condition,  tiie  practitioner  should  seek  to  obviate 
the  tendency  to  death  and  to  bring  about  reaction  as  soon  as  possible.  Among 
the  means  he  may  employ  are  the  external  apjdication  of  heat,  alcoholic  stim- 
ulants, ammonia,  camphor,  and  the  hypodermatic  use  of  sulphuric  ether  and 
of  strychnia. 

Labor  in  Pneumonia. — By  most  obstetricians  the  occurrence  of  labor  in 
a  patient  suffering  with  pneumonia  is  regarded  as  very  unfavorable,  and  tluy 
therefore  seek  to  avert  any  threatening  of  this  event ;  but  if  parturition  is 
inevitable,  the  latter  is  facilitated  as  much  as  ])ossible.  Great  encroacluncnt 
upon  the  chest-cavity  by  tiie  uterus  may  be  lessened  by  early  rupture  of  the 
membranes,  and  the  injury  to  the  already  overtaxed  heart  by  labor-pains  is 
avoided  as  soon  as  possible  by  artificial   delivery. 

Sudden  Death  in  Labor  .  Delivery  of  the  Child. — The  chief  causes  of 
sudden  death  of  the  ])arturitiit  are  apoplexy,  eclampsia,  rupture  of  (he  uterus, 
of  the  li(>art,  or  of  the  aorta,  exhaustion  from  protracted  labor,  uterine  hemor- 
rhage, pulmonary  embolism,  and,  quite  rarely,  rupture  of  the  spleen. 

In  sudden  death  in  labor  it  is  important  that  the  child  be  delivered 
promptly.  If  the  dilatation  of  the  os  is  sufficient,  the  application  of  tlic 
forceps  is  indicated  in  vertex  presentation ;  in  that  of  the  pelvis,  the 
immediate  bringing  down  of  one  or  both  feet,  and  extracting.  Accordiiii:  to 
Kaltenbaeh,  not  even  one-tenth  of  the  children  delivered  after  the  deatii  nf 
the  mother  live.  He  quotes  Pnech's  statistics  showing  that  in  453  operations 
one  hundred  and  one  children  gave  signs  of  life,  but  only  forty-five  survival. 


iJ 


DYSTOCIA. 


G4o 


Nevertheless,  though  the  child  be  dead,  its  delivery  should  be  made,  "  out  of 
lonsideration  for  the  relatives  and  friends  of  the  woman  and  for  the  profession 
to  Avhich  we  belong,  especially  if  the  accoucheur  has  been  in  charge  of  the 
labor  for  some  time  and  has  already  made  attempts  at  delivery  "  (Spiegel berg). 
Some  advise  that  when  the  mother  is  dying  from  pulmonary  tuberculosis, 
(Voin  severe  apoplexy,  or  other  hopeless  disease,  delivery  be  made  while  she  is 
vot  alive,  if  consciousness  and  sensibility  are  lost. 

If  the  mother  die  from  slow  asphyxia  or  from  hemorrhage  (either  uterine 
or  from  rupture  of  the  heart  or  of  a  large  blood-vessel),  the  probability  of 
saving  the  child  is  very  slight,  but  if  her  death  be  from  a  sudden  injury,  from 
embolism,  or  from  apoplexy,  the  chance  of  the  child's  living  is  greatly 
iinjiroved.  It  is  usually  held  that  if  more  than  ten  minutes  intervene  between 
tlio  death  of  the  mother  and  the  extraction  of  the  child,  its  living  is  doubtful ; 
vet  there  are  a  few  eases  in  which  this  period  was  considerably  passed  and  the 
oliild  was  extracted  alive. 

As  proving  that  in  some  cases  a  much  longer  period  than  ten  or  fifteen 
minutes  may  intervene  between  the  death  of  the  mother  and  the  removal  of  a 
living  child,  the  following  facts  are  of  value  :  '^^  During  the  Connnune  of  Paris, 
Tarnier  one  night  at  the  Maternity  was  called  to  an  inmate  who,  while  lying  in 
bed  near  the  end  of  pregnancy,  had  been  killed  by  a  ball  which  fractured  the 
base  of  the  skull  and  entered  the  brain.  He  removed  the  child  by  the  Cesarean 
operation,  and  it  lived  for  several  days.  He  states  that  the  delivery  may 
have  taken  place  three-quarters  of  an  hour,  or  even  an  hour,  after  the  death  of 
the  mother.  In  another  case  a  j)regiiant  woman  fell  to  the  pavement  from  a 
window  a  distance  of  more  than  30  feet,  instant  death  resulting ;  thirty  min- 
ute's at  least  after  the  death  of  the  mother  an  infatit  was  retnovcd,  which  after 
some  (lifHculty  was  resuscitated,  and  which  lived  for  thirteen  years.  Tarnier 
also  quotes  the  case,  recorded  by  Hubert,  of  a  successfid  Cesarean  operation 
two  hours  after  the  mother's  death  :  the  woman,  who  was  eight  months  preg- 
nant, was  instantly  killed  by  a  locomotive  while  crossing  a  railroad  track. 

In  case  the  os  bo  not  sufficiently  dilated  for  immediate  delivery,  Depaul 
stated  that  he  could  not  too  nmch  insist,  with  almost  all  those  wiio  have 
studied  this  question,  upon  the  advantages  ofliered  by  extraction  of  the  infant 
pn-  vids  naturalcs.  One  need  not  fear  multiple  incisions  of  the  cervix  by  a 
bistoiny ;  there  can  thus  be  obtained  in  a  few  seconds  dilatation  sufficient  to 
iiiai<e  version  or  to  apply  the  forceps.  Thevenot''^'  states  that  the  advice  to 
<lcliver  the  child,  in  case  the  mother  dies  in  advanced  pregnancy,  by  the 
natural  passage  was  first  given  in  16G5  by  Schenk.  He  cjuotes  Baudelocque, 
(lardien,  and  Velpeau  as  having  approved  of  this  method.  One  advantage 
of  it  is  that  there  need  be  no  delay  in  case  the  evidence  of  the  mother's  death 
is  not  conclusive,  and  such  delay  in  the  Cesarean  operation  may  bo  fatal  to  the 
cliild.  It  should  be  remembered  that  in  several  cases — not,  however,  occur- 
ring in  recent  years — the  operator  was  startled  by  finding  his  subject  oidy 
apparently  dead.  In  case  the  Cesarean  operation  is  selected,  the  same  precau- 
tions are  to  '.c  employed  as  if  operating  upon  the  living  subject. 


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646 


AMEIirCAN   TEXT-BOOK   OF   OBSTETRICS. 


Aveling'^^  collected  44  cases  in  which  spontaneous  expulsion  of  the  child 
occurred  after  the  death  of  the  mother.  The  force  concerned  in  such  expul- 
sion is  usually  the  gases  arising  from  decomposition  accumulated  in  the  ah- 
dominal  cavity,  causing  pressure  upon  the  uterus,  or  such  gases  in  the  uterus 
itself.  It  has,  lu)\vever,  been  claimed  that  in  some  cases  expulsion  of  the 
fetus  was  caused  by  contractility  of  the  uterus  continuing  after  the  death  ot" 
the  mother,  while  the  resistance  of  the  pelvic  floor  was  lessened.  Post-mortotn 
inversion  of  the  uterus  may  occur  from  gases  resulting  from  decomposition  in 
the  intestines,  the  organ  protruding  from  the  vulva.  Kaltenbach  mentions 
a  case  in  which  a  woman  died  from  hemorrhage,  the  cause  charged  being  tlio 
midwife's  pulling  upon  the  cord.  Four  weeks  after  death  the  body  was  ex- 
humed and  the  inverted  uterus  was  found  in  front  of  the  vulva.  Kaltenbach 
explained  the  inversion  as  post-mortem,  and  the  midwife  was  acquitted. 


REFERENCE    LIST. 


/. 
8. 
9. 

10. 

n. 

12. 
IH. 

14. 

Ki. 
17. 

18. 
10. 

20. 
21. 
22. 


Lehrluich  dcr  GebnrlMfe,  18!t3.  2.S. 

Tmn.<(tclioni*  of  llic  London  Ohifktriml  Sn-  24. 

cii'tij,  vol.  xviii.  25. 
Lehrbueh  (hr  Gi-huiixhiilfe,  2(1  edition,  1893. 
Traitc  dcst  AcconchcmentH,  172(). 

McdimI  r,rK.«  niid  Cirndar,  .June  0,  1892.  20. 

London  JfrdimI  Jonrnid,  vol.  2,  178G.  27. 

Text-book  of  Mkhvifenj.  28. 

/)('.«  Dispoxilions  du  Cordon,  rtr.  29. 

Transactions  of  the  London  Obstetrical  So-  30. 

cietji,   vol.   xxiii.  31. 
Paris    Thesis,    "  De  la   Teniioitd  et  de  la 

Cordon  oniliilical."  32. 

American  ,Tournal  of  Obstetrics,  1SS6.  33. 
Ibid.,  1SS9. 

Transactions  of   the   Tuli)ibnr(ih    Obstetrical  34. 

Sofietji,   vol.  xiii. 

CliantriMiil  :    Cenlralblatt  fiir    Giimikoloriie,  35. 

ISS."). 

Observations  sur  les  f'ertes  de  Sane/,  177t>.  3(i. 

Annedcs  il' Ifjir/ieue  publiqne  ct  de  Meilecinc  3/. 

(cfialc,  1S41.  3S. 

Transactions   of    the    Edinbnr^/h    Obstetrical  39. 

Societji,   vol.  xvii.  40. 
Transactions   of    the    I-Jdinbiirr/h    Obstetrical  ' 

Societii,   vol.  viii. 
American  Jonrnal  tf  Obstetrics,  1881  ;  ibid., 

ISSd;  Transactions  of  the  American  Gi/nc-  41. 

coloejieid  Societii. 

Dennian's    Introduction   to  the  Practice   of  42. 

Midwifenj.  43. 

Transactions  of  the   London    C)bstetrica!  So.  44. 

cieti/,   vol.  xxiii. 
ProijrI's  Medical,  1888.  i  45. 


Pro(,ris  Medical,  1887. 

London  Lancet,  1S44. 

I'roeeedln(/s  of  Dublin    Obstetrical  Socirti/  ; 

The  Ob.ttetrical  Journal  of  Great  lirilain 

and  Lreland,  1880. 
Philadelphia  Obstetrical  Swietij,  18S8. 
Traitc  Complet  des  Accouchcments,  1835. 
Monatsschrift  fiir  Gebnrt.ihiilfe,  18()3. 
Die  Menschliche  Placenta,  1890. 
Lehrbueh  dcr  Geburtshiilfe,  1893. 
Conffres  periodiijnc  de  Gipiecologie  et  d'Oh- 

stetriipie,  Brussels,  1892. 
Proi/res  Medical,  ISltO. 
Transact ioii.'<  of  the  American  Medical  Asm- 

ciation,  1855. 
Placenta   Pran-ia;    its   Ilistort/   and    Tnul- 

ment,   18(11. 
Annali  di  Olistetricia  e  Ginecolor/ia,  No.  5, 

1894. 
Poslon  Medie(d  anil  Suri/iral  Jonrn<d,  IS'.i;!. 
Miiller's  nionojri'apli  upon  Placenta  Prurio. 
Lancet,  May,  1S92. 
Lecons  de  ('Unique  obstetricale. 
De   r Jfemorrha(/ie  prodnite  jxir   l' fuserlinn 

dn   Placenta  sur  le  Serpnent  ct  le   Cul  d, 

ri'terns.    par   I5eiijaniiii   Dunal,    Moiii- 

pellier,   1S.55. 
Transactions   <f    the    Edinhuri/h    Ohstrtriinl 

Societji,   vol.  iii. 
American  , Ion rnal  ef  Obstetrics,  1889. 
Lonilon  Lancet,  .\pril  (i,  1SS9. 
An   L'ssaji  on  the  Cterine  Ifemorrhai/e,  etc., 

4lli  edition,   17S9. 
F.dinbnrtjh  Medical  Jonrnal,  Nov.,  1873. 


REFERENCE  LIST. 


G47 


i^tetricdl  Sorirli/  ; 
)/  Great  liritain 


Medical  .l.<.-')- 

rji   mid    Triiil- 

ccolmiiit,  No.  ■">, 

Journal,  lS'.i:>. 
''Idccntd  I'rirrin. 


jiiir   P  fii/'i'i'liiiii 

ml  rt   Ir    ('"I  'I' 

Diiiiid,   Mtiiit- 


-IC). 

17. 

48. 

•lit. 
r.d. 

r.i. 

:■,•> 


.VI. 

.")t;. 


58. 

r)it. 
f.(). 
fii. 

(iii. 
o:!. 

G4. 


05. 
(Jt). 
07. 
08. 
Oil. 
70. 
71. 

I     M. 

~t> 
I    >>. 

71. 

7'). 
70. 


Trnite  pratique  iP Aecoueheuienix, 
TrauiiactionK  nf  the  Lomhii  Obntetrical  So- 

eiety,   vol.   .\x.\i. 
Le(;i)iin  de    Cliniijue   obnltiricale,    Brussels, 

181)2. 
AmericHii  JnuriKil  of  Obatetricn,  1880. 
CiiiH/rtu  periodiqtie  Inlcrmilional,  Brus.sels, 

1802. 
Lehrbuch  dcr  Geburtxhiilfe,  1891. 
.\(]ilress  on   "  ( Jbstetriiw  iiiid   Disejuscs  of 

Women,"    Britixh   Medieid   Anftociation, 

I8U3. 
American  Journal  of  Obstetric.t,  1894. 
I'mnmrtidnn  of  the  Auie.ricari  Gynecotogiad 

Socictij,  vol.  xvii. 
Miilk'i-'.s  JLindbuch. 
Tnumictionx  of  the  American  Qynecoloyical 

Societi/,  vol.  xvl. 
"I'eber  Vorzeilifre  Losnnff  der  Placenta 

bei  Normalon  Sitz,"  Zeitachrift  far  Gc- 

burlMUfe  und  Gjindkoloi/ic,   1892. 
ObMetrical  Journal  of   Great   Britain   and 

Ireland,   1878. 
American  Jouruid  of  ObstetricD,  1870. 
liriti-^h  Medical  Journal,  1892. 
Klinik    der    Geburti>hiilliichen    Operationen, 

1894. 
Ifaudbuch  der  GeburtMlfe  (Miiller). 
Transactions  of  the  .Imerican  G t/necoloyical 

Societij,  vol.  iii. 
Verliandlun;/  der   Gescllschaft  file   Gebtirtii- 

hiilfe  und  Gyniikoloiiic  zu  Berlin,  July  13, 

1894. 
J/'{(H.s'(«'/ ('«;(.<  (//"  the  ^Imerican   Gynecological 

Society,   vol.  iii. 
Etude  liurlcK  lleniorrhayien  (pii  xurvcnicnnent 

pcmlant  lex  unites  de  Couches,  1876. 
System  of  Obstetric  Medicine  and  Surgery, 

London,  1885. 
Text-book  of  Midwifery,  Sydenham  Society's 

translation,   1888. 
(Jhstetricid   Journal  of  Great    Britain   and 

Ireland,  1878. 
Allijemcine      meilicini.^che      Central-Zrituny, 

.Jan.  27,   1875. 
Klinik  der  Geburtshiilllichen  Operationen. 
Lehrbuch  der  Gehnrtshiilfe. 
Ilritish  Medical  Jcurnol,  1892. 
Trausactions   of   Jie   St(de    Medical   Society 

of  Indiana,  1884. 
Tea  nxaet ions  if  the  Londiox    OhMetrieid  So- 
ciety,   vol.   XXXV. 
Lehrbuch  der  Geburtshiilfe,  zweitc  .Vullafii'. 

1893. 
Hundbuch  der  Geburt^hi'ilfe,  iii.  Band,  1889. 
liCKcarches  in  ObMetrics. 


79. 
80. 

81. 


82. 
83. 
84. 
85. 
80. 
87. 
88. 

89. 
90. 

91. 

92. 
93. 

94. 
95. 
9(). 
97. 

98. 

99. 

100. 

101. 
102. 

103. 

104. 
105. 
10(i. 


107. 

108. 
109. 

110. 
111. 
112. 
113. 
114. 
115. 
110. 


Traitc  clinique  de  F Inversion  utirinc,  188,3. 
Transactions  if  the  American  Gyneeuloi/ical 

Society,  vol.  ix. 
"  Es.-<ay  upon  I'terine  Invci-sion,"  Trans- 
actions  of  the   Provincial   Medical  and 

SurgiuU  Association,  London,  1844  and 

1847. 
American  Journal  of  Obstetrics,  1885. 
Centralblidt  file  Gyniikoloyie,  1892. 
Clinical  Memoirs  on  Diseases  if   Women, 
Lehrbuch  der  Geburtshiilfe,  1891. 
Diclionnaire  de  Medeeine,  tome  xi. 
Grundriss  der  Geburtshiilfe,  1881. 
Traite  des  Maladies  de  la  Grossesse,  etc., 

I'aris,   1894. 
Centralblatt  fur  Gyniikoloyie,  1891. 
Nourean    Diclionnaire   de  Medccine  el   de 

Chiruri/ie  pratique,  tome  xii. 
Oui  and  SabrazJr:  Anndesde  Gynecolixjie, 

1893. 
Centralblatt  file  Gyniikoloyie,  1893. 
"  I'eber  P^kiamjisie,"  Sammlung  klinischer 

Vortriifie,  No.  39. 
Archie  fiir  Gyni'-'  ilogie,  1892. 
Annales  de  Gyu^  ^iluijie,  1893. 
Obstetric  Clinic,  p.  291. 
Legons  sur  les  Antointoxicatioiis  dans   les 

Maladies. 
Winckel's  Geburtshiilfe,  2d  edition,  1893. 
Annales  de  Gynecologic,   1893. 
Xonvelles    Archives     d'Obalelriipie     el    de 

Gynecologic,  April,  1S93. 
Medical  Times  and  llegisler,  1890. 
Southern     Medical   and   Surgical   Journal, 

18.59. 
Tran.mctions  of  the  American  Gynecological 

Society,  1887,  vol.  xii. 
Transactions  of  the  Berlin  Congress. 
Lancet,  1893. 
youvelles  Archives  d' Obstetrique  el  de  Gyue- 

cologie,   February,   March,   and  April, 

1893. 
Transactions  of  the  Edinburgh    Obstelrical 

Society,   1890-91. 
Obstelriquc  el  Gynecologic. 
Trintise  on  the  Theory  and  Practice  if  Mid- 

ivifery,  edited  by  M'Clintock. 
American  .loiirnal  of  ()l).<lelrics,  1893. 
Ilandbuch  dee  Gebiielshiilfe. 
Lehrbuch  der  Geburtshiilfe. 
Manuel  des  Accoiichements, 
Traiti'  lies  .]fiiladies  de  la  Grnssestie. 
Miiller's  lluudbuch  der  Geburtshiilfe. 
Cliuicid    Meilieiue,    Sydenliain    Society's 

translation,  vol.  v.,  "  Loosen iuK  ol"  t lie 

I'elvic  i^ymphyses." 


\\i 


AMERICAN  TEXT-HOOK  OF  OBSTETRICS. 


648 

117.  The  Piirrpeml  DlHefMes. 

118.  Amfi-inui  Joiirmil  oj'  ObnMric-i,  February, 

1870. 
lilt.    IiitnuliKiiim  to  tlw  I'ri'ctice  of  Midwifery, 

120.  W'iviirr  iimliziimfhe  Bliiltcr,  181)1. 

121.  Airl,iir.'<  (le  TurohKjie,  1881)  und  1890. 

122.  XiK'ffole  and  (Jrensor. 

12.'{.    (.'eiitntlhhll  fill-  (ii/iiiikotDf/ie,  181)0. 

124.    Unirermli/  Mcdiail  Mui/dzine,  181)4. 

12r).   "Observations  regarding  Chronic  Heart 

Disease   eoniplicatinu    Pre^jnanev    and 

LalK)r,"  IlnspiUd,    181)4. 
12G.   Dixeunen  of  Wumfii,  iMIi  edition,  1804. 


127. 

128. 
121). 

130. 
131. 
132. 

133. 


134. 


/>('.i   PnrnhjdvH  pwrper(deK,   18(il  ;    I'rnili 

pnitiijiir  dex  Aecoiirlteme.ntx. 
Tniile  diK  Aecoitrlinnrnln. 
St.   Louis  Medical  und  Snr<jic(d  Jmmiol, 

Dee.,   188.3. 
Sew  York  Medieid  Jimrmd,  March,  l88o. 
Ventralhlalt  fUr  (liiiuikolof/ie,  1885. 
Second  I'art  of  Tarnier's   Truife  prntifjin 

dcK  AceourhementH. 
De   AccouchemeiU   arlijieiel   par  lea    VoiiA 

imUirellen  Hubxtilne  a  ropiration  C'eaiu-i- 

eiiiie  ixist-iiiiirlein. 
Tranmc.tioim    London    Obstelrical    Societi/, 

vol.   xiv. 


'J 


/     I. 


mjicdl  Jnnriiiil, 


iletflcal    Socii-tii, 


IV.  THE  PUERPERIUM. 


I.  PHYSIOLOGY  OF  THE  PUEF^^ERIUM. 

The  piierperiiim  is  the  period  of  convalescence  fVoi.-  ■'  ./irtli.  It  hopns 
with  the  close  of  the  third  stage  of  iab(jr,  and  ends  with  the  regressive  changes 
which  take  place  in  the  uterus  and  other  genital  organs  after  parturition.  This 
process  usually  occupies  six  weeks;  in  exceptional  cases  it  is  not  complete  until 
the  eighth  or  tenth  week. 

The  condition  of  the  puerperal  woman  has  been  aptly  compared  to  that  of 
a  w<nuided  patient.  While  not  sick,  she  is  "  eminently  predisposed  to  disease." 
The  exhaustion  following  labor,  the  wounds  and  contusions  of  the  birth-canal, 
the  presence  of  putrescible  fluids  in  the  passages,  together  with  the  resorption 
activity  of  the  utero-vaginal  tract,  are  conditions  which  border  closely  upon 
tlie  pathological,  and  are  an  ever-present  menace  to  the  safety  of  the  post- 
partum state.  The  exalted  irritability  of  the  nervous  system,  too,  contributes 
to  the  unstable  equilibrium  which  characterizes  the  childbed  condition.  The 
puerperal  process,  therefore,  though  a  physiological  one,  demands  the  constant 
exercise  of  care  and  skill  in  its  management  to  prevent  the  invasion  of  disease. 

Post-partum  Chill. — A  sense  of  chilliness,  or  even  a  distinct  rigor,  is  fre- 
quently experienced  at  the  close  of  labor  or  during  the  third  stage.  It  is  of 
siiort  duration,  rarely  exceeding  ten  minutes,  and  is  not  attended  with  rise  of 
temperature.  The  j)robable  cause  of  the  chill  is  the  lessened  heat-j)roduction 
due  to  the  abrupt  cessation  of  nuis(!ular  effort  after  the  expulsion  of  the  child, 
and  the  rapid  loss  of  heat  by  evaporation  from  tlie  lungs  and  skin.  It  has 
no  pathological  sigiiifi(;ance,  and  requires  no  treatment  except  warm  coverings 
and  ])()ssibly  a  hot  drink. 

The  Pulse. — Soon  after  delivery  the  pidse-rate,  which  lias  been  somewhat 
increased  diu'ing  labor,  falls,  as  a  rule,  below  the  usual  normal  standard.  This 
retardation  of  the  pulse  generally  begins  within  from  eight  to  forty-eight 
lionrs  after  labor,  and  in  exceptional  cases  continues  until  the  end  of  the  sec- 
ond week.  Usually  it  lasts  for  a  period  of  not  more  than  three  or  four  days 
ill  primiparaj,  somewhat  longer  after  subsequent  births.  The  duration  of  the 
rcdnced  pulse-rate  is  generally  prolonged  in  j)roportion  as  the  reduction  is 
more  marked.  The  frequency  most  commonly  observed  is  from  fifty  to 
seventy  per  minute;  rarely  a  minimum  of  forty  or  less  has  been  noted. 
This  alteration  in  the  pulse  is  not  attended  with  a  corresponding  variation 
of  temperature.  The  cause  of  this  phenomenon  is  doulitless  connected  with 
tlic  mental  and  physical  rest  which  follows  delivery,  and  the  suddi'ii  diminu- 
tion in  the  amount  of  labor  put  upon  the  heart  in  consequence  of  the  inter- 
ruption of  the  utero-placental  circulation.  For  several  days  after  childbirth 
tlic  frequency  of  the  pulse  is  variable  under  slight  disturbing  influences. 

The  Temperature. — At  the  close  of  labor  the  temiierature  ranges  from  one 

CM 


mi 


as 


660 


AMKlilVAX    TEXT-JiOOK    OF    OJiSTETlUCS. 


to  throo  (Icgroi's  above  tlie  normal,  according  to  the  lencth  and  severity  of  tlio 
labor.  Witiiiri  twelve  hours  it  falls  again  nearly  or  (\-.hr>  to  the  usual  stand- 
ard. In  twenty  strictly  normal  cases  selected  from  the  writer's  hospiud 
service  the  average  temperature  at  the  close  of  labor  was  99.67°  F.,  the 
maximum  being  100.5°  and  the  minimum  98.4°  ;  at  the  end  of  twelve  hours 
the  average  temperature  was  99.18°;  twenty-four  hours  after  labor  it  was 
98.()5°,  the  maximum  being  99.5°  and  the  niinimum  98°  F. 

For  the  first  four  or  five  days  of  the  puerperium  99.5°  F.,  and  for  the 
balance  of  the  period  99°  F.,  should  be  regarded  as  the  physiological  upper 
limit  of  thermometrieal  range.  Transient  elevations  of  temperature,  however, 
may  occur  from  comparatively  unimportant  causes,  such  as  emotional  excite- 
ment, digestive  disturbances,  or  ccmstipation.  A  slight  rise  is  sometimes 
observed  on  the  establishment  of  lactation  if  the  breasts  are  much  engorged 
and  painfid.  This  rise  is  most  likely  to  occur  in  debilitated  and  weakly 
women  and  in  those  unable  to  nurse.  A  temperature  persistently  above  the 
foregoing  limits  must  be  regarded  as  evidence  of  some  comj)lication. 

Secretions  and  Exartioiht. — The  general  effect  of  labor  upon  both  secre- 
tions and  excretions  is  to  increase  the  activity  of  these  functions.  The  skin 
acts  freely.  If  the  body  is  kept  warm,  perspiration  is  usually  profuse. 
Hyperemia  of  the  skin  and  consequent  exudation  into  the  hair-follicles 
sometimes  result  in  partial  loss  of  hair. 

There  is  a  notable  increase  in  the  volume  of  urine  during  the  first  week. 
Its  specific  gravity  is  a  little  lower  than  usual,  the  amount  of  water  elimi- 
nated being  greater  than  during  pregnancy,  while  the  total  excretion  of  uri- 
nary solids  per  diem  remains  nearly  or  quite  unchanged.  This  superabundant 
secretion  of  urine  is  one  of  the  causes  of  over-distent  ion  of  the  bladder  to 
which  the  patient  is  exposed  after  labor  (Fig.  411).  Other  contributing 
causes  of  retention  in  the  first  few  days  are  the  posture  of  the  patient,  the 
lessened  intra-abdominal  pressure,  urethral  spasm,  and  the  dread  of  pain 
during  micturition  owing  to  the  bruised  and  fissured  condition  of  the  vesical 
neck,  the  urethra,  and  the  vulva. 

Glycosiu'ia  is  observed  in  a  considerable  proportion  of  instances  for  a  short 
time  after  as  well  as  before  labor.  This  is  due  to  resorption  of  lactose,  and 
the  ])roportion  of  sugar  in  the  urine  fluctuates  with  the  fulness  of  the  breasts. 
It  disa])i)ears  as  soon  as  the  balance  is  established  between  secretion  and  con- 
sumption. Peptoiuu'ia  exists  for  several  days,  jieptone  being  a  product  of 
uterine  involution. 

Zoss  of  Weir/ht. — It  is  stated  that  during  the  first  puerperal  week  there  is 
a  loss  of  weight,  variously  estimated  by  different  observers  at  from  one-twelftli 
to  one-eighth  the  body-weight  at  the  close  of  labor.  This  loss  is  attributed  to 
the  increased  activity  of  the  secretions  and  excretions  and  the  small  amount  of 
food  ingested  during  this  period,  together  with  the  retrograde  changes  wliicii 
normally  take  place  in  the  pelvic  organs.  Under  the  present  practice  of 
allowing  the  patient  a  moderately  full  diet  after  labor  the  loss  is  generally 
confined  to  the  first  few  days  post-partum,  and  is  soon  made  good. 


riiYsioLOdV  OF  Tin:  Pi'i:iirKi{ir}f. 


(Ml 


Uterine  Contructiom. — Rliytlimical  utorino  contractions,  .similar  to  those  of 
labor,  continue  tor  a  variable  Iciij^tli  of  time  after  the  delivery  of  the  placenta. 


X.-:.,  ^., 


•nitiliiji>i<S 


&'  ^ 


Kiii.  411.— Kxtreme  over-dlstentlon  of  the  bladder  during  labor  (from  a  skotcli  by  K.  L.  l>ickinson,  M.  1).). 


Tiie  contractions  t»f  tiie  nteriis  tend  to  exclude  blood-clots  from  its  cavity,  to 
establish  complete  retraction,  and  thus  to  accomplish  the  permanent  ligation 
of  its  vessels:  by  diminishing  the  blood-supply  they  promote  in  the  uterus 
the  retrograde  changes  which  normally  take  place  in  the  j)uerperal  period. 
In  primipara)  they  are  seldom  painful.  In  mnltiparje,  in  whom  there  is 
greater  relaxation  of  the  uterus  and  gi-eater  tendency  to  the  retentiun  of 
clols,  they  arc  more  intense  and  are  freijuently  accomj)anied  with  pain. 
After-pains  in  exceptional  cases  may  continue  for  two  or  three  days.  Usu- 
ally they  cease  after  a  few  hours.  They  are  intensified  when  the  child  nurses 
by  the  reflex  influence  of  the  mammary  irritation.  Even  in  women  who  have 
borne  children  they  are,  to  a  great  extent,  i)reventcd  by  the  use  of  measures 
to  secure  full  and  persistent  retraction  of  the  uterus  immediately  after  the 
expulsion  of  the  placenta. 

Sometimes  uterine  contractions  of  a  painful  character  occur,  without  the 
retention  of  clots,  from  jnirely  neurotic  causes.  Pains  of  unusual  severity, 
unduly  prolonged  and  accompanied  with  great  sensitiveness  to  pressure,  may 
suggest  the  possible  jiresence  of  beginning  peritonitis. 

Thv  Digestive  Orr/ans. — Usually  the  ai)petite  is  diminished  for  the  first  few 
•lays  after  labor  and  the  digestive  j)owers  are  enfeebled.  Owing  to  the  rapid 
(■liMiination  of  fluids  by  the  skin  and  the  kidneys,  thirst  is  increased.  The 
bowels  act  sluggishly  in  consequence  of  the  small  quantity  of  food  ingested, 
the  increased  secretory  activity  of  the  skin,  the  diminished  peristalsis,  the 
lessened  tonicity  of  the  abdominal  muscles,  and  the  complete  rest  in  bed. 

Gknital  Ougaxs. —  Cumlition  of  the  Fartavient  Tract. — By  palpation 
over  the  lower  portion  of  the  abdomen  at  the  close  of  labor  the  uterus  may 
be  felt  as  a  hard,  irregularly  rounded  mass  reaching  about  halfway  from  the 
pubic  bones  to  the  umbilicus.     Owing  to  the  relaxation  of  the  abdominal 


If': 


4 


fmr 


■  I 


■'  u  ■} 


"I  1'  .1 1  A 


rV'i  A 


:)  V 


:  i 


[M» 


iV 


:!='  -■ ' 


IBP 


<;:)i 


AMKIiKWX    TEXT-HOOK    OF    OtlSTETRirS. 


walls,  tlio  fundus  may  be  jjrasjuHl  in  tlio  hand,  and  evon  the  round  lij^ainonts 
and  ovaries  ean  generally  be  mapped  out.  Within  a  few  iiours  the  uterus 
will  be  found  somewhat  relaxed,  with  the  fundus  at  the  level  of  the  navel  or 
a  little  above  it.  Usually  it  is  slightly  anteflexed,  and  its  position  is  one  of 
partial  dextroversion  and  dextrotorsion.  It  is  somewhat  larger  in  nudtipane 
than  after  the  first  eonfinement.  'V\w  placental  area  is  somewhat  elevated  ;  its 
surfiiee  is  uneven,  and  is  studded  with  thrombi  lying  in  the  mouths  of  the 
utero-plaeental  vessels.  The  outer  layer  of  the  decidua  and  fragments  of  the 
inner  layer  remain  for  a  time,  to  be  gradually  east  off  with  the  lochia!  dis- 
charge. A  layer  of  blood  or  bloody  mneus  covers  the  entire  wall  of  the 
uterine  cavity.  The  cervix  remains  soil  and  relaxed  for  several  lionrs  after 
labor,  having  an  almost  gelatinous  consistence.  Its  length  is  2|  inches  or 
little  more.  The  os  internum  presents  the  feci  of  a  resisting  ring,  and  in  the 
intervals  between  uterine  contractions  it  is  suflfieicntly  open  to  admit  two  or 
three  fingers. 

The  lower  border  of  the  cervix  is  always  bruisetl  and  fissured,  sometimes 
deeply  torn.  After  twelve  hours  the  neck  of  the  tjterus  begins  to  regain  its 
former  shape.  Even  in  the  absence  of  notable  lacerations  the  vagina  and 
vulva  are  swollen,  abrade<l,  fissured,  bruised,  and  sensitive  to  the  touch.  For 
two  or  three  days  there  is  fre(piently  more  or  less  edematous  swelling  of  the 
labia.  The  hymen  in  primiparu;  is  torn  at  numerous  points,  its  fragments 
skirting  the  vaginal  orifice  as  small  projections  which  ultimately  form  the 
earunculjB  myrtiformes.  The  vulvar  orifii-e  gapes  more  or  less  according  to 
the  extent  to  which  the  soft  structures  have  been  overstretched  or  torn  diu'ing 
the  birth  (Pis.  42,  43). 

Involution. — In  all  the  pelvic  organs  which  have  undergone  hypertrophy 
during  j)regnancy  a  corresponding  atroph}  of  the  tissue-elements  takes  ])hice 
during  the  puerperium.  This  prr'-'css  affects  the  ovaries,  the  Fallopian  tubes, 
the  uterine  ligaments,  the  vagina,  the  external  genitals,  and  especially  luo  uterus. 
Except  in  primipane  the  pelvic  structures  are  in  normal  conditions  fully 
restored  to  the  pre-gravid  state.  After  the  first  labor  the  return  to  the  virgin 
condition  is  never  complete,  particularly  in  the  uterus  and  the  vagina.  The 
enlargement  of  these  organs  remains  in  some  degree  permanent. 

'The  Uterus. — The  uterus,  as  the  principal  seat  of  tlie  building-up  process 
during  gestation,  undergoes  the  most  imjwrtant  retrograde  changes  in  course 
of  the  lying-in  jwriod.     The  rate  of  uterine  involution  is  shown  in  the  folluw- 
ing  tables.     According  to  Ileschl,  the  weight  of  the  uterus  is — 
At  the  close  of  labor,        770  to  80")  grams. 
"    end  of  the  first  week,  665  to  73o      " 


"     two  months,        45  to    75      " 
According  to   Kaltenbach,  the  organ   immediately  after  labor  weighs  abonf 
1000  grams  (2  pounds). 

The  uterus  measures  at  the  close  of  labor  from  11)  to  21  centimeters  (7;j  in 
83  inches)  in  length,  and   11  centimeters  (4|  inches)  in  width  at  the  level  i<\' 


rn;i!i'KKHM. 


Vi.xn:  r. 


■c(l,  somotiinos 
IS  to  regain  its 
c  vagina  and 
ic  toneli.  For 
.veiling  of  the 
,  its  tVagnionts 
ately  form  the 
IS  according  to 
or  torn  during 


/'«  Hl/u. 


C/l'St'ii   Si'l 

ulcrhif 


l^ttrn-fesii,!/  /,.«,/; 

Kiliiutioii  I  iii^ 

I.iiwcr  ut,i  ill.'  .\, XIII, lit 

Aiitcriiii-  joriiix 


l.OU'i'l     /i.lll    11/ 

VtiX'iiti 

I'm  iiuiim 


iL 


f^ii^M^i 


''lolltiilttnly. 


I'/meiilii/  silt 


l-'uihiii.<  iilcii. 


B!,i,td,r. 
Symphysis  pubis. 

l'i'illii\il  oi-ifue. 


(\iTily  of  iilffiis 
ul'niv  iiii'i.r. 

•    (V(77>. 

/  •'III  ii ,'/  nuiix/iis. 


J'li'iiit'iitory. 


Cil-'i/y  of  lit,- 1 
'        iu\  tlllll . 


_L_         I'dll,  ll  of  i'fllghis. 

ri,-l,>-7;si\.l/  pollJl. 

Os  t-Ait'r/iitiii. 


mm^ 


ll 


I 


/   - 

1 

i 

1 

lit  the  level  nf 


1.  V,.rti,.„l  „u.si„l  M.,.ti„„  ,„■  ut,.,us  Mt  rlns..  nf  lal.nr.  (iv..  xniuntr.  niu;-  .Mn;-n  .MthT  W.hM.n     ■>    Vvrti.,.! 
musial  s,.,n,,i,  ,,1  iitiTus  sfc,,i„i  ,l,i.v  .,(■  i.iK-ii„Tiiiiii  ,jUUt  UVliMcn. 


I    \ 


w 

l(  * 


) 

1  "■ 

i 

IM 

i*ii:Hi*KHir>F. 


I'l.ATi;  43. 


I  'I,- 1  II!.      -    - 

H/a,/,/,-, .  — 

S_\in/itiysis  />u/-ii    — 
Kt-tr,>/>ii/'ii-  //.\sitt'.\  — 

L'l't-tlntilofif'ue  - — 


-  —  rroinoutory. 


I  —      Uteiim-  iUTit). 


I'tero-vi'ihiil  /(>«i/(. 
I'oiich  of  />ciut;/iti. 

Reiliim  !('il/i  /'lii's. 


S\in/>liysis  I'uhh 
(  'i  i-.lfi'rUHiil. ' 

Vi.tht.il  oiifice. 


^r*  .'fuontoiy. 

h'tiiuius  r/  ittt  nts. 
Onily   i<J  iiUiiis. 


_r('>tiini   ,1/    ii/;ht  Kill  I 
.wji  III/  /i[t;iim,iit . 

r>'ii(L'i  i:'y    /,'yni.v. 
-A\\  tunt 


.w. 


V.rtU'Ml  III, •Mill  M'Ctinll  nf  lilrrilv,  -ixtll  .ImV  n|-  flUTlHTlUIM  Uld.T  W.'I.Mofl.      J.    Wl'lirlll  lllrsilll  s<Tli.,|l 
«il'  ri'tiuvcili-.l  uluni>,  lilirniili  iliiy  ,,r  piiiTiPiTiuiii  ^nltor  WrhsU'r). 


PIIYSIOLOCY    OF    TllK    PUKRPKRHJM. 


(jr):5 


the  Fallopian  tubes,  and  its  npper  8ep;ment  is  from  3  to  4  centimeters  (1^  to  \\ 
iiu'lu's)  in  tliii/kness.  The  cavity  is  from  15  to  18  centimeters  (6  to  1\  inches) 
in  depth.     The  following  sonnd  measnrements  are  from  Hansen: 


Tenth  dav, 


8.    to  13.5  cm. 


Fifteenth  day,  8.3  to  11. o 
Third  week,      7.5  to  10.5 


Fonrth 
Fifth 


7.    to    9.3 
G.5  to    y. 


Sixth    week,  6.2  to  9.1  em. 

Seventh    "  6.    to  8.5    " 

Eighth     "  5.6  to  8.5    " 

Tenth       "  5.4  to  7.5    " 


The  fnndns  nteri  lies  ahont  midway  between  the  lunbiliens  and  the  pnbic 
hones  at  the  close  of  labor.  Within  a  few  honrs  it  is  jnst  above  the  nmbili- 
( lis,  and  is  at  the  level  of  the  pnbic  bones  by  the  tenth  day.  The  elevation 
of  the  fnndns,  however,  varies  with  the  fnlness  of  the  bladder  and  the  rectum. 
The  nterns  is  pnshed  nj)  bodily  when  these  viscera  are  distended. 

Involution  is  retarded  in  non-nursing  women,  after  twin  births,  much 
hemorrhage,  retention  of  secundines,  sepsis  of  the  endometrium,  or  getting  up 
too  soon. 

Utvrhw  Mui^cnlnrh. — Various  theories  have  obtained  with  reference  to  the 
nature  of  the  changes  in  the  uterine  nmscnlar  structure  during  involution, 
some  authorities  holding  that  a  part,  others  that  all,  the  muscle-fibres  are 
destroyed  by  a  process  of  acute  fatty  degeneration,  and  that  there  is  partial 
or  total  re-formation  of  muscle-elements.  Sanger  has  shown  by  a  large  num- 
Ikt  of  observations  that  the  regressive  process  is  one  of  atrophy,  by  which 
the  muscle-fibres  are  reduced  to  their  primitive  dimensions.  The  nuiscle- 
fibres  are  not  destroyed  by  complete  fatty  degeneration  :  they  undergo  a  true 
involution  initil  they  have  reached  their  earlier  size  and  form.  Similar  con- 
clusions have  been  reached  by  Dietrich.  The  nutritive  activity  in  the  uterus 
is  greatly  diminished  by  the  lessened  blood-supply  conse(iuent  upon  uterine 
retraction  after  labor,  and  atrophy  ensues,  fat-globules  appearing  only  in  the 
interior  of  the  muscle-cells  and  never  externally  to  the  fibrilla\  The  fat- 
lilobnles  "  do  not  enter  as  such  into  the  circulation,  but  are  oxidized  in  the 
place  where  they  occur.  The  intermuscular  connective  tissue  experiences  a 
similar  involution  in  its  cellular  and  fibrillar  elements." 

/>Voof/-jr.swAs'  of  the  llcnix. — Thrombosis  takes  place  in  some  of  the  siinises 
at  tiic  placental  site  during  the  ninth  month  of  pregnancy.  The  remaining 
(UK'S  ai'c  ))romptly  closed  by  compression  and  by  the  formation  of  coagula  after 
labor.  A  portion  of  the  blood-vessels  become  atrophied  as  the  icsult  of 
pressure.  Fatty  dcgenera'iou  takes  place  in  the  media.  Th(>  larger  arteries 
Mi'c  partially  or  wholly  obliterated  by  connective-tissue  ])rolifcration  of  the 
iiitima.  In  women  who  have  borne  children  the  coats  of  the  uterine  arteries 
ninain  permanentlv  thickened  ar.d  the  arteries  larger  than  in  the  nidliparous 
uterus.  The  walls  of  the  venous  sinuses  are  thickened  and  (Convoluted  for 
sc\i!'al  weeks  after  delivery;  the  location  of  the  placental  site  is  disi'crnible 
many  months  after  labor.  The  nuieous  membrane  is  studded  with  pigmentary 
deposits,  an  unfailing  sign  of  recent  childbirth. 


/ 


I 


] 


.'U. 


Eff^^TWUHMJW 


ii 


II,     1 


m 


r  I 


m.m 


ii 


III '!  "m 


654 


AMERICAN    TKXT-BOOK    OF   OliSrETRICS. 


lieconstnidion  of  the  Uterine  Mueomt. — Tiie  deep  glandular  layer  of  the 
decidiia,  together  with  IVagments  of  the  snpi'rticial  layer,  remains  attached  to 
the  uterus  after  the  expulsion  of  the  placenta.  From  the  glandular  layer  the 
regeneration  of  the  mucous  membrane  takes  place.  All  the  remaining  decidual 
structure  not  concerned  in  the  development  of  the  new  nuicous  membrane  suf- 
fers factv  degeneration  and  is  gradually  thrown  (tif  in  the  lochial  discharyre. 
The  glands  are  crowded  close  together  by  the  uterine  retraction.  About  the 
mouths  of  the  glands  islands  of  new  epithelium  are  formed,  developed  from 
the  gland  fundi.  These  coalesce  until  the  surface  of  the  uterine  wall,  includ- 
ing, last  of  all,  the  placental  area,  is  ciovered.  By  the  end  of  the  fifth  week, 
as  a  rule,  the  new  mucous  membrane  is  complete. 

Loc/tia. — The  genital  discharges  of  the  puerperium  are  termed  the  lochia. 
They  have  their  origin  in  the  cavity  of  the  uterus,  and  continue  during  the 
greater  part  of  the  period  of  involution.  They  consist  at  first  of  blood  with 
clots  and  decidual  shreds,  and  usually  are  of  a  distinctly  bloody  character  for 
three  or  four  days — lochia  rubra  or  cruenta.  During  the  next  two  or  three 
days  they  are  pale  in  color,  are  thinner,  and  consist  mainly  of  scrum — lochia 
serona  ;  they  contain  blood-corpuscles,  epithelial  cells,  and  shreds  of  decidua. 
Finally,  after  about  seven  days,  the  discharges  assume  a  grayish  or  a  yellowish 
color  and  are  of  a  creamy  consistency — lochia  alba.  The  microscopic  elements  are 
chiefly  leucocytes,  new  epithelial  cells,  connective-tissue  cells,  fat-globules,  and 
cholestevin  crystals.  The  reaction  of  the  lochia  is  neutral  or  alkaline  duriii"- 
the  first  week;  later  it  is  acid.  The  discharge  gradually  diminishes  in  quan- 
tity, ceasing  altogether  by  the  end  of  from  two  to  six  weeks.  The  average 
amount  for  the  fii'st  eight  days  is  about  three  and  a  quarter  pounds  ;  the  quantity, 
however,  varies.  It  is  greater  in  multiparaB  than  after  first  labors  ;  it  is  more 
abundant  and  lasts  longer  in  non-nursing  women  and  in  those  wiio  menstruate 
profusely.  There  is  frc(]uently  complete  or  partial  sujipression  of  the  flow  on 
the  establishment  of  the  milk-secretion.  The  lochia  rubra  persists  longer  in 
retroversion  of  the  uterus  and  after  getting  up  too  soon.  Normally,  tlic 
lochial  discharge  has  oidy  a  faint  odor  and   is  never  fetid. 

J^ven  in  normal  conditions  micro-organisms  are  i'ound  in  the  genital  dis- 
charges after  the  first  two  or  three  days.  Their  abundance  varies  in  difl'ereiit 
cases  and  increases  with  the  progress  of  the  fl(tw.  The  principal  varieties  ;irc 
single  cocci,  staphylococci,  and  bacilli.  Tlicir  occurrence  in  the  lochia  is 
explained  partly  by  th<'  ju'cscnce  of  bacteria  |)rimin'ily  in  the  vagina,  pni'llv 
by  entrance  from  williout.  The  uterine  lochia,  as  a  rule,  are  free  from  bactci'ia 
in  normal  cases. 

Lactation. — Important  changes  in  the  mammary  glan<ls  take  place  durin<: 
pregnancy  in  preparation  for  lactation.  They  Ih'comic  enlarged  by  growth  nl' 
the  acini,  by  interlobular  deposit  of  fat,  antl  by  swelling  and  prolilcration  of 
connective  tissue.  In  the  later  months  of  gestation  a  milky  scrmn  miiv  lie 
expressed  from  the  nipples.  The  mammary  seci'iiion  of  the  first  'iays  of  the 
puerperium  is  similar  to  that  of  the  latter  part  of  pregnancy,  and  is  tcrnnd 
coloHtrma.     It  is  a  viscid  fluid  of  a  fiiint  lemon-yellow  color,  and  is  richer  in 


PHySIOLOUY    OF    THE   PUEJtPERIUM. 


isr^h 


fat,  sugar,  and  the  inorganic  waits  than  the  fully-<levehipeil  ni ilk-secretion. 
At  this  early  period,  before  the  function  of  the  gland-cells  is  established,  it 
is  little  more  than  a  transudation  from  the  bhjod.  A^^Bngly,  there  is  a 
pi-eponderance  of  albumin  and  a  deficiency  of  casein.  I^^hief  microscopic 
elements  are  fat-globules,  mucous  ctM'puscles,  pavement  ej)itlielium,  occasional 
milk-corpuscles,  and  large  round  granular  ei)ithelial  cells,  known  as  colodrum- 
corprndes.  The  latter  do  not  wholly  disajjpear  for  several  days  after  the  true 
milk-secretion  is  established.  The  laxative  property  of  colostrum  is  attributed 
l)y  Winckel  and  others  to  the  abundance  of  phosphate  of  calcium,  chlorids  of 
sodium,  potassium,  and  magnesium  in  its  compositic^i.  The  large  j)roportion 
of  fat  and  of  milk-sugar  doubtless  contributes  to  the  cathartic  action.  De  Sindty 
ascribes  the  laxative  effect  of  colostrum  to  its  indigestibility. 

The  true  milk-secretion  begins  usually  on  the  second  day  in  multiparoe,  on 
the  third  day  in  primipane.  The  mammary  glands  become  swollen  and  more 
or  less  painful,  the  veins  are  prominent  over  the  breasts,  and  the  axillary 
glands  are  freqnently  enlarged  and  sensitive.  Some  general  disturbance  is 
experienced  in  the  presence  of  great  tension  and  pain  in  the  breasts,  particu- 
larly in  nervous  women.  Thirst,  loss  of  appetite,  malaise,  and,  in  exceptional 
cases,  a  slight  elevation  of  temperature,  may  be  observed  on  the  developinent 
of  the  milk-secretion. 

True  milk  fever,  it  is  generally  conceded,  does  not  exist.  That  painful 
engorgement  of  the  breasts,  however,  may  give  rise  to  transient  fever  in  the 
condition  of  unstable  e(pii!ibrium  which  characterizes  the  puerperal  woman 
camiot  be  doubted.  Yet  it  must  not  be  forgotten  that  a  rise  of  temperature 
at  this  time  may  be,  and  most  Impiently  is,  due  to  septic  absorption  from  the 
genital  wounds. 

Human  milk  contains  on  an  average  l.o  per  cent,  of  albuminoids,  4  per 
cent,  of  fat,  7  per  cent,  of  sugar,  1.4  per  cent,  of  inorganic  salts,  and  86  to  87 
]t('r  cent,  of  water.  Tli(>se  proportions,  however,  arc  subject  to  con.sidcrable 
fluctuation.  They  are  affected  by  the  health  and  habits  of  the  woman,  and 
even  by  emotional  disturbance^,  and  they  vary,  too,  with  the  period  of  lacta- 
tion. There  is  an  increase  in  casein  until  the  second  month  ;  thereafter  it 
(limiiiishcs  until  the  ninth  month.  Similar  variations  occur  in  the  ])ercentage 
(if  fat.  The  sugar  increases  after  the  first  month.  Authorities,  however,  are 
not  agreed  on  the  nature  and  the  extent  of  the  changes  which  take  place  in 
ilie  composition  of  breast-milk  from  month  to  i;:"nth. 

Tlu!  composition  of  the  lacteal  secretion  dc|)arts  soi  lewhat  from  the  n>ual 
normal  standard  on  the  return  of  the  menstruation.  These  chauges  arc  gcn- 
ei'iilly  of  short  duration,  lasting  but  a  few  days  after  the  menstrual  period.  In 
exceptional  cases  tiiey  I'cmain  to  a  greater  or  lesser  extent  perniaMeiit.  Fre- 
i|iieiitly  no  harm  comes  to  the  mother  or  the  child  from  the  continuance  of 
nursing  even  when  the  menstrual  functicma  is  resumed  in  the  early  weeks  of 
lactation  ;  in  exceptional  instances  it  may  l»e  necessary  in  the  interests  of  the 
child,  and  possibly  of  the  mother,  to  discoiitir'ie  nursing. 

The  liquid  })ortion  of  milk  is  derived,  with  some  modification,  from   the 


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AMERICAN    TEXT- HOOK    OF    OJiSTETIilCS. 


blood ;  the  fat,  sugar,  and  casein  are  i)rodiicts  of  the  metabolic  changes  in  tlio 
protoplasm  of  the  secrctorv  cells  of  the  mammary  glands.  Thc^  fat  or  butter 
is  held  in  suspension  in  the  liquid  portion  in  niimite  globules  of  variable  size, 
forming  a  fine  emulsion. 

The  average  normal  period  of  lactation  is  about  one  year.  In  most  mu's- 
ing  wohien,  however,  the  milk  begins  to  fall  otf  in  both  quality  and  quan- 
tity after  the  seventh  or  eighth  month.  Both  the  abundance  and  the  diu'ation 
of  the  secretion  vary  greatly  in  different  cases  according  to  the  health  and 
vigor  of  the  woman.  \\\  normal  conditions  the  (juantity  increases  during  ;it 
least  the  first  six  months  proportionately  to  the  needs  of  the  child's  nutrition. 
In  non-nursing  women  the  secretion  continues  for  a  few  days,  then  rapidly 
declines,  and  soon  ceases  altogether,  the  parenchyma  of  the  gland  undergoing 
involution. 


II.  DIACJXOSIH  OF  THE  PUEIIPERAL  STATE. 

The  puerperal  condition  can  usually  be  recognized  with  little  difficult v 
within  the  first  one  or  two  weeks ;  later  the  diagnosis  is  not  so  readily  estab- 
lished. The  evidence  of  recent  delivery  is  to  be  sought  ]n'incipally  in  the 
condition  of  the  breasts,  the  abdomen,  and  the  genital  tract.  After  the  first 
two  days  the  breasts  are  enlarged  and  tense.  The  mammary  glands  are  firm 
and  nodular  and  milk  is  freely  secreted. 

The  abdominal  walls  are  lax,  and  the  skin  can  be  taken  up  in  folds  over 
the  underlying  muscles ;  ntrice  gravidarum  and  the  pigmentary  changes  are 
evidence  that  advanced  pregnancy  has  at  somi;  time  existed,  other  causes  of 
abdominal  enlargement  sufficient  to  explain  the  presence  of  strite  being 
excluded.  The  external  genitals  are  gaping,  swollen,  bruised,  and  fissured 
for  several  days  after  childbirth,  and  for  at  least  two  weeks  they  present  the 
marks  of  recent  injury  of  greater  or  lesser  degree.  The  vagina  is  enlarged 
and  relaxed  ;  the  rugre  are  ef!aced  and  the  introitus  stretched  and  torn.  Tlio 
uterus  is  enlarged,  the  (;ervix  is  notched  or  deeply  fissured  by  recent  tea^s, 
and  its  canal  admits  one  or  more  fingers.  The  size  of  the  uterus  in  normal 
conditions  diminishes  daily.  The  lochial  discharges  are  found  flowing  from 
the  cervix,  and  the  placental  site  presents  to  the  examining  finger  the  nodular 
surface  and  fresh  thrombi  characteristic  of  recent  delivery.  The  lochial  dis- 
charges are  distinguished  from  hemorrhage  of  non-puerperal  origin  by  their 
microscopic  constituents.  When  the  importance  of  the  question  justifies  it, 
conclusive  evidence  may  sometimes  be  obtained  by  curetting  the  uterine  cavity. 
The  ])resence  of  decidual  shreds  or  chorial  villosities  in  the  scrapings  aifurils 
in(lul)itai)le  proof  of  recent  jiregnancy. 

The  length  of  tim<'  that  has  elapsed  since  confinement  may  during  the  first 
two  weeks  be  estimated  approximately  by  t!ie  condition  of  the  breasts,  the  si/c 
of  the  uterus,  and  the  character  of  the  lochia.  For  the  first  two  or  three  days 
the  mammary  secretion  is  colostrum  ;  for  several  days  subsequently  the  glands 
are  swollen  and  hard  and  milk  is  abundantly  secreted.     The  fundus  uteri  is 


MAXAdKMKXT   OF    TUK    JTKni'Klil I'M. 


657 


just  alnn'o  tlio  umbilicus  on  the  day  fbllowiiij^  dolivery,  and  it  gradually  sinks 
t(i  tiie  synipiiysis  by  tlio  tcntli.  Tho  cliangcs  in  the  lucliia  indicate  roughly  the 
jiiogross  of"  tlie  puor|KM'al  jicriod.  The  vulvar  wounds  arc  in  a  stage  of  repair 
[iidportionate  to  the  number  of  days  that  have  passed  since  the  birth. 


in  folds  over 


111.  MANAGEMENT  OF  THE  PUERPERIUM. 

PoHlmr. — During  tiie  first  few  hours  after  labor  the  best  jiosition  for  the 
patient  is  the  dorsal  decubitus,  ff  she  turns  u{)ou  the  side,  owing  to  the  lax 
(•(iiulition  of  the  abdominal  parietes  the  uterus  I'alls  forward,  and  air  may  be 
drawn  into  the  passages,  exposing  the  patient  to  the  jntssible  danger  of  air- 


iboli 


After  the  uterus  has  bee 


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I'onie  perni! 

al  tlic  i)lacental  site  are  firndy  closed  by  thrond^i,  the  posture  of  the  patient 
may  be  left  to  her  own  choice. 

Rixt. — A  sound  sleep  of  several  hours  after  delivery  is  a  favorable  prog- 
nostic. It  not  oidy  sj)caks  well  for  the  condition  of  the  patient,  but  is  a 
|)iitciit  restorer.  Care  slioidd  be  t;d<en,  therefore,  to  procure  rest  and  sleep  as 
-(1(111  as  possible  aftor  the  necessary  attentions  to  mother  and  child  have  Ircii 
(•(iMiplotod.  The  room  should  be  (piiet,  and  the  light  be  subdued  by  drawing 
the  curtains.  The  U;m'  of  hypnotic  drugs  is,  if  j)ossible,  to  be  avoided.  It  is 
c-)xc!ally  important  that  the  child  be  not  permitted  to  disturb  the  mother's 
rest.  It  ought  not  to  sleep  iii  the  same  bed  with  the  mother,  and  if  it  cries 
-houhl  be  removed  to  another  room. 

Plit/.sieiftn^'i  Vlsit.'i. — It  is  generally  desirable  that  the  first  visit  be  made 
witliin  twelve  hours  after  confinement.  This,  however,  is  not  always  necessary 
wlicii  a  conn)et(!nt  graduate  nurse  is  in  charge.  It  is  the  duty  of  the  physician 
to  make  a  systematic  examination  of  botii  mother  and  child  at  each  visit.  The 
principal  points  to  be  oljserved  during  the  first  days  after  delivery  are — the 
general  aj)pearance  of  the  woman,  whether  she  has  rested  sutticiently  ;  what 
and  how  much  nourishment  slu;  has  taken  ;  the  amount  and  character  of  tiie 
flow;  whether  the  bladder  has  been  emptied,  and  the  (piantity  of  urine  passed  ; 
if  the  liowels  move  daily  after  the  first  twenty-four  hours;  tiie  presence  or 
ab>ciice  of  after-pains,  and  how  severe  they  are.  Tin;  ])ulse  and  temperature 
ill!'  to  be  noted.  The  binder  should  be  loosened  at  each  visit,  and  the  uterus 
(xainincd  through  tiie  abdondnal  walls  for  the  rate  of  involution  as  indicated 
l»y  flic  height  and  widtii  of  tiie  fundus  ;  the  degree  of  tenderness  over  the 
iil(  rns  and  broad  ligaments  should  be  noted.  It  is  especially  important  at  the 
lii-t  visits  to  examine  tiie  suprapiil)ic  region  by  palpation  to  learn  whether  tlie 
lilaildcr  is  distended.  The  urinary  secretion  is,  as  a  rule,  greatly  increased 
liming  the  first  few  hours  after  delivery.  Injurious  distention  of  tlie  bladder 
iVcijiieiitly  results.  The  assurance  that  the  ])atieut  has  passed  water  freely  is 
not  t(»  be  taken  as  ])roof  that  there  is  no  retention.  When  overfilled  the 
Madder  may  easily  be  made  out  as  a  fiiiid  tumor  between  the  ut<'rus  and  the 
alnloiniiial  walls.  Pressure  with  the  hand  over  this  region,  too,  will  cause  a 
ile-ire  to  urinate.     Marked  fulness  of  the  bladder  fre(pieiitly  presents  a  visible 

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AMKIiJCAX    TEXT-HOOK    OF    OliSTF/fniVS. 


tumor  alxivo  tlio  pulios  (Fiir.  41 1).  Tlio  foiiditioii  of  tlio  broasts  and  ni|)j)l(v 
and  the  aiuouiit  of  milk  secreted  should  be  watched,  especially  diirinj;  the 
first  week. 

Daily  inquiry  should  bo  made  with  reference  to  the  child — wiiether  it 
nurses  properly  and  shows  sif^ns  of  tlirivinj;;  the  condition  of  th';  eyes, 
mouth,  skin,  the  stump  of  the  navel  cord,  or  the  und)ilical  woiuid  should  lie 
learned,  and  whetiier  the  bladder  and  bowels  are  properly  evacuated.  It  i: 
well  for  the  first  few  days  to  know  the  rectal  temperature.  The  nurse,  if  slic 
be  capable,  will  keep  a  systematic  record  of  the  foregoing  and  other  facts  f<ir 
the  doctor's  insjiection  at  liis  daily  visits.  Her  observations  ought  to  be  taken 
at  stated  hours  two  or  three  times  during  the  day,  and  recorded  on  suital)lc 
blanks.  This  is  particularly  important  during  the  first  week.  After  that 
time  if  all   is  normal  a  simpler  record  will  suffice. 

After-pahis,  if  severe  enough  to  de})rive  the  ])atient  of  sleep  or  to  be 
exhausting,  must  b(!  relieved.  A  grain  or  two  of  opium  or  an  equivalent 
dose  of  morphin  may  be  given,  and  be  repeated  once  or  twice  subsequently  if 
required.  Since  many  women  do  not  bear  opium  well,  and  as  it  is  especial! v 
liable  to  injure  the  appetite  and  digestion,  the  object  may  usually  be  better 
accomplished  by  the  use  of  chloral  in  doses  of  20  or  30  grains.  It  may 
be  given  in  water  or  in  milk,  by  the  mouth  or  by  the  rectum.  Tiie  coal- 
tar  analgesics  are  effective,  but  their  repeated  use  is  open  to  the  objection 
that  they  lessen  the  strength  of  the  uterine  contractions  and  consequently 
retard  involution.  Little  harm  will  be  done  when  but  one  or  two  doses  nw 
required.  Of  these  drugs,  phenacetin,  in  doses  of  5  grains,  is  to  be  prefei-red 
to  acetanilid  or  to  antii)yrin,  as  it  has  a  less  depressant  effect. 

A.sep,sis. — ]\[()st  imj)ortant  is  a  rigid  cleanliness  of  the  external  genitals 
of  the  patient,  her  linen,  and  the  bed-linen.  The  vulvar  dressings  should 
be  changed  every  three  to  six  liotu's  during  the  first  two  or  three  days,  and 
at  all  times  as  often  as  much  soiled.  Each  time  the  dressing  is  renewed 
the  external  genitals  and  their  immediate  surroundings  are  to  be  carefully 
(ileansed  with  soaj)  and  water,  and  finally  washed  with  an  antiseptic  solution. 
A.  convenient  method  of  cleansing  the  vulva  is  by  irrigation  with  a  fountain 
syringe,  the  stream  being  projected  against  the  })arts  to  be  cleaned  and  its 
action  assisted  by  gentle  friction  with  ase|)tic  fingers.  A  bed-pan  in  position 
beneath  the  buttocks  receives  the  washings. 

If  any  fetor  is  perceptible,  it  nnist  be  assumed,  as  a  rule,  that  the  toilet  of 
the  ])atient  has  not  been  pro])erly  cared  for.  If  the  passages  have  not  been 
infected  during  the  labor,  external  measures  will  be  sufficient  to  keep  the  dis- 
charges sweet.  Douching  and  all  other  interference  within  the  passages  are  U> 
Ije  strictly  avoided  in  normal  cases.  If  the  discharges  become  fetid  notwilli- 
standing  proper  external  precautions,  an  antiseptic  vaginal  douche  should  lie 
given  two  or  three  times  daily  or  often  enough  to  suppress  all  ])utrid  odor. 
The  approaches  must  first  be  rendered  aseptic:  the  douche-tube,  sterilized  l>y 
boiling,  is  introduced  for  only  1  or  2  inches,  with  care  to  avoid  abradin*; 
the  mucous  surfaces.     ^Mercurials  shoidd  not  be  used  for  the  purj)ose,  owiiiu^ 


J/AXAChMhWT   OF    TIIK    IT EL'I'FJil LM. 


(JO!) 


to  the  (laiififer  of  inoroiirial  iiitoxifjitiijii.  A  1.5-voliiino  solution  of  liydrogen 
•lioxiil,  in  full  .strength  or  diluted  with  tiircc  or  four  volumes  of  water,  or 
Labarraque's  solution  in  water  (1  :  0),  is  suitable.  It  is  unneeessarv  to  say  that 
otlier  soiled  portions  of  the  body  should  be  cleansed  as  often  as  soiled,  and  no 
blood-stained  linen  should  be  permitted  to  remain  about  the  ])atient  or  the  bed. 
The  lying-in  woman  perspires  actively ,  hence  her  .skin  ought  to  be  frequently 
cleansed  by  sponging  with  tepid  water  or  with  water  and  alcohol.  This  bath 
should  be  followed  by  gentle  frietii)n  with  a  towel  until  a  warm  glow  is  j)ro- 
duced.  Cleanliness  of  the  bed  is  pmmoted  by  the  use  t)f  a  draw-sheet,  which 
consists  of  a  common  bed-sheet  folded  to  foiu'  thicknesses,  it  is  placed  upon 
the  bed  beneath  the  patient's  hips,  and  is  changed  as  often  as  soiled. 

Vnitihttion. — The  atmosphere  of  the  lying-in  room  nnist  as  nearly  as  pos- 


ible  be 


Air  should  be  admitted  as  freelv  b 


d. 


Slide  oe  pure.  Air  snould  l)e  admitteil  as  ireely  Dy  open  windows  as  is  con- 
sistent with  a  proper  temperature  of  the  apartment.  As  the  air  is  constantly 
vitiated,  so  the  ventilation,  to  be  effective,  must  be  continuous.  Light  is  essen- 
tial to  the  healthfulness  and  cheerfulness  of  the  lying-in  chamber.  The  practice 
of  darkening  the  room,  exce[)t  when  temporarily  necessary  to  promote  sleep, 
is  irrational  and  has  justly  become  obsolete.  Even  the  full  sunlight  may  be 
admitted,  provided  the  child's  eyes  are  properly  protected.  For  the  first  few 
weeks  the  eyes  of  the  new-born  infant  should  be  shielded  from  strong  light 
from  whatever  source. 

Diet. — The  diet  for  the  first  twenty-four  hours  is  to  be  restricted,  as  a  rule, 
to  liquids.  In  most  cases  even  liquid  food  is  to  be  withheld  until  the  patient 
has  had  a  few  hours'  rest.  After  the  use  of  anesthetics  no  nourishment  will 
1)0  borne  until  she  has  recovered  from  the  effect  of  the  anesthetic.  Excep- 
tionally, when  the  labor  has  been  an  easy  one  without  anesthesia,  a  little 
warm  liquid  nourishment,  such  as  clear  soup,  bouillon,  gruel,  or  cocoa  and 
milk,  may  be  allowed,  if  the  patient  requests  it,  directly  after  the  close  of 
lal)or.  On  the  second  day  soft-boiled  eggs,  boiled  custards,  panadas,  and 
similar  easily-digested  semi-solid  foods  are  suitable.  From  this  time  on  a 
moderately  full  diet  is  generally  to  be  recommended.  The  dietary,  however, 
must  be  varied  to  suit  the  needs  of  the  individual  case.  As  liberal  a  diet  as 
tiio  ])atient  can  digest  is  essential  to  the  normal  progress  of  convalescence  and 
to  tlic  proper  quantity  and  quality  of  the  inilk-secretion  in  ntirsing  women. 

Retention  of  Urine. — The  enfeebled  control  dver  the  bladder  in  the  first 
lidiirs  after  delivery  frequently  leads  to  retention  of  urine.  Tiiis  is  esj)ecially 
liable  to  occur  from  the  added  effect  of  refiex  disturbance  when  the  jierincum 
Ikis  been  sutured.  Owing  to  the  copious  secretion  of  urine,  which  is  common 
at  this  time,  painful  and  injurious  distention  of  the  bladder  often  results. 
Xot  only  may  serious  injury  thus  be  done  to  the  bladder,  l)Ut  uterine  hem- 
iirrliage  after  delivery  is  liable  also  to  occur  from  ovcr-distcntion  of  this 
vise  us.  The  patient  must  be  warned,  therefore,  of  the  importance  of  passing 
lur  urine  within  six  or  eight  hours  following  the  close  of  labor  and  at  similar 
intervals  thereafter.  The  difficulty  of  urination  dei)ends  partly  upon  the 
rrcuiiilx'nt  position,  and  it  may  frecjuently  i>e  overcome,  therefore,  by  allowing 


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A.v/:/i'f('A\  Ti:xT-iiooK  or  onsTF/nucs. 


the  jiatit'iit  to  assiiini!  a  sittiiij^  or  lialt-sittiiif^  posture  (liirin<^  attempts  at 
niietiiritioii.  Tlie  soiiiul  of  rimnin<^  water,  warm  fomentations  over  tlic 
meatus  urctlirju,  and  moderate  pressure  ap{)lied  with  tiie  hand  over  the  supnt- 
puhie  rej^'ion  are  iisetul  aids,  and  are  frecpiently  eil'eetive  even  in  tlie  reelininjj; 
])osition.  The  eatheter  should  l)e  withheld  as  a  last  resort,  owinj:;  to  the  dan^^cr 
ol'  settiiij^  up  a  more  or  less  intense  eatarrh  of  the  vesieal  neek  from  infeetidiis 
material  earried  on  the  instrument.  The  nmeosa  of  the  lower  portion  of  the 
bladder  is  liable  to  lu;  bruised  and  fissured  duriuj^  labor,  and  its  resistiiii:; 
power  thereby  imjjaired.  In  rare  cases  the  ureters  and  the  ])elvis  of  liic 
kidneys  may  b(!  invaded  by  tiie  septic  process  which  frequently  takes  its 
orijfin  from  catheterization. 

Unc  of  the  Catheter. — When  catheterization  is  unavoidable,  every  iirc- 
caution  nuist  be  used  to  prevent  inlection  of  the  bladder.  The  soft-rubbci' 
instrument,  which  is  least  liable  to  do  nieclianical  violence  to  the  vesicnl 
mucous  membrane,  is  generally  the  most  suitable  catheter  for  use  by  the 
mu'se.  The  Kelly  or  other  glass  catheter,  which  consists  of  a  short  glass 
tube  with  a  foot  or  two  of  rubber  tubing  attached,  has  the  advantage  that  it 
]>rcsents  a  perfectly  smooth  ])olislied  surface,  and  causes,  therefore,  a  mininniiu 
amount  of  urethral  irritation,  lioiling  in  water  for  ten  minutes  inunediatciv 
belbre  using  the  instrument  renders  it  aseptic.  It  is  jierhaps  needless  to  say 
that  after  boiling  the  catheter  is  to  be  handled  only  with  hands  that  have  been 
carefully  sterilized. 

The  instrument  must  never  be  ]>asscd  blindly  by  the  sense  of  touch  alone. 
AVith  the  i)atient  in  the  dorsal  position  and  the  thighs  separated,  the  labia 
•should  l)e  held  well  apart,  either  by  the  patient  herself  or  by  an  assistant,  so 
as  to  exj)ose  fidly  the  meatus  urethrte  to  view  until  the  eatheter  is  introduced. 
The  vestibule  and  labia  are  then  to  be  cleansed  with  soap  and  water  and 
washed  with  a  suitabU;  antiseptic.  The  catheter,  well  lubricated  with  vaselin 
previously  sterilized  by  heat,  is  then  passed — only  far  enough  barely  to  enter 
the  bladder — until  the  urine  begins  to  flow.  Care  should  be  taken  on  with- 
drawing the  instrinnent  that  no  urine  be  permitted  to  trickle  into  the  vagina 
or  ov(>r  the  vulvar  wounds.  If  the  ))arts  accid(.'iitally  become  soiled,  tiny 
should  l)e  cleansed  by  ])ressing  them  with  a  clean  damp  cloth.  The  catheter 
is  to  be  washed  carefully  with  soaj)  and  water  and  rinsed  with  clear  water 
after  using.  The  bladder  should  be  emptied  at  the  same  intervals  as  in  vol- 
mitary  urination. 

Ju-((ci((if!(»i  of  the  Jioirelti. — It  is  a  long-established  custom  to  open  the 
bowels  on  the  third  day.  There  an;  good  reasons  for  adopting  the  practice, 
now  so  generally  followed  after  abdominal  section,  of  evacuating  the  bowt'ls 
soon  after  labor,  not  later  than  thirty-six  hours.  The  most  suitable  measure 
is  a  mild  saline  laxative.  An  eligible  saline  for  the  purpose  is  the  solution 
of  citrate  of  magnesiinu  (lifiuor  magnesii  citratis).  The  action  of  the  bowcis 
may,  if  necessary,  be  assisted  by  a  rectal  injection  of  warm  water  or  of  sweet 
oil.  llsefid  stimidating  enemata,  if  required,  arc  salt  water,  soap  and  wali  r, 
a  drachm  or  two  of  undiluted  glycerin,  or  one  or  two  oimees  of  a  satiu'atrii 


ittcmiits  !it 
s   over  till' 

•  tlio  supra- 
ic  nH'liiiiii;j; 

•  tlio  (liui<ii'r 
11  infoctiim-; 
rtioii  of  tilt' 
its  resist  i I iii; 
'Ivis  ut'  till' 
Iv  takes  its 

cvorv   prc- 
!  solt-nilihi'i' 

-  tlio  vesical 
use  by  tlic 

I  short  ^-lass 
uitage  that  it 
,  a  niiniiiiiim 
immediately 
edless  to  say 
lat  have  been 

-  toueh  ah)iie. 
ted,  the  labia 
1  assistant,  >o 
is  introduced, 
id   water  and 

with  vaselin 

[irely  to  enter 

Ikeii  on  with- 

u  the  vaji;in!i 

soiled,   they 

The  catheter 

1  clear  water 

als  as  in  vol- 

to  open  the 
the  practice, 
lo-  the  bowels 
lable  measuiv 
tin;  sohitiiiii 
pr  the  bowels 
Ir  or  of  sweet 
Ip  and  water. 
If  a  siiturated 


.i/.i.v.u//;.i//;.V7'  o/'  the  I'Veiu'ERhm. 


oui 


ihition  of  Kpsom  salts.     Tiie  bowels  should   l)o  oiH.'iied  daily  after  the  first 


day. 

Lacfatimi. —  In  the  interests  of  i)oth  herself  and  her  infant  the  mother 
niijrlit,  as  a  rule,  to  nurse  her  own  child.  In  certain  conditions,  however,  this 
may  be  inadvi.sd)lo  or  even  impossible.  Syphilis  contracted  late  in  pre;riiaiicy 
and  tuberculosis  are  coiitra-iiidications  to  maternal  nursinjr,  owinj;  to  thedanjijer 
of  infectinj;  the  child.  Rarely,  suel<lin<r  may  be  impracticable  by  reason  of 
inversion  of  the  nipples,  or  may  have  to  be  discontinued  in  consctpicnce  of 
(■\eoriation  and  j)ersistent  sensitiveness  of  these  organs.  Sometimes  the  mother's 
milk  is  deficient  in  quality  or  in  (piantity.  In  marked  jieneral  debility  from 
whatever  cause  niu'sing  would  be  injurious  to  both  mother  and  child. 

The  early  application  of  the  child  to  the  breast  promotes  tlu;  uterine  con- 
tractions; it  is  particularly  advi.sable  when  the  uterus  remains  relaxed  after 
labor.  As  a  I'ule,  the  child  is  put  to  the  breast  only  after  the  mother  has  rested, 
after  six  or  eight  hours.  It  should  be  nursed  once  in  four  hours  during 
the  first  few  days  until  the  mammary  function  is  established.  Usually  the 
child  will  thus  have  learned  to  nurse  before  the  onset  of  the  true  milk-secretion, 
and  the  danger  of  painful  engorgement  of  the  breasts  will  be  diminished. 
Uejrnlaritv  in  nursing  is  as  essential  to  the  interests  of  the  mother  as  to 
tlio.se  of  the  child.  The  nipple  is  injured  by  prohttiged  and  fre(|uent  macera- 
tion. The  milk  becomes  concentrated  by  ()ver-fre([uent  suckling,  thin  and 
dilute  when  the  intervals  are  too  prolonged.  For  this  reason  the  child 
should  not  be  permitted  to  sleej)  in  the  same  bed  with  its  mother :  it 
should  lie  in  a  crib  by  itself.  The  healthy  condition  of  the  nipples  will 
he  promoted  by  carefully  cleansing  and  drying  them  after  the  child  has 
ninsed.  A  .sitnrated  solution  of  boric  acid  is  a  simple  and  efrective  lotion 
fiir  the  purpose.  If  they  are  ilisposcd  to  crack,  it  is  usefid  to  anoint  the 
nipples  with  fresh  cacao-butter  after  cleansing.  During  the  fir.st  few  days 
of  lactation  the  breasts  frequently  become  painfully  swollen.  Painful  iiidura- 
tidii  of  the  glands  in  the  absence  of  inflammation  is  relieved  by  gentle  nia.s- 
saii'e,  stroking  the  breasts  outward  from  the  base  toward  the  ni|)pl( .  This 
manipulation  is  best  practi.sed  immediately  before  putting  the  child  to  the 
breast.  Distention  from  over-free  secretion  is  relieved  by  saline  cathartics, 
liv  abstention  from  litpiids,  and  by  the  use  of  a  compression  breast-bandage. 
.All  easily  improvised  binder  is  the  ]\Iur|)liy  binder.  It  is  made  of  a  straight 
piece  of  muslin,  with  a  shallow  notch  cut  in  one  edge  for  the  neck  and  a  deep 
iiotcii  for  each  arm  ( Fig.  412).  The  bandage  is  closely  applied  over  the  breasts, 
the  ends  being  pinned  in  front  (I'l.  27,  Fig.  2). 

Not  infrc'  ".ently,  especially  in  debilitated  women,  the  supply  of  milk  is 
iiisiillieient.  Phe  most  reliable  evidence  of  defective  lactation  is  alforde<l  by 
tlie  signs  Oi"  inanition  in  the  child.  If  the  infant  ceases  to  gain  in  weight  or  if 
the  weeklv  gain  falls  short  of  the  normal,  in  the  absence  of  disease  it  is  to  be 
as-;iinied  that  the  (piantity  or  the  (piality  of  the  mother's  milk  is  at  fiiiilt.  In 
iiuiny  cases  it  is  ])ossil»le  to  do  soiiiethiiig  to  improve  the  character  and  to 
increase  the  quantity  of  the  l)n>ast-milk   by  attention  to  hygienic  measures. 


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23  WIST  MAIN  STRtET 

WEK&VeK,  i^i  V  MS  SO 

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AMERICAN    TEXT-nOOK   OE    OHSTETRICS. 


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The  l)est  galacta^o^iies  are  tonics,  a  generous  diet,  including  the  use  of  ni!'k, 
and  attention  to  the  habits  and  liygienie  surroundings  of  the  mother.     Precaii- 


Fi<i.  412.— MndllU'd  Mur|)liy  hreast-binder  (cut  on  the  dotted  lines). 

tions  must  be  taken,  however,  again.'it  over-foe<ling  and  consequent  derange- 
ment of  tlie  digestive  organs.  Tiie  chiily  a])])lication  of  a  mild  faradic  current 
through  the  breast.s,  it  is  claimeil,  acts  to  stimulate  the  mammary  function,^. 
In  the  writer's  exjierience  tiie  sulphate  of  strychnin  in  doses  of  from  -^^f  to  -^(^ 
of  a  grain,  three  times  daily,  has  apparently  done  good  service,  probably  more 
by  its  general  tonic  effect  than  by  any  specific  influence.  When,  owing  to  the 
death  of  the  child  or  for  other  reasons,  it  becomes  necessary  to  dry  up  the  milk,  a 
purely  expectant  treatment  usually  answers.  The  patient,  however,  generally 
suffers  more  or  less  pain  in  the  breasts  for  two  or  three  days.  Her  comfort  is 
promoted  and  the  disap|)earance  of  lactation  is  more  rapid  with  the  use  of  tlic 
compression  binder.  Daily  applications  of  the  oleate  of  atropia  are  of  groat 
value  for  the  relief  of  pain  and  for  their  specific  effect  in  drying  up  the  secre- 
tions. Restriction  of  liquids  and  the  use  of  a  saline  cathartic  also  help.  The 
iodid  of  potassium  in  15-grain  doses  repeated  two  or  three  times  daily  exer- 
cises a  remarkable  influence  in  diminishing  the  flow  of  milk. 

Tardy  Involution. — When  in  the  daily  examination  of  the  uterus  it  is  found 
that  involution  is  not  ])rogressing  normally,  measures  should  be  used  to  accel- 
erate the  j)rocess.  Friction  applied  two  or  three  times  daily  is  useful  for  thi.s 
purpose.  The  nurse  lays  the  hand  flat  upon  the  alxlomen  over  the  uterus, 
and  moves  the  abdominal  walls  in  a  circular  direction  over  the  anterior  surface 
of  the  uterus,  precisely  as  is  done  for  stimulating  uterine  contractions  in  tlic 
third  stage  of  labor.  This  procedure  should  Ik)  conducted  gently,  so  as  to 
give  no  pain,  and  it  may  l)e  continued  for  ten  minutes  at  each  sitting.  Fara- 
dism  or  galvanism  is  useful  for  hastening  involution.  A  mild  faradic  cur- 
rent may  be  used  ten  or  fifteen  minutes  daily,  or  a  smooth  galvanic  current 
of  ten  to  twenty  milliam|)6res  may  l)e  employed  for  the  same  length  of  tiinc. 
One  electrode  is  placed  over  the  upper  part  of  the  sar  uni  and  the  other  on 
the  abdomen  over  the  uterus.  A  hot  vaginal  douche  once  or  twice  daily  is 
an  agent  of  value  for  ])romoting  involution.  The  temperature  of  the  water 
should  be  about  115°  F.,  and  the  quantity  useil  not  less  than  two  or  tliicc 
gallons.  Ergot  in  doses  of  a  grain  of  the  solid  extract  or  its  equivalent  three 
times  daily  may  be  given  with  benefit.  Sometimes  the  cause  of  the  retardul 
involution  is  a  septic  condition  of  the  endometrium.     The  remedy  in  siieli 


MANAGEMENT  OF    THE  PUEPPEJi/UM. 


em 


use  oi 

ni'.'U 

ler.    Prwau 

4'    1 

'•. 

^ 

\ 

\ 
* 

cases  is  a  thorough  currotting  of  the  uterine  cavity.  An  iodoform-gauze 
drain  may  be  left  in  the  uterus  after  curretting.  The  gauze  should  be 
reiuove<l  in  three  or  four  days,  sooner  in  case  of  fetid  lochial  discharges. 

Special  Directions. — Few  women,  particularly  of  the  better  classes,  ap- 
|)roach  labor  in  the  full  vigor  of  health.  The  pressure-effects  of  the  later 
weeks  of  pregnancy,  the  impaired  nutrition,  the  loss  of  exercise,  and  the 
mental  anxiety  which  are  common  at  this  period,  all  conduce  to  enfeeble  the 
physical  powers.  When  to  these  conditions  are  added  the  exhausting  effects  of 
lal)(»r,  it  is  not  surprising  that  childbirth  is  frefpicntly  followed  by  more  or  less 
debility,  even  in  the  absence  of  complications.  Restorative  measures,  there- 
fore, usually  constitute  an  important  part  of  the  management  of  convalescf  nee. 
Tiie  necessity  for  plenty  of  sleep  and  a  proper  diet  has  already  been  alluded 
to.  In  addition  to  this  the  use  of  tonics  is  often  of  signal  service.  In 
anemia  one  of  the  proto-salts  of  iron  may  he  given  for  several  weeks.  The- 
]{laud  pill  is  a  popular  and  valuable  hematinic.  The  arsenate  of  iron  is 
especially  efficacious  in  the  treatment  of  anemia  in  puerperal  women.  Atten- 
tion shoidd  be  paid  to  the  condition  of  the  digestive  organs,  and  the  amount 
and  character  of  the  patient's  food  should  be  regulated.  If  the  apjietite  is 
poor,  a  bitter  tonic  may  be  prescribetl.  An  eligible  mixture  for  the  purpose 
is  the  elixir  of  calisaya  with  strychnin  ;  sij  of  the  former  and  gr.  ^  of 
the  latter  may  be  given  three  times  daily.  A  good  general  tonic  is  citrate  of 
iron  and  quinin  with  strychnin  or  nux  vomica.  A  drachm  of  the  double 
citrate  with  a  grain  of  strychnin  may  be  prescribed  in  a  four-ounce  mixture, 
with  directions  to  take  a  teaspoonful  three  times  a  day ;  or  2  grains  of  the 
citrate  with  one-third  grain  of  extractum  nucis  vomica;  may  he  administered 
in  pill  form  with  the  same  frequency. 

Special  attention  should  be  given  to  the  condition  of  the  pelvic  organs 
during  the  post-partum  month.  For  the  first  ten  days  the  daily  examination 
of  the  uterus  by  the  alxlominal  touch  Avill  enable  the  physician  to  observe  the 
progress  of  involution.  After  that  time  the  position  and  size  of  the  uterus 
c'liinot  readily  be  determined  by  abdominal  examination.  It  is  generally 
advisable,  even  in  private  practice,  to  make  a  bimanual  examination  during 
the  third  or  fourth  week  with  si>ecial  reference  to  the  shaj)e  and  position  of 
till'  uterus.  In  hospitals  it  is  the  rule  to  explore  the  pelvic  contents  shortly 
iK'fore  the  patient's  discharge.  If  the  uterus  be  retrovertetl,  it  should  be 
rcposited,  and  be  held  in  place  by  a  suitable  pessary.  Often  persistent  retro- 
version may  thus  be  preventetl.  The  pessary  may  be  disusetl  after  two  (»r 
tlu-oc  months.  Undue  persistence  of  the  ret!  flow  or  an  abnormally  open 
cervix  is  generally  to  be  taken  as  evidence  of  endometritis.  For  the  treat- 
iiu'iit  of  this  condition  applications  within  the  uterus  of  tincture  of  iodin  or 
iodized  phenol  (carbolic  acid  and  tincture  of  iodin  equal  parts)  at  intervals  of 
a  few  days  are  useful.  Most  effectual  is  a  currettage  with  drainage  of  the 
uterine  cavity  with  iotloform  gauze.  This  procedure  should  be  conductetl  with 
strict  antiseptic  precautions.  The  gauze  is  to  be  removed  in  from  three  to 
five  days. 


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AMKItlCAX    TEXT- BOOK   OF   OliSTETRICS. 


litynlutioti  of  the  Lyiufi-in. — Tlic  loiigth  of  time  which  it  is  desirable  that 
the  wotnaii  shoiihl  ho  kept  at  rest  after  hibor  will  obviously  vary  with  tlio 
rate  of  uterine  involution  and  with  the  general  progress  of  eonvaleseence. 
During  the  first  week  she  ought  not  to  leave  her  bed.  Ordinarily  she  may 
be  all()\ve<l  to  rise  partly  or  fidly  into  a  sitting  posture  during  micturition. 
This  often  obviates  the  necessity  for  using  the  catheter  in  patients  who  have 
difficulty  in  passing  water  in  the  reclining  posture.  It  also  favors  the  expul- 
sion of  vaginal  blood-clots,  and  alter  the  first  six  or  eight  hours  does  not,  as 
some  writers  have  asserted,  expose  the  patient  to  displacement  of  thrombi  or 
to  hemorrhage.  Tliroughout  the  second  week  the  patient  ought  to  maintain 
for  the  most  part  the  recumbent  position,  though  she  need  not  be  confined  iu 
bed.  She  may  for  a  ]>art  of  the  day  be  removed  to  a  lounge  or  may  lie 
upon  the  outside  of  the  bed,  and  may  sit  erect  when  taking  her  meals. 
During  the  third  week  a  large  portion  of  each  day  may  be  spent  in  a  chair. 
The  ])afient,  however,  shoidd  not,  as  a  rule,  be  allowed  on  her  feet.  In  the 
fourth  week  she  can  have  the  liberty  of  the  room,  and  at  the  end  of  the  j)uer- 
pcral  month,  if  all  goes  well,  may  be  permitted  to  leave  her  room.  It  is 
advisable,  however,  that  she  should  not  fully  resume  her  usual  duties  for 
two  or  three  weeks. 

Caim-;  ok  Tin-;  Nkw-uoux  Infant. 

Innnediately  after  birth  of  the  head  the  child's  face  should,  when  opportun- 
ity permits,  be  bathed  with  warm  water,  the  eyes  cleansed  and  carefully  dried. 
Tliis  is  done  as  a  ])rophylacti(!  against  ophthalmia.  As  a  still  further  preven- 
tive, within  an  hoiu'  after  birth  a  drop  of  ('rede's  solution  (a  2  per  cent,  soln- 
tion  of  nitrate  of  silver)  should  be  instilled  into  the  conjunctival  .sacs  of  eaeli 
eye.  The  latter  precaution,  when  properly  exetuited,  is  absolutely  protective. 
No  permanent  injury  is  d(»ne  to  the  delicate  structures,  and  the  serous  oozino 
wliicii  fre(|uently  results  subsides  within  a  few  days.  Should  it  be  excessive,  it 
may  be  promptly  controlled  l>y  a  single  application  of  a  drop  or  two  of  a  |  per 
cent,  solution  of  the  sulphate  of  atropin. 

The  ligation  of  the  fiuiis  and  the  dressing  of  the  stump  have  been  already 
cousideretl.  Usually  respiration  is  promptly  established  at  birth,  partly  l»y 
the  air-hunger  developed  by  interruption  of  the  utero-plaeental  eirculatinii. 
and  partly  by  the  reflex  effect  of  the  contact  of  cool  air  with  the  moist  sni- 
laces  of  the  body.  When  the  new-born  infant  does  not  breathe  properly  soim 
after  birth,  means  should  be  employed  to  seciu'e  the  full  expansion  of  the 
lungs.  Useful  measures  for  this  purpose  are  blowing  forcibly  upon  the  face, 
dashing  a  few  drops  of  cold  water  up(,u  the  chest  or  the  face,  or  gently  slap- 
ping the  buttocks  with  the  hand  or  with  the  end  of  a  wet  towel.  These  elforts 
shoidd  be  continued  until  the  child  cries  lustily.  When  respiration  is  obstructed 
by  mucus  in  the  throat,  the  offending  material  may  be  removed  by  the  finger 
wrapped  with  a  soft  rag.  Still  better  for  the  purpose  is  a  soft-rubber  tube 
with  a  bidb  attached.  The  tube  is  passed  deeply  in  the  j)harynx  and  suctimi 
applied  by  means  of  the  bidb.     Two  or  three  repetitions  of  this  process  will 


MAXAf:i:}fi:xT  of  the  prKUi'F.imwf. 


GC,-) 


usually  serve  to  clear  the  throat  of  the  ohstructiiig  niucus.  Susix'ndiii}?  the 
child  by  the  ieet  facilitates  drainage  of  liquids  Irom  the  air-passages.  The 
tieatineiit  of  asphyxia  does  not  fall  within  the  seojw  of  this   section. 

Care  must  be  used  to  protect  the  child  against  injurious  chilling.  It  must 
not  be  forgotten  that  an  abrupt  transition  has  taken  place  from  a  temj)erature 
of  about  100°  F.  to  one  nearly  or  (piitc  thirty  degrees  lower,  and  harm  wa\  be 
(lone  by  prolonged  exposure.  The  child,  therefore,  is  to  be  wrappctl  carefully 
ill  flannels,  and  as  soon  as  the  cord  is  cut  it  should  Ik*  laid  in  a  warm  place 
until  the  necessary  attentions  to  the  mother  are  compIctcMl.  The  head  while 
moist  should  be  covere<l  as  well  as  the  trunk  and  limbs.  The  stump  of  the 
navel  cord  ought  to  be  inspected  occasionally,  to  see  that  it  does  not  bleeil 
Irom  loosening  of  the  ligature  as  the  stiunp  shrinks.  After  the  principal 
duties  to  the  mother  have  been  disposed  of,  the  obstetrician  examines  the 
child  tor  possible  faults  of  development  and  for  injuries  during  birth.  The 
weight  and  length  of  tlu*  new-born  child  and  the  ]>riucipal  measurements  of 
the  head  are  niattei-s  of  scientiflc  interest  :  the  weight  especially  ought  to  be 
noted  for  comparison  with  the  results  of  subsetpient  weighings  as  a  means  of 
(leterinining  whether  mitrition  is  going  cm  properly.  A  small  and  awurate 
spring  balance,  therefore,  may  well  be  a  part  ol'  tlu;  obstetrician's  outfit.  A 
^^(•hidtze  pelvimeter  or  other  simple  calipers  is  a  suitable  instrument  for  meas- 
uring the  head. 

It  is  well  to  direct  the  nurse  to  administer  to  the  child,  within  a  few 
hours  alter  birth,  a  rectal  injection  of  a  tablespoonful  of  warm  water  ibr  the 
])iu'])ose  of  determining  the  ])resence  or  the  absence  of  atresia  ani.  If  the 
rectum  be  impervious,  the  water  retiwns  as  last  as  injected.  Should  no 
incconimn  be  passal  within  a  few  hoiu's,  the  physician  must  ex|)lore  the 
lower  bowel  for  possible  occiusion.  The  nurse  is  also  to  observe  whether 
tlic  child  urinates  as  evidence  that  the  urethra  is  pervious.  Failure  to  pass 
urine  for  several  hoiu's,  however,  need  not  excit(!  alarm.  The  bhuhler  is 
usually  emptied  in  course  of  the  birth,  and  but  little  in'ine  is  secreted  until 
the  child  begins  to  nurse.  Atresia  of  the  urethra  is  much  los  i"re(|uently  met 
with  than  that  of  the  rectum;  it  is,  in  fact,  extremely  rare.  Usefid  informa- 
tion may  sometimes  be  attbrdod  by  taking  the  temperature  per  rectum.  The 
notion  that  the  new-born  infant  should  be  placed  upon  its  right  side  to  favor 
the  closiu'c  of  the  foramen  ovale  has  no  foundation  in  fact.  It  may  lie  iiidif- 
Icrcntly  upon  the  back  or  upon  either  side,  changing  its  position  occasionally. 

Bnlh'inf). — The  first  bath,  if  the  child  be  robust,  may  be  given  soon  after  it 
is  separated  from  its  mother.  Jji  case  of  feeble  children  the  ftdl  bath  should 
he  ])ostponed  for  several  days.  In  the  latter,  iinuu'tions  of  sweet  oil,  vaselin, 
or  fresh  cacao-butter  are  to  be  substituted  for  the  general  bathing.  As  a  pre- 
liminary to  the  first  cleansing  the  skin  is  to  be  well  rubbed  with  sweet  oil  or 
similar  fatty  material  to  facilitate  the  subsequent  removal  of  the  vernix  oiseosa. 
TJK!  temperature  of  the  water  should  be  !)H°  F.  The  regidation  of  the  tein- 
|)(raturc  nnist  not  be  trusted  to  the  hand.  A  bath-tliernKinieter  should  be 
used.     While  the  temperature  ought  not  to  I'all  below  'J8°  F.,  it  must  not 


I 


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A.yrKiiicAX  TExr-iiOOK  OF  oiisiKrnics. 


nuu^h  excoofl  that  |K)int,  owing  to  the  danger  that  too  high  a  temperature  iii:u- 
inthice  trismus.  As  a  safeguard  against  injurious  chilling  the  nurse  should  U- 
taught  to  bathe  the  child  by  inunersion.  An  infant's  bath-tub  is  the  most 
convenient  vessel.  The  head  is  first  to  be  wet,  and  the  Ixnly  is  then  gradually 
lowercnl  into  the  water  to  the  neck.  The  head  is  supported  above  the  water  hv 
the  ntu'se's  hand.  Sea-sponges  should  Im)  replaced  by  soft  cheese-cloth  servi- 
ettes, which  can  Im;  destroyed  after  once  using,  or  if  usetl  again  should  first  lie 
boiled.  Care  njust  be  taken  that  the  soap  used  is  bland  and  non-irritatiiio. 
Most  suitable  is  white  castile  or  a  glycerin  soap;  nor  should  even  this  he  usi^d 
too  freely.  The  skin,  too,  of  the  new-born  infant  is  easily  injured  by  much 
friction.  More  harm  than  go(Hl  will  often  l)e  done  by  too  great  thoroughness 
in  the  first  bathings.  The  duration  of  the  bath  ought  not  to  exceed  five 
minutes.  On  rem()val  from  the  water  the  child's  bcwly  is  quickly  dritnl  by 
wrapping  in  a  large  soft  towel.  Little  or  no  friction  is  permissible  for  the 
first  week  or  more.  The  scalp  and  the  ears  must  be  dried  ciu'cfully.  The  full 
bath  may  be  re|)eated  daily  in  warm  weather,  and  three  times  weekly  in  the 
colder  m«)nths.  Soiled  portions  of  the  IxMly,  however,  should  be  cleansed  as 
often  as  soiled.  Especial  attention  is  to  be  direetetl  to  keeping  the  scalp  clean. 
The  l)est  time  for  the  bath  is  a  morning  hour,  midway  between  fee<lings.  If 
the  bath  is  repeatetl  before  the  renniant  of  the  cord  falls  oif,  care  must  i)c 
taken  to  dry  thoroughly  and  to  re-dress  the  stunij)  with  dry  borated  cotton  aft<'r 
each  bath.  It  is  usually  better  to  omit  the  daily  immersion  of  the  child  in 
water  until  the  funic  stump  separates.  Daily  sponging  with  water  or  inunc- 
tions of  sweet  oil  may  be  praciised  instead.  After  the  navel  stump  conies 
away  the  umbilical  wound  is  to  ho  drie<l  with  care  after  each  bath  to  prevent 
abrasions,  and  then  to  be  sprinkled  with  boric  acid,  bismuth  powder,  or  finely- 
powdered  oxid  of  zinc.  Should  any  fetor  develop  before  the  cord  separates 
or  while  the  wound  is  healing,  the  parts  after  bathing  should  be  disinfected 
with  the  peroxid  of  hydrogen  or  other  suitable  disinfectant  and  dried  befoio 
re-<hvssing.  After  one  or  two  weeks  genth?  friction  with  the  hand  may  In- 
used  to  promote  reaction  after  bathing.  For  vigorous  and  healthy  infants  tlic 
temperature  of  the  bath  may  be  lowered  gradually  to  90°  F.  by  the  age  dt' 
six  months. 

Infant  jwwders  are  not,  as  a  rule,  to  be  advised.  Shoidd  any  irritation 
develop  in  the  folds  of  the  skin,  a  finely-powderetl  talc  or  a  powder  eonsistiiiij 
of  equal  parts  of  oxid  of  zinc  and  lycopodium  may  be  employed.  It  is  well 
to  cleanse  the  mouth  gently  with  pure  water  after  each  nui-sing. 

Oofliinf/. — It  is  desirable  that  the  infant's  clothing  be  loose,  with  few  or  no 
pins  or  buttons,  and  capable  of  being  easily  changed.  The  clothing  should 
also  permit  reasonable  freedom  of  motion  for  the  limbs.  It  is  unnecessarv 
to  say  that  all  parts  of  the  body  except  the  head  ought  to  be  proteetcti 
equally.  The  outfit  describetl  below  is  a  simple  and  suitable  method  ol' 
dress  for  the  first  six  months. 

The  belly-band,  which  should  be  of  the  lightest  material,  is  to  be  discarcicHl 
after  the  umbilical  wound  has  healed.     It  is  used  merely  for  the  retention  ot' 


MAXAUEMKXT   OF   THE  PCKIiPKIilUM. 


6r,7 


I  lie  navel  dressing,  luul  it  serves  no  useful  |>urp()so  alter  the  navel  has  healed. 
It  is  a  mistake  to  suppose  that  a  tight  abdominal  bandage  helps  to  prevent 
Hinbilieal  protrusion.  On  the  contrary,  by  increasing  the  iutra-ab<lominal 
jjfcssure,  it  has  the  opposite;  efi'eet.  The  belly-binder,  therefore,  like  the  rest 
lit"  tlie  child's  clothing,  ought  to  be  loose  enough  to  admit  easily  two  or  three 
lingers  underneath  it.  The  customary  triangular  napkin  may  be  of  muslin 
or  of  linen  diaper.  A  single  safety-})in  here  is  all  that  need  he  used  in  the 
ell. tiling.  Napkin-covers  of  rubber,  wiiich  are  obviously  insanitary,  should 
never  be  tolerated.  The  clothing  proper  consists  of  an  undersiiirt  and  two 
(bosses.  The  undershirt  sixmld  1m'  made  of  the  softest  Hamiel,  without  sleeves 
;m<l  opening  in  front.  Next  is  a  fine  flannel  dress  with  high  neck  and  long 
sleeves,  cut  (\  la  prhiceHHc,  and  about  25  inches  in  length  ;  tiiis,  too,  opens  in 
front.  Over  all  is  a  muslin  slip  of  a  pattern  similar  to  tiie  flannel  dress.  The 
l('(>t  and  legs  are  to  be  prottx-ted  with  woollen  socks  reaching  to  the  knees. 
Tlie  undershirt  and  dresses  may  be  fastened  with  tapes.  All  clothing  shoidd 
he  laundered  before  using,  and  should  be  changed  daily.  At  night  the  muslin 
.111(1  flannel  slips  may  be  replaced  by  a  suitable  night-dress.  The  weight  of 
these  garments  is  to  be  adjusted  to  the  reijuirements  of  the  season. 

XitrKiuf/. — As  a  rule,  when  the  mother's  nipples  are  of  normal  size  and 
wc^ll  formed  the  fully-developed  and  healthy  child  instinctively  suckles  wIumi 
first  placed  to  the  breast.  Not  infrequently  the  new-born  infant  does  not  take 
the  nipple  willingly,  particularly  if  the  nipples  are  small  or  nn'sshapcn  or  the 
cliild  is  jiuny  or  feeble.  Much  trouble  nuiy  be  saveil  by  teaching  the  child  to 
nurse  before  the  breasts  become  engorged.  Patience  and  tact  will  usually 
ensure  success.  Wetting  the  nip])le  with  a  few  drops  of  milk  squeezed  from 
the  breast,  or  with  a  little  sugar  and  water,  before  aj)plying  the  child  may  be 
tried  if  necessary  to  induce  it  to  nurse. 

The  infant  should  be  put  to  the  breast  as  soon  as  the  mother  has  rested, 
usually  within  six  or  eight  hours  after  birth,  and  should  nurse  once  in  four 
hours  until  the  milk-secretion  is  established.  Subsecpiently  the  average 
interval  is  once  in  two  hours.  The  intervals  should  be  lengthened,  as  a  rule, 
to  three  hours  by  the  end  of  the  third  month,  and  thus  continued  until  the 
sixth.  About  six  hours  shoidd  be  allowed,  however,  between  the  last  nursing 
at  night  and  the  flrst  in  the  morning.  From  ten  to  twenty  minutes  is  enough 
for  each  nursing.  As  the  child  usually  falls  asleep  easily  after  its  meal,  it  is 
well,  if  necessary,  to  wake  it  on  the  hour.  Regidarity  of  feeding  is  of  the 
utmost  importance  in  the  interest  of  good  digestion  and  ])roper  nutrition,  and 
the  habit  should  be  established  early.  It  is  generally  best  to  apply  the  child 
to  b(jth  breasts  at  each  nursing.  Regurgitation  of  food  soon  after  feeding  is 
usually  to  be  taken  as  evidence  that  the  stomach  is  overfllled.  For  the  first 
two  or  three  days  after  birth  the  child  gets  but  little  nourishment  from  the 
breasts,  but  it  nee<ls  little.  Should  it  become  restless  and  fretfid  from  hiujger 
during  this  time,  an  occasional  teaspoonful  of  plain  water,  |)reviously  boiled, 
will  often  serve  to  quiet  its  cravings.  Cow's  milk  diluted  with  two  volumes 
of  water,  and  prepared  in  the  maimer  usually  practistnl  for  infant  feeding, 


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AMFJilCAX    TKXT-UOOK    OF   OliSTKTIilCS. 


may  he  jrivcii  in  qiiantitios  aiuountiiig  to  oiio  or  two  ounces  daily  ;  but  a  cliild 
that  is  f'ttl  (Iocs  nctt  so  roailily  take  the  breast,  an<l  hand-feeiling  is  tiierednv 
not,  as  a  rule,  advisable  if  the  child  is  to  1k'  nursed.  The  b<'st  evidence  dl' 
proper  nutrition  is  a  projjjressive  gain  in  weight.  It  is  a  gcKnl  practice  to 
weigh  the  child  weekly.  Since  a  loss  of  several  ounces  usually  takes  place 
during  the  tirst  few  days  after  birth,  the  child  docs  well  if  at  the  end  of  tlic 
wc'k  it  has  regaincil  its  birth-weight.  After  the  tirst  week,  in  normal  condi- 
tions, its  weekly  gain  tor  the  first  five  months  shouUl  not  fall  below  five 
ounces. 

\Vet-)iu)'ttivff. — When  for  any  reason  maternal  nursing  fails  or  must  be  dis- 
continued, the  best  substitute  for  the  mother's  breast  is  that  of  a  suitable  wi  t- 
nurse.  The  greatest  care  nnist  Imj  exercised  in  her  selection.  The  best  age  is 
between  twenty  and  thirty-five  years.  A  multipara,  or  at  least  a  woman  wIk* 
has  had  some  experience  in  nursing,  is  to  be  preferred.  It  is  desirable  that 
the  nurse's  child  be  of  about  the  same  age  as  that  to  be  nui-sed.  A  difference 
of  a  month,  however,  is  unimportant,  especially  if  the  foster-child  be  tlic 
younger.  A  menstruating  woman  is  sometimes  undesirable,  particularly  if 
the  flow  be  proltmged  or  be  copious.  Her  breasts  should  be  well  formed,  and 
should  promptly  refill  after  nursing.  The  nipples  should  be  sound  and  bo 
well  developed.  Women  whose  breasts  are  of  a  conical  sha|)e  and  not  too  large 
usually  make  the  best  nurses.  The  best  evidence  of  the  amount  and  quality 
of  the  nurse's  milk  is  to  be  f(»und  in  the  way  her  own  child  thrives.  In  case 
of  doubt  a  chemical  examination  of  the  nulk  may  be  made.  It  is  nnneccssarv 
to  say  that  sound  health  is  indispensable.  In  addition  to  the  direct  examina- 
tion, useful  information  may  be  gained  on  this  point  by  consulting  the  ])hysi- 
cian  who  attended  the  woman  in  her  confinement.  Any  serious  impairment 
of  her  general  health  will  usually  disqualify — tuberculosis  or  syphilis  always. 
Even  after  she  is  established  in  her  new  office  her  health  and  habits  must  ho 
looked  to  and  the  child  be  watched  to  see  that  it  thrives. 

Artificial  Fccdinr/. — While  there  is  no  substitute  which  fully  equals  the 
natural  food  of  the  new-born  infant,  yet  many  children  thrive  on  artificial 
foods  :  success  in  most  cases  is  possible,  however,  only  at  the  expense  of  nnicli 
care  and  skill  in  the  management  of  the  feeding.  The  first  requisite  in  a 
substitute  food  is  the  closest  possible  approximation  to  breast-milk — 

1.  In  its  physical  and  chemical  properties;  and 

2.  In  its  freedom  from  bacterial  organisms  and  the  effects  and  products  of 
bacterial  life. 

The  first  condition  is  approximately  fulfilled  by  preparations  of  cow's  milk 
with  such  modifications  as  are  indicated  by  analyses  of  human  milk  ;  tlio 
second,  by  proper  supervision  of  the  primal  milk-supply  and  by  the  further 
aid  of  sterilization. 

A  defect  in  substitute  foods  prepared  from  cow's  milk  that  cannot  easily 
be  obviated  lies  in  the  difference  between  the  chemical  character  of  its  ca^'iii 
and  that  of  breast-milk.  The  casein  is  somewhat  more  difficult  of  digostimi 
than  that  of  the  human  milk.     The  former  coagulates  in  hard  masses,  while 


jrAXAa/:Mi:xT  or  the  pvi:iii*i:iiirM. 


GGi) 


tlic  latter  forms  fine  soft  ciirils.  This  tlillicnlty  is  partially  overcome  by 
simple  dilution.  But  the  addition  of  water  to  the  point  necessary  to  render 
tlie  casein  easily  dij^cstible  results  in  a  food  very  deficient  in  fat  and  snji;ar. 
riidiluted  cow's  milk,  predifjested,  is  open  to  the  objection  that  it  docs  not 
ivpresent  the  proportions  of  albuminoids,  fat,  and  sujjar  tbund  in  breast-milk. 
Moreover,  feeiling  with  predijjjcsted  food  is  unfavorable'  to  die  development  of 
the  child's  dijjestivc  powers,  and  its  uses  are  therefore  limited. 

Human  milk  contains  from  1  to  2  per  cent,  of  albuminoids,  from  3  to  4 
per  cent,  of  fat,  and  from  (5  to  7  per  cent,  of  sujjar.  In  cow's  milk  the  pro- 
|)iirtion  of  each  of  these  ingredients  is,  in  round  numbers,  4  per  cent.  It 
will  be  seen  by  these  figures  that  the  reconstruction  of  the;  animal  product 
r('(|uires  a  slight  increase  in  the  prtiportion  of  milk-sugar  and  a  reduction 
in  that  of  the  albuminoids.  Simple  dilution  is  clearly  not  enough,  since 
the  addition  of  water  to  the  point  necessary  to  re<luce  the  allniminoids  to  the 
n'(iiiired  proportion  yields  a  jmiduct  which  is  extremely  poor  in  fat  and  sugar, 
and  entirely  inadequate,  therefore,  for  the  proper  nutrition  of  the  infant.  Of 
tlic  various  preparations  of  cow's  milk,  none  more  nearly  meets  the  require- 
niciits  than  the  Meigs  mixture  as  modified  by  llotch.  The  analysis  of  this 
mixture  when  properly  ]>repared  yields  the  prt)portions  of  albumin,  fat,  and 
sugar  found  in  breast-milk.  The  formula  for  the  Kotch-Meigs  mixture  is  as 
follows : 


Cow's  milk,  mixed-herd  milk, 

Cream, 

Water,  previously  boiled, 

Milk-sugar, 

Lime-water, 


51.). 
5>'j- 

3vi  gr.  xlv, 
5j.— M. 


To  ensure  the  correct  percentage  of  fat  in  the  mixture  it  is  necessary  that  the 
cream  used  in  its  preparation  contain  20  per  cent,  of  fat.  Such  a  cream  will 
1)1'  moderately  thin.  Ft  is  scarcely  necessary  to  emphasize  the  importance  of 
attention  to  the  jjrimal  milk-supply.  For  obvious  reasons  mixed  milk  from 
a  Ik  rd  of  cows  is  more  likely  to  be  of  uniform  quality  than  that  of  one  cow. 
Much  impurity  is  preventable  by  scrupulous  cleanliness  in  milking  and  in 
tlic  subsequent  handling  of  the  jiroduct.  Attention  to  the  health  of  the  ani- 
mals is  ((f  ])riniary  importance,  and  the  sooner  the  milk  is  fed  after  milk- 
iiiir  the  i)etter  is  its  condition,  other  things  being  equal.  The  milk-sugar 
ill  the  market  is  frequently  unsuitable  for  use  by  reason  of  gross  impurities, 
("arc  must  be  used  to  procure  an  article  which  has  been  fully  purified  by 
rccrystallization. 

Cream  obtaineil  bv  the  ordinary  method  of  allowinir  the  milk  to  stand 
until  th  cream  has  risen  has  necessarily  suiiered  some  degree  of  decomposition, 
fo  be  liad  fresh,  it  must  be  separated  from  milk  directly  after  milking  by 
means  of  the  centrifugal  machine.  Unfortunately,  cream  by  the  centrifugal 
process  is  in  most  localities  not  obtainable.  For  a  i\'\\  years  ])ast  a  milk 
lahoratory  for  the  preparation  of  infant  foo<l  has  been  in  successful  operation 


,:j  Hi.      , 


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(J7() 


J.V/;/.7r.LV    TKXTliOOK    OF    OBSTKTlilCS. 


ill  Boston  under  tlio  dircctioii  «)f'  I'rof.  llotrli.  llocontly  a  brunch  laboratniv 
lias  boc'ii  cstablisluHl  in  New  York.  The  iiiilk  is  obtained  I'roin  selected  ani- 
mals, with  sj)eeial  eare  in  colleeting  and  handling:,  and  is  delivere<l  at  the 
laboratory  within  a  few  hours  after  milking;.  The  ereani  is  obtained  by  the 
centrifugal  separator.  Milk  mixtures  are  compounded  on  the  physieian's 
prescription,  with  proportions  of  albuminoids,  fat,  and  sugar  to  suit  the  needs 
of  individual  eases.  This  plan,  which  has  l)een  attended  with  signal  succe>s, 
marks  an  im])ortaiit  advance  in  the  scientific  feetling  of  infants. 

But  these  refinements  in  infant  feeding  are  not  always  practicable,  nor  aic 
they  in  all  cases  indispensable  to  successful  nutrition.  In  exceptional  instances 
the  new-born  child  thrives  on  cow's  milk  simply  diluted  with  one  volume  ol" 
water  to  one  or  two  volumes  of  milk.  A  lairly  goo<l  formula  for  a  robust 
child  is  the  following : 

Cow's  milk,  5x. 

Water,  previously  boilefl,  .?v. 

Milk-sugar,  recrystallized  and  perfectly  pure,  3vi,  gr.  xlv. 

Common  salt,  gr.  viij. 

Lime-water,  .?j. — M. 

Tiie  defect  in  this  mixture  is  that  the  proportion  of  the  albumoids  is  too  larce 
and  that  of  fat  too  small.  It  usually  requires  further  dilution  for  new-boni 
infants.  If  not  well  borne,  a  ])artial  pretligestion  may  be  practised  fi)r  tlio 
first  two  or  three  months  by  the  addition  to  the  foo<l,  immediately  before  fcc*!- 
iiig,  of  \  grain  of  pancreatic  extract  and  ^  grain  of  bicarbonate  of  sodium  to 
each  ounce  of  the  mixture.  The  use  of  artificial  aids  to  digestion,  however, 
should  be  limited  to  such  exigencies  as  cannot  otherwise  be  met.  The  digestive 
powers,  like  other  functions,  suffer  impairment  by  disuse. 

The  addition  of  barley-water  or  oatmeal-water,  gum-water,  or  similar  admix- 
ture is  adviscfl  by  some  writers  to  promote  the  coagulation  of  the  casein  into 
soft  fine  curds.  According  t<i  Ilotcli,  carefully-conducted  experiments  show- 
that  these  attenuants  act  solely  by  reason  of  the  water  they  contain. 

As  Professor  Rotch  remarks,  the  natural  food  of  the  infant  in  the  first 
twelve  months  of  its  life  is  a  ]>urely  animal  food.  This  fact  would  seem  a  sui- 
ficient  reason  for  excluding  also  all  farinaceous  materials  from  substitute  foods 
during  the  first  year. 

Condensed  milks,  like  ordinary  cow's  milk,  when  diluted  sufficiently  to 
reduce  the  proportion  of  albumin  to  the  required  standard,  must  obviously 
yield  a  result  which  is  deficient  in  fat,  and,  in  the  case  of  unsweetened  prejia- 
rations,  must  be  poor  also  in  sugar.  JJut  this  is  not  all.  Analyses  have  sh(»\\  ii 
that  nearly  all  brands  of  condensed  milk  lack  primarily  the  due  proportion  ot' 
fat.  With  one  or  two  exceptions  they  are  made  from  milk  from  which  a  jxn- 
tion  of  the  cream  has  first  been  removed.  Moreover,  the  sweet  brands  are 
sweetened  with  cane-sugar,  which  is  not  an  ingredient  of  natural  milk,  and  is, 
furthermore,  open  to  the  objection  that  it  is  more  likely  than  milk-sugar  to 
favor  butyric-acid  fermentation.     A  condensed  milk,  however,  to  which  no 


MAXAf{j:.vj:xr  of  the  puEitPKituM. 


671 


h  laboratniy 
selccttHl  ani- 
ivcnnl  at  tlic 
aiiic<l  by  tlu' 
0  physician's 
<nit  the  uocils 
igiial  sut'cc.-s, 

['able,  nor  arc 

oiial  instances 

ne  volume  nf 

for  a  robust 


r.  xlv. 

'J- 
\\. 

ids  is  too  larjje 
for  new-born 
ictised  for  tlio 
ly  before  fi'ctl- 
?  of  sodium  to 
ition,  however, 
The  digestive 

similar  admix- 
Ithe  casein  into 
iriments  show 
!ontain. 
it  in  the  first 
Id  seem  a  suf- 
iibstitute  foods 

Isufficiently  to 
Ust  obviously 
ectene<l  prepa- 
Ics  have  shown 
[proportion  of 

which  a  jxn- 
tct  brands  arc 

milk,  and  is, 
|milk-sugar  to 

to  which  no 


cine-sugar  lias  been  atldetl,  and  which  has  been  evajwrated  at  a  low  tcnipcr- 
atiirc,  provided  the  pcr(!(>ntages  of  its  nutritive  constituents  arc  known,  nu»y 
M  rve  as  the  basis  from  which  to  construct  a  pr(»pcr  flxHl  for  infant  feeding. 
Water,  cream,  and  sugar-of-milk  are  to  be  adde<l  in  proportions  which  must 
l)('  d(!termined  by  the  analysis  of  the  particular  brand  of  condenscil  milk 
niiployed. 

In  view  of  the  progress  that  has  Immmi  made  in  the  knowknlge  of  infant- 
l(  eding,  the  use  of  proprietary  fotnls  for  infants  ought  long  since  to  have  been 
aliiUidoncd. 

No  less  important  than  the  proper  adjustment  of  the  principal  nutritive 
iiigre<lients  is  freedom  from  disease-germs  and  the  bacteria  of  putrefaction. 
Complete  stcrilizatitm  is  possible  by  prolonged  boiling.  Milk  boiletl  for  half 
an  hour,  and  reboiled  for  the  same  length  of  time  on  the  following  day,  will 
keep  unchange<l  for  several  weeks.  E.\j)erience,  however,  has  shown  that 
under  prolonged  exposure  to  temperatures  near  the  boiling-point  certain 
clianges  take  place  in  the  albuminoids  of  the  milk  by  which  its  digestibility 
is  greatly  impairwi.  To  so  great  an  extent  is  this  true  that  many  infants  arc 
totally  unable  to  subsist  upon  milk  thus  treated.  Full  sterilization  of  milk 
for  infant  feeding  has,  therefore,  Ix'en  |)ractically  abandone<1.  It  is  found 
that  milk  heated  to  167°  F.  for  twenty  mini'.tes  and  promptly  chilled  by 
placing  on  ice  remains  practically  sterile  for  twenty-four  hours,  and  it  is 
spared  the  injurious  changes  which  take  place  at  higher  temperatures.  This 
process  is  known  as  Padeurization.  The  Arnold  steam-sterilizer  affords 
a  convenient  means  of  Pasteurizing.  If  used  with  the  cover  removed,  the 
st('ani-ehand)er  being  o|kmi,  the  temjwrature  of  the  steam-chamber  does  not 
cxcwhI  170°  F. 

The  writer  has  found  by  experiments  in  the  use  of  the  Arnold  steam- 
storilizer  with  a  suitable  gas  stove  that  the  water  l)egins  to  boil  at  the  end 
of  two  minutes  after  the  gas  is  lighted.  A  four-ounce  bottle  of  milk  at  an 
initial  temperature  of  70°  F.  in  the  open  steam-chamber  attains  a  temperature 
of  170°  in  just  one  hour.  An  exposure  of  about  an  hour  and  twenty  mimitcs 
in  tlic  steam-chamber  is  therefore  requiretl  for  Pasteurization.  It  is  taken 
fi)r  granted  that  further  details  of  the  ju'ocess  require  no  description  here. 
A  simple  substitute  for  Pasteurizing  consists  in  rapidly  raising  the 
temperature  of  the  milk  for  an  instant  to  the  boiling-point,  then  promptly 
chilling  the  milk. 

The  capacity  of  the  stomach  in  the  infant  at  birth  is  approximately  Y,Vir  ♦''*' 
body-weight.  The  average  quantity  of  food  at  each  meal  for  the  new-born 
child  is,  therefore,  about  one  ounce.  The  average  rate  of  increase  is  1^ 
drachms  per  week  for  the  first  six  months,  subsequently  somewhat  less. 
The  intervals  between  feedings  should  be  about  two  hours  at  birth,  and  shoidd 
he  increasetl  gradually  to  three  hours  by  the  end  of  the  third  month.  Thcs(! 
rules,  however,  will  serve  oidy  for  general  guidance,  and  they  must  be  ni(xli- 
fied  to  suit  the  needs  of  individual  cases.  Tiie  food  should  be  fed  at  a  tempcr- 
atim;  of  100°  F.  and  directly  from  the  sterilizing  bottle. 


iin 


■t'^^^i 


G72 


AMHIUCAS    Th\\'T-Ji(JOh'    OF    nliSTF/rii ICS. 


-f-U 


IV.  PATIIOLOCJY  OF  THE  PrERPK'UUM.* 

I.  Injuries  to  the  External  Genital  Organs  following 

Labor. 

Tlio  dilatation  of  the  parturient  canal  an<l  tlic  pxpiilsion  of  the  fetus  ami 
tile  plaeenta  are  almost  always  associated  with  nutre  or  less  injury  to  the  iii,i- 
ternid  tissues. 

These  injuries  are  usually  in  direct  proportion  to  the  resistance  which  tlic 
parts  in  question  oiler  to  the  passage  of  the  fetus.  They  arc  therefore,  as  a 
rule,  greatest  in  priiniparte,  and  they  may  be  absent  in  women  that  have  rcpe;il- 
edly  given  birth.  They  are  smallest  in  natural  confinements — that  is,  in  cases  in 
which  the  forces  of  nature  are  sufficient  to  effect  safe  expulsion  of  the  fetus  iff; 
the  proper  time  and  manner — and  they  are  greatest  when  a  meclianical  dispiw- 
portion  between  the  fetal  parts  and  the  parts  of  the  mother,  or  a  iual|»<i>itiiiM 
of  the  fetus,  or  any  of  the  lunnerous  complications  of  lalnir,  endangers  <'itlicr  the 
nu>thcr  or  the  child,  and  calls  for  (vperativc  interference  ( instrumental  «»r  manual  I 
on  the  part  of  the  obstetrician.  They  are  iiUcly  to  be  especially  great  wlicn 
this  ojH'rative  interference  bect)mes  imperative  at  a  time  when  the  parturient 
canal  is  only  incomi)letcly  dilated. 

The  most  common  of  these  injuries  .ousist  in  contusions  and  tears  of  the 
vulva,  the  perineum,  the  vagina,  and  the  neck  of  the  uterus  ;  some  of  the  rater 
accidents,  such  as  lacerations  of  the  body  of  the  womb,  inversion  of  the  uterus, 
and  injuries  to  the  pelvic  bones,  have  been  described  under  Dysfocid. 

Injuries  to  the  Vulva. — At  times  we  find  transverse  lacerations  of  the 
vidva  that  involve  the  deeper  tissues,  perforating  the  nymplue  and  leaving 
them  fenestrated  for  the  rest  of  the  patient's  lite,  or  going  completely  through 
either  labia  minora  or  majora  or  both,  and  causing  these  structurv's  to  hang  in 
shreds.  Ti\e  most  frecpient  accident  to  the  vulva,  however,  consists  in  tcai- 
of  the  nuicous  membrane,  which  are  most  numerous  in  the  vestibulum  and  (ni 
the  inner  surfaces  of  the  labia  minora.  Sometimes  the  tears  are  near  the 
urethral  orifice  or  they  extend  into  it,  and  under  these  conditions  will  cause  a 
burning  pain  during  urination  or  will  lead  to  retention  of  urine  on  account  nt' 
the  accompanying  swelling.  These  injuries  do  not,  as  a  rule,  cause  miieli 
hemorriiage,  but  at  times  they  will  do  so,  especially  if  one  of  the  eonvolutinns 
of  blood-vessels  known  as  the  hxfbs  of  the  trxfibufe  is  involved. 

Trvaimcnt. — Superficial  tears  of  the  mucous  mend)rane  of  the  vulva  will 
heal  without  much  treatment.  They  should  be  kept  clean  and  may  be  dusted 
with  iodoform.  All  deeper  lacerations  and  those  followed  by  henu>rrhage  are 
best  closetl  by  fine  silk  sutures.  Union  by  first  intention  takes  place  aliiidst 
invariably,  and  the  stitches  may  be  removed  on  the  fourth  or  the  fifth  d:iy. 
When  there  is  retention  of  urine  it  may  become  necessary  to  use  the  catheter 

*  Tlie  sup'rior  fifjuros  ( ' )  occurring  througliout  the  text  of  this  section  refer  to  the  bililinj,'- 
rapiiy  given  on  page  SO-1. 


■'^.U,  r  H 


PATiioLoav  OF  Tin:  I'ri'Jx'i'HmiM. 


♦I7;l 


nil 


til  th 


II 


ir  swollllij;  liiis  siihsKlct 


(  )tt('ii 


I,  liowcvcr,  tilt'  iKitii'iit  will   lu'  t'lia 


l)l.-(l 


V\n.  li;i.- I'rriiKiil  Imcralidiis:  A,  liiciriit'oii  I'XicncliiiK  tllrlHl^;ll  the  siihimliT  i.  >  iiitu  tli"  riM'tuiii, 
siilclics  iMtnKliiciil  tlimiiyli  t<irii  iimrnins  "I'  ri'<luin  mid  tlnniiHli  ends  uf  s|iliiiiiti'r  (m,  icmly  In  \n-  liid 
with  till'  knots  in  tlic  rcctiini.  11,  sutures  in  rccliil  tear  tied  :  rcinfnrci'i;,'  stitch  i;i  piivsccl  ilin.iinli  cinls 
i.r  s|ihiiii  trr  iiml  iipin'iiriiiK  at  njiux  nf  rectal  tear,  ready  tn  he  tied ;  vaniniil  Kutiircs  also  |iliiee(l. 

to  iiriiiatt'  s|)(»ntaiuM)iisly  it' tlic  vulva  is  wrll  clcanffd  with  sonic  warm  antiseptic 
solution,  and  a  bed-pan  half  filled  with  hot  water 
or  with  hot  ehanioinile  tea  is  plaeed  under  the 
pelvis  in  siieh  a  niannei*  that  the  vapor  eoines  in 
coiitaet  with  the  swollen  parts. 

Iryuries  to  the  Perineum. — liiiptnres  of  the 
perineum  eonstitiite  the  eoinnutnest  injuries  of 
lalior.  In  primipariK  tlu!  freniilnin  tears  almost 
always,  and  more  extensive  lacerations  will  oc- 
cur in  at  least  one-third  of  the  cases.  In  nnd- 
tipane  the  lacerations  arc  less  frc(|iient  and  arc 
usually  less  forinidahlc ;  they  may  he  .ivoiiutl 
altoL:etlier  in   nine  cases  ont  of  ten. 

For  practical  purposes  lacerations  of  the  peri- 
neum are  divided  into  lacerations  ■  f  the  first, 
the  second,  and  .!:c  third  dej^rce,  accordinij  to 
their  extent.  Whenever  one-half  of  the  peri- 
ueuiii  is  left  uniiiinrcti,  the  laceration  is  one  of 
the  /(V.s7  dej^ree.  When  the  tear  extends  farther 
back,  even  as  far  as  the  sphincter  ani,  but  with- 
out iuvolvinj;  that  strnctiire,  then  there  is  a  lac- 
eration of  tlie  nccond  ile<free.     The  lacerations  of  the  t/iird  deforce,  also  called 

43 


riii.  11 1.- Vayinal  and  rectal  su- 
tures tied:  sutures  pluied  to  rejiuir 
perineal  hody. 


674 


AMEllIVAN    TEXT-BOOK   OF   OBSTETRICS. 


"complete  niptuns  of  the  perineum,"  extend  through  the  sphincter  ani  into 
tlie  reetuni  (Figs.  4i;j,  414).  At  times  we  meet  with  a  hiceration  of  the  peri- 
nenm  that  cannot  be  brought  under  either  of  these  lieadings.  We  refer  to  the 
.so-called  "central  rupture,"  in  which  the  anterior  and  the  posterior  boiuidarifs 
of  the  perineum  remain  uninjured,  while  the  central  portion  becomes  torn  and 
j)erforated  and  may  even  afford  passage  to  the  fetus. 

In  addition  to  the  perineal  lacerations  Just  enumerated,  tears  extending  up 
one  or  both  lateral  sulci  of  the  vagina  (Fig.  415)  are  of  very  frequent  occur- 


KJ  f 


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Fig.  ■115.— Perineal  liicerution.s :  A,  luceratiDii  I'.xti'iKlint;  up  riKlit  Ititerul  sulcus.    H,  lucoratidii  involviiin 

both  lateral  sulci. 

rencc,  and  the  resulting  injury  to  the  levatores  ani  muscles  destroys  in  varyiajj; 
<legree  the  subsequent  usefulness  of  these  structures  as  supports  to  the  |)clvi(' 
viscera.  Indeed,  this  typo  of  so-called  "perineal  laceration"  is  jjerhajjs  of 
greatest  importance,  since  it  is  the  factor  which  more  than  any  other  deteriuines 
sul)se(pient  relaxation  and  (consequent  displacement  of  the  pelvic  organs.  It 
should  also  be  remembered  that  the  integrity  of  the  levatores  ani  mii.-iilc< 
may  be  destroyed  by  being  over-stretched  without  a})parcnt  laceration  of  tlit' 
Huperimposed  vaginal  tissues. 

(huscH. — In  ])rimi])ar.'e  with  the  best  of  can;  and  under  perfectly  noniKil 
conditions  ruj)tures  of  the  |)erineum  cannot  altogether  be  avoided.  No  matter 
how  much  softened  an<l  how  yielding  the  parts  become,  the  passage  of  the 
fetal  head  forces  the  vulvar  ring  so  far  open  that  in  most  cases  there  will  be  a 
giving  way  of  tissue  at  the  moment  when  the  greatest  diameter  of  the  ciiild's 
head  pa.sses  this  ring.  Jn  vertex  presentations,  v/ith  rotation  of  the  occiiml 
forward,  this  moment  arrives  after  the  greater  fontanelle  has  appeared  in  Iroiit 
of  the  frenulum,  the  fetal  head  going  through  the  pelvic  outlet  with  its  lesser 


I'ATHOLOaV   OF    THE   PIIERPERIUM. 


(J75 


lutoratitpu  involvini; 


(il)liqiie  (liamctcr.  In  iill  other  presentations  the  chances  for  rupture  are  very 
niiKth  increased.  They  are  greatest  in  face  presentations,  in  whicli  the  chin  has 
tu  rotate  forward  and  the  head  leaves  the  vulva  in  its  greatest  diameter,  the 
trieater  oblique.  The  causes  of  the  rupture  are  also  frequently  found  in  the 
peculiarity  of  the  maternal  tissues.  Small  women  with  narrow  vaginal  open- 
iiiirs  may  give  birth  to  good-sizetl  children  and  escape  with  scarcely  a  scratch, 
till'  parts  possessing  a  wonderful  elasticity ;  while  in  other  women  perfectly 
liciiltliy,  and  having  the  parts  of  good  dimensions  and  apparently  quite  clastic, 
the  parts  tear  easily  and  extensively  when  the  test  comes.  In  still  other  cases  the 
cimditions  are  such  that  we  know  beforehand  that  the  elasticity  of  the  parts 
is  hc'low  the  average.  This  abseiujc  of  elasticity  is  usually  found  in  elderly 
piiinipane,  especially  when  they  are  above  thirty-five  years  of  age.  Moreover, 
a  protracted  labor  will  make  the  perineum  dry  and  unyielding,  or  it  may  cause 
ail  edematous  or  inflammatory  swelling,  which  in  turn  frustrates  all  efforts 
(111  the  part  of  the  obstetrician  to  avoid  a  ruptiu-e.  A  proper  guarding  of  the 
perineum  and  a  slow  transit  of  the  fetus  through  the  pelvic  outlet  tend  to  avoid 
liieerations.  Precipitate  labors  and  labors  without  skilled  assistance  must  there- 
tore  increase  the  chances  for  such  injuries. 

Si/ii)})fom,'f. — A  burning  pain  is  usually  the  only  symptom  that  a  lacerated 
perineum  causes  at  the  time  of  its  occurrence.  In  some  few  eases  there  is  free 
hemorrhage  from  torn  blood-vessels,  but  these  eases  are  exceptions,  and  the 
lileeding  generally  does  not  amount  to  more-  than  a  free  oozing  of  blood  from 
tlu'  raw  surfaces.  If  left  to  themselves,  most  ruptures  of  the  first  and  second 
(legnie  will  heal  spontaneously  ;  the  more  extensive  ones  will  heal  by  granula- 
tion and  cicatrization,  leaving  the  parts  in  an  unyielding  condition  for  subse- 
quent laliors.     The  ruptures  of  the  third  degree  extending  into  the  rectum  and 


I'lii.  111!.— Cmnpletu  proliiiisi'  nf  tliu  uterus  iiiiil  viiniiial  walls  I'liUowiUK  oxlousivo  ami  uiuiiiilt'il  pi'riiu'al 

lacL-ratioii. 

those  involving  the  levatores  ani  muscles  seldom  heal  spontaneously.  Tli(>  later 
<niisequences  of  an  ununited  perinea,  hueration  are  a  gradual  descension  of  the 
v:i<j,iiia  and  uterus,  starting  with  [mdapsus  of  the  anterior  vaginal  wall,  and 
ulteii  ending  with  complete  inversion  of  the  vagina  and  complete  prolapsus  of 


.:!a5!:i,li»K'-' 

m 

■      \       '■■ 

i%: 

in| 

1      ■:           1 

'IK* 

'  i ' 


676 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


the  uterus,  so  that  there  is  found  in  front  of  the  pelvic  outlet  a  large  tumor,  tl.,' 
covering  of  which  is  forniecl  by  the  vaginal  mucous  membrane  except  at  tln' 
apex,  where  the  os  uteri  externum  is  visible.  The  body  of  the  uterus  is 
found  inside  this  tumor  (Fig.  416).  In  complete  ruptures  the  impairment  di" 
the  sphincter  ani  makes  it  impossible  for  the  patient  to  control  the  passage  of 
gases  and  of  litpiid  fecal  matter,  and  it  renders  her  condition  so  miserable  that 
she  usually  applies  for  a  surgical  restoration  of  the  injured  parts  long  bclinc 
a  prolapsus  has  had  time  to  develop.  The  principal  danger,  however,  fnun 
lacerations  of  the  perineum  of  any  degree  is  found  in  the  great  liability 
they  offer  to  septic  infections  of  all  kinds  during  the  lying-in  state.  The 
lacerations  form  large  raw  surfaces  which  are  ready  to  absorb  and  t(t  carry  into 
the  system  any  infectious  material  that  may  be  brought  near  them.  Tims, 
infection  from  outside  sources,  such  as  may  be  communicatal  by  the  hands  or 
the  instruments  of  physicians  and  nurses,  will  take  place  with  greater  facility 
and  surety  when  the  perineum  is  torn  than  if  the  materia  peccans  would  have 
to  reach  the  cervix  uteri  before  it  could  find  an  easy  entrance  into  tlio 
lymphatic  and  vascular  systems.  The  experiments  of  Kehrer  of  Heidelberg 
have  demonstrated  that  the  lochial  discharge  of  healthy  puerperse  contains 
pyrogenic  and  phlogogenic  elements ;  thus  we  find  that  lying-in  women  with 
perineal  rupture  have  fever  from  absorption  of  the  normal  lochial  discharge 
while  passing  over  the  raw  wounds.  This  fever  subsides  as  soon  as  healthy 
granulations  spring  up  to  form  a  living  barrier  against  further  absorption.  It' 
the  lochial  flow  becomes  offensive  from  any  cause,  then  its  absorption  will  not 
produce  simple  elevation  of  temperature,  but  will  be  followed  by  puerperal 
septicemia  with  more  or  less  local  manifestations. 

Treatment. — The  first  object  of  the  treatment  of  lacerations  of  the  perineum 
must  consist  in  trying  to  avert  them,  or  where  this  not  practicable  at  least  to 
limit  their  extent  so  far  as  possible.  Supporting  the  perineum  at  the  time  the 
head  passes,  securing  the  proper  mechanism  at  the  moment  of  its  delivery,  and, 
most  important  of  all,  resisting  too  rapid  expulsion  by  forcibly  retarding  the 
expulsion  of  the  head  and  by  crowding  the  latter  well  against  the  under  sur- 
face of  the  symphysis,  will  often  avoid  extensive  laceration.  The  details  of 
managing  the  birth  of  the  head  and  the  methods  to  be  employed  to  avert 
serious  injury  to  the  pelvic  floor  have  been  described  and  illustrated  on  page 
369.  During  the  passage  of  the  shoulders  the  support  must  be  continued,  for 
often  the  passage  of  the  head  causes  just  the  smallest  tear,  perhaps  extendiiiif 
(<nly  through  the  frenulum,  and,  if  the  shoulders  are  carelessly  allowed  to  pass, 
this  tear  may  be  increased  to  great  dimensions. 

When  the  uterine  contractions  are  so  violent  that  they  tend  to  force  the 
fetal  head  out  with  great  rapidity,  they  should  be  regulated  by  a  hypodermatic 
injection  of  morphin,  or,  still  better,  by  inhalations  of  chloroform.  If  a  rup- 
ture of  the  perineum  is  apprehended,  it  is  advisable  to  deliver  in  the  lateral 
position  (see  illustration,  p.  372).  The  passage  of  the  head  will  be  slower  than 
in  the  dorsal  jwsition,  and  the  parturient  woman  can  use  less  force  in  bearing 
down.     The  perineum  can  be  more  closely  observal,  and,  in  suitable  eases,  an 


ge  tumor,  tl.^' 
except  at  the 
the  uterus  is 
npairment  of 
lie  passage  ut' 
luiserable  tluit 
s  long  bei'orc 
liowever,  IVoin 
great  liability 
n  state.     T\w 
il  to  carry  into 

them.  Tims, 
V  the  hanils  in- 
greater  facility 
ins  would  have 
ranee  into  the 

of  Heidelberg 
irperje  contains 
in  women  with 
ichial  discharge 
soon  as  healthy 
absorption.  It' 
jrption  will  not 
d  by  puerperal 

if  the  perineum 
iable  at  least  to 
at  the  time  the 
;s  delivery,  and, 
y  retarding  the 
the  under  siir- 
The  details  of 
ployed  to  avert 
istrated  on  page 
continued,  lor 
•haps  exten(lin;j; 
iUowed  tt)  pass, 

[id  to  force  the 
la  hypoderniiitic 
Irm.  If  a  '"ip- 
|r  in  the  lattMul 
be  slower  tlmn 
lirce  in  bcurins: 
liitable  cases,  an 


PATHOLOGY   OF    THE  PLERPERIIM. 


677 


impending  laceration  may  be  avoided  by  the  so-called  "bilateral  incisions"  or 
( |)isi()toniy,  an  operation  described  and  illustrated  on  page  373  (see  Fig.  202). 
Many  a  laceration  of  the  perineum  may  tiuis  be  avoided,  and  a  clean  incised 
wound,  which  can  easily  be  united  by  one  or  two  sutures,  is  substituted  for  a 
torn  wound,  whose  extent  could  not  be  foreseen. 

In  eases  in  which  the  perineum  appears  rigid,  warm  moist  applications 
(luring  labor  will  help  to  soften  the  parts ;  chloroform-inhalations  carrieil  to 
(oinplete  anesthesia  seem  also  to  render  the  tissues  more  yielding.  Where  the 
delivery  is  accomplished  by  the  aid  of  forceps,  an  impending  rupture  of  the 
perineum  may  be  avoided  by  taking  off  the  instrument  just  before  the  greatest 
(liaineter  of  the  child's  head  passes  the  pelvic  outlet ;  otherwise  the  instrument 
will  lielp  to  augment  the  distention  of  the  vulvar  ring  and  will  make  a  lacera- 
tidii  more  probable.  If  the  forceps,  however,  is  not  removed,  it  should  be  used 
t(i  hold  the  head  back  during  expulsive  efforts  and  thus  permit  gradual  dilata- 
tion of  the  vaginal  outlet. 

When  these  prophylactic  measures  fail  to  prevent  a  rupture  of  the  perineum, 
it  becomes  the  duty  of  the  obstetrician  to  see  that  the  injury  is  repaired  in  the 
manner  previously  described  (page  379)  and  immediately  after  the  completion 
ot'  labor.  No  physician  should  attend  a  case  of  labor  without  carrying  in  his 
siitehel  the  necessary  imjilements  for  suturing  perineal  lacerations. 

Complete  lacerations  are  the  only  cases  in  which  a  good  obstetrician  may 
defer  repairing  the  injury  until  he  can  obtain  skilled  assistance,  yet  it  is  desir- 
able that  they  should  be  attended  to  within  twenty-four  hours  after  delivery. 

The  after-treatment  is  very  simjile,  and  is  usually  limited  to  irrigations  of 
the  wound  with  an  antiseptic  wash  and  to  keejiing  the  parts  covered  witii 
proper  dressings,  being  caretiil,  if  the  syringe-nozzle  is  introduced  into  the 
vagina,  to  avoid  separating  the  surfaces  of  the  wound  that  the  sutures  have 
a|)pntximated.  The  external  or  perineal  sutures  are  removed  between  the 
fifth  and  tiie  seventh  day,  while  the  vaginal  and  rectal  sutiu'cs  may  be  left  in 
place  a  little  longer.  Treated  in  tlie  way  previously  described,  about  75  per 
eeiit.  of  lacerations  of  the  perineum  will  heal  by  first  intention.  In  some  cases 
the  union  will  be  incomplete,  and  part  of  the  defect  will  have  to  be  made  good 
by  granulation. 

Sometimes  the  tissues  of  the  vtdva  are  in  such  a  bruised,  swollen,  and  un- 
healthy condition  that  a  union  of  the  parts  cannot  be  expected ;  it  is  better  in 
these  cases  not  to  attempt  closing  up  by  sutures.  At  other  times,  the  parts 
having  been  sewed  up,  there  develop  symptoms  of  puerperal  infection  which 
make  it  necessary  to  reopen  the  wound  ;  as,  for  instance,  when  the  lochial  dis- 
ehar<;e  has  found  its  wav  between  the  wound-edyres  and  is  cnterinu:  the  svstem 
tlinmgh  pockets  which  cannot  be  disinfected  without  laying  the  i)arts  well  open. 
Ill  the  latter  cases  the  wound  has  to  be  frequently  irrigated  with  antiseptic 
solutions,  and  the  formatitm  of  granulations  must  be  assisted  as  much  as  pos- 
siiile  by  the  lavish  use  of  powdered  iodoform.  Whenever  the  wound-surface 
looks  unhealthy  and  is  covered  with  a  grayish  coating  (diphtheritic  plaques), 
applications  of  the  following  dressing  will  be  found  of  the  greatest  service : 


\  tl? 


v-A-m, 


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'%^U. 


678 


AMKRICAN    TEXT- BOOK   OF    OBSTETRICS. 


ISf,  Olci  tcrcbinthiiiffi, 
Olei  oliviB, 
Sig.  Locally. 


3iij. — M. 


Not  only  does  the  spirit  of  turpentine  act  as  a  good  antiseptic  agent  and  as  a 
powerfnl  ])romoter  of  granulations,  bnt  it  also  acts  as  a  stimulant  to  thegoncral 
system,  and  its  use  is  therefore  perfectly  safe  even  in  those  low  conditions  in 
which  the  free  application  of  some  one  of  the  other  antiseptic  remedies  mioht 
be  fraught  with  danger.  The  mode  of  aj)plying  the  turpentine  is  simple. 
After  the  wound  has  been  cleansed  by  irrigations,  its  edges  are  well  separated 
by  the  hand  and  a  flat  layer  of  absorbent  cotton  soaked  in  the  turpentine  mix- 
ture is  introduced  between  them.  The  dressing  is  renewed  three  or  four  times 
a  day  imtil  the  surface  of  the  woimd  is  entirely  covereil  by  granulations,  when 
the  ordinary  treatment  may  be  resumed. 

Iiyuries  to  the  Vagina. — With  deep  perineal  ruptures  there  is  always 
more  or  less  laceration  of  the  posterior  vaginal  wall  (see  page  674),  but  tlieic 
are  also  found  tears  of  the  vagina  ihat  are  not  so  connected.  These  injuries 
may  be  superficial,  involving  the  mucous  membrane  only,  or  they  may  extend 
through  the  muscular  coat  of  the  vagina,  laying  open  the  pelvic  cellular  tissue 
or  penetrating  into  the  surrounding  viscera.  If  the  injury  is  located  at  llie 
upper  portion  of  the  posterior  vaginal  wall,  the  peritoneum  may  be  exposed  or 
the  abdominal  cavity  may  be  opened. 

After  protracted  labors,  especially  when  there  is  a  narrow  pelvis  or  a  dis- 
proportionately large  child,  we  sometimes  find  contusions  of  the  vagina  that 
later  on  cause  sloughing  of  the  raucous  membrane,  followeil  by  cicatrization 
and  constriction  of  the  entire  vaginal  canal.  At  other  times  circumscrihcd 
portions  of  the  upper  vagina  have  been  contused  to  such  a  degree  that  in  a 
very  few  days  they  become  necrotic  and  lead  to  perforations  of  the  wall. 
These  injuries  are  particularly  likely  to  happen  when  in  a  flat  pelvis  the  letal 
head  has  for  hours  been  wedged  in  between  the  symphysis  pubis  and  the  prom- 
ontory. The  pressure-marks  in  the  vagina  correspond  in  such  cases  with  sim- 
ilar marks  on  the  fetal  head  (see  Fig.  315,  p.  513) ;  they  are  of  round  or  oval 
form,  measuring  from  1  to  2  centimeters  (-|  to  f  inch)  in  diameter,  and,  becom- 
ing gangrenous,  ultimately  produce  vesico- vaginal  or  recto-vaginal  fistuhe,  as 
the  case  may  be.  At  times  we  meet  with  submucous  lacerations  of  the  vaginal 
wall,  resulting  in  the  formation  of  more  or  less  extensive  hematoma. 

Causes. — A  narrow  and  unyielding  vagina,  especiaii/  in  primiparaj  of  ad- 
vanced age,  will  often  be  the  cause  of  these  injuries.  A  ra|)id  passage  of  tlio 
fetal  head,  an  over-distention  of  the  parts  by  abnormal  positions  of  the  fetus, 
will  also  work  in  the  same  direction.  Sometimes  the  vagina  is  rij)ped  open  hy 
undue  sharpness  and  projection  of  the  spines  of  the  ischium  or  by  abnormal 
excrescences  of  the  pelvic  bones.  At  other  times  the  injury  has  been  bromrlit 
about  by  splinters  of  fetal  bones  present  during  craniotomy  or  embryotomy. 
The  most  extensive  laceration  of  the  vagina  ever  observed  by  the  writer  was 
caused  by  the  use  of  the  forceps  in  unskilled  hands.     An  elderly  prim i|)ara  was 


PArilOLOGY   OF    THE   PUEIirKlillM. 


679 


(Iclivorecl  by  a  midwife,  who  liad  not  only  applied  foreeps,  but  liad  also  sewed 
tip  in  the  rudest  manner  an  extensive  perineal  laeeration.  The  writer  saw  the 
patient  four  days  after  the  operation,  and  found  in  the  middle  portion  of  the 
vagina,  backward  and  to  the  left,  a  longitudinal  gap  through  which  could  be 
])assed  the  entire  hand  into  a  cavity  filled  with  coagulated  blood. 

Symptoms. — Injuries  of  the  vagina  do  not  at  first  cause  nuich  disturbance 
uidess  there  be  a  free  hemorrhage ;  in  the  rare  cases  in  which  the  peritoneum 
has  been  injured,  the  symptoms  of  peritoneal  irritation,  such  as  pain  and 
nausea,  will  not  be  missing. 

Frof/nosis. — Deep  lacerations  of  the  vagina  are  of  grave  importance.  They 
allow  the  direct  entrance  of  the  lochial  discharge  into  the  cellular  tissue,  and 
are  therefore  very  often  followed  by  pelvic  inflammation  and  by  pelvic  abscess. 
The  contused  wounds  often  cause  extensive  sloughing  of  the  vaginal  mucous 
mend)rane,  and  lead  later  on,  by  cicatrization,  to  a  stricture  of  the  vagina  that 
may  approach  an  occlusion.  Necrosis  of  circumscribed  regions  of  the  vaginal 
wall  lead,  as  already  mentioned,  to  the  formation  of  vaginal  fistulse. 

A  hematoma  usually  disappears  without  leaving  bad  effects,  but  at  times 
its  contents  decompose  and  threaten  the  general  system  with  septic  infection. 

Superficial  lacerations  may  heal  spontaneously  without  causing  any  symp- 
toms, but  more  frequently  they  become  infected  by  the  lochial  flow,  and  are 
changed  into  puerperal  ulcers  which  cause  more  or  less  disturbance,  and  which 
finally  heal  by  granulation,  leaving  in  the  vaginal  wall  a  scar  which  in  siibse- 
(|uont  labors  may  prove  the  source  of  further  trouble. 

Treatment. — Lacerations  of  the  vaginal  mucous  membrane,  if  in  any  degree 
oxfcnsive,  should  always  be  united  by  sutures  if  recognized  soon  after  their 
occiHTence,  and  they  will  usually  heal  by  first  intention.  Penetrating  wounds 
with  escape  of  blood  or  of  secretions  into  the  cellular  tissue  are  kept  clean  by 
frequent  irrigations  with  antiseptic  solutions,  followed  by  packing  the  wound 
cavity  with  iodoform  gauze.  After  severe  contusions  with  unavoidable 
sloughing  of  the  mucous  membrane  the  patient  can  often  be  kept  free  from 
■septic  infection  by  the  use  of  permanent  irrigations.  For  this  purpose  a  large 
tank  or  irrigator  is  filled  with  sterilizeil  water  and  placed  near  the  bed,  at  a 
height  not  exceeding  60  centimeters  (2  feet)  above  the  patient's  genitalia ;  a 
vaginal  tube,  which  is  best  made  of  glass,  is  connected  with  the  tank  by  rubber 
tubijig,  and  the  flow  is  controlled  by  a  faucet.  The  patient  is  placed  on  an  air- 
cushion  over  a  bed-pan  (or  a  tin  box  made  for  the  purpose),  which  in  turn  has 
a  waste-tube  leading  to  a  larger  vessel  on  the  floor.  The  faucet  is  so  set  as  to 
allow  the  water  to  flow  very  slowly  or  merely  to  trickle ;  the  tube  is  inserted 
into  the  vagina  and  is  kept  In  position  by  tapes  tied  around  the  thigh  or  the 
waist  of  the  patient ;  the  vulva  is  covered  with  antiseptic  dressings.  In  this 
way  a  little  stream  of  sterilized  water  is  kept  running  over  the  contused  parts, 
washing  away  the  lochial  flow  and  every  particle  of  d(!'bris  as  soon  as  formed. 
Several  times  a  day  an  antiseptic  wash  is  plactnl  in  the  tank  and  a  fidl  stream 
is  turned  on,  to  give  the  parts  r.  thorough  disinfection.  Most  patients  can 
stand  this  treatment  for  twenty-four  hours  and  longer ;  they  pass  the  urine 


■(  \ 


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il 

i 

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it        ? 


680 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


without  iiocoKsitatiiig  a  stop  in  the  irrigation,  and  they  rest  quite  comfortably. 
Others  complain  so  mueh  of  discomfort  that  the  irrigation  cainiot  he  continued 
for  more  than  three  or  four  hours  at  a  time,  but  even  in  this  imi)erfect  appli- 
cation it  will  do  a  great  deal  of  good. 

Hematoma. — Subcutaneojis  and  interstitial  bleeding,  forming  a  circimi- 
scribed  blood-tumor,  is  a  rare  complication  of  the  puerj)erium  that  may  Itc 
attended  with  considerable  danger.  Hince  the  monograj)h  of  Deneux,  all  sy.s- 
tematic  writers  on  obstetrics  have  distuissed  these  blood-formations,  and  the 
only  new  feature  that  modern  obstetrics  has  added  to  the  subject  is  a  lowered 
mortality  under  the  newer  antiseptic  methods  of  treatment.  'J'his  accident, 
which  is  rare,  occurring  once  in  about  1600  labors,  is  commonly  caused  by  jircs- 
sure-laceration  or  necrosis  of  one  or  more  veins  which  have  not  been  able  lo 
withstand  the  strain  of  the  increased  venous  pressure  occurring  during  labor. 
Exceptionally  the  rupture  has  occnirrcd  in  the  latter  part  of  pregnancy,  and 
very  rarely  the  torn  ve.s.sel  may  be  an  artery,  as  in  a  case  reported  by  Himon. 

Etiolof/y. — Several  conditions  have  been  reported  as  predisposing  causes, 
the  most  important,  doubtless,  being  weakening  of  the  vessel-wall  by  disease. 
Varico.se  veins  of  the  vulva  and  vagina  are  of  common  occurrence,  and,  a  priori, 
they  would  seem  to  predispose  to  this  accident,  yet  the  rarity  of  hematomata 
and  the  fact  that  most  cases  have  not  been  jjreceded  by  markedly  varicose 
veins  force  the  conclusion  that  in  thcm.sclves  they  are  not  a  factor  of  first 
im])ortancc.  Croom  has  asserted  that  anterior  displacement  of  the  uterus, 
producing  a  pendulous  abdomen,  is  a  factor  by  stretching  the  posterior  vaginal 
wall  and  tearing  its  vessels  before  the  head  descends  into  the  jielvic  canal. 
Hypertrophy  of  the  cervix,  the  use  of  instruments,  excessive  si/e  of  the  head, 
undue  length  of  the  labor,  and  jirolonged  and  powerful  expulsive  efforts  have 
been  .said  to  favor  the  occurrence  of  hematomata. 

>Si/tnptonis  and  Sif/)is. — The  swelling  formed  by  the  extrava.sated  blood 
usually  does  not  appear  until  labor  is  ended,  and  in  some  cases  even  .several 
days  later,  the  time  of  its  appearance  depending  upon  the  kind  of  injury  tlie 
veins  have  received.  When  the  vessel  has  been  ru|)tured  early  and  the  |)re- 
senting  part  has  not  advanced  sufficiently  to  exert  direct  pressure  upon  the 
injured  veins,  the  tumor  appears  at  once,  and,  immediately  reaching  its  fid! 
size,  may  seriously  obstruct  labor ;  if,  however,  the  presenting  ])art  exerts 
sufficient  prcssjire  to  control  the  bleeding  temporarily,  tiie  tumor  may  be  vdv 
small  or  may  not  be  noticed  until  after  labor.  When  the  vein  which  is  sid)- 
jected  to  prolonged  compression  is  only  contused,  and  which  later  gives  w;i\ 
either  s]>ontaneously  or  after  sudden  exertion,  as  coughins;,  straining  at  stool. 
or  (luring  micturition,  the  tumor  first  appears  in  the  ])uerperium,  usually 
within  a  day  or  two,  but  very  rarely  so  late  as  the  twenty-first  day,  as  in  ;i 
case  reported  by  Heifer.  The  situation  of  the  tumor  varies ;  anatomically  it 
is  determined  by  the  d'  itribution  of  the  fascia,  either  of  the  pelvis  or  of  tlio 
perineum.  Usually  the  blood  is  ettused  below  the  pelvic  fascia,  and  the  tniiior 
appears  in  the  labium,  or  beneath  the  vagina,  or  in  the  perineum,  extcndiiij: 
exceptionally  to  the  anus,  to  the  gluteal  region,  and  in  front  to  the  abdominal 


PATHOLOGY   OF   THE   PIERPERIUM. 


681 


(rf  v" 


:!onifortal)ly. 
1)0  continucil 
(crf'ect  appli- 

iir  a  oircuni- 
tliat  may  \w 
KHix,  all  sys- 
oiis,  and  llio 
:  is  a  lowered 
riiis  accidont, 
used  by  pi'«"^- 

been  able  to 
during  labor, 
rcgnancy,  and 
teil  by  Hinion. 
posing  causes, 
all  by  disease. 
,  and,  a  priori, 
)t'  lieniatonialu 
kodly  varicose 
factor  of  first 
of  the  uterus, 
)sterior  vaginal 
}  pelvic  canal, 
ze  of  the  head, 

e  ett'orts  have 


iv 


asated    blood 
■s  even  several 

of  injury  tlie 

and  the  pre- 
isure  upon  the 
whing  its  full 
ig  part  exert> 
)r  may  be  vfiV 

which  is  sub- 
Hater  gives  w:iy 
Lining  at  stool. 
leriuni,  usually 
[st  day,  as  in  :i 
lanatonueally  it 
lelvis  or  of  the 
and  the  tumor 

kitn,  extendiii;-' 
the  abdominal 


walLs.  If  the  bleeding  has  occurred  above  the  pelvic  fascia,  the  effused  blood 
may  be  situated  in  the  broad  ligaments  or  the  periuterine  connective  tis,sue, 
and  it  may  extend  even  to  the  diaphragm.  Very  rarely  the  tinnor  may  be 
found  in  the  cervix.  Clinically,  the  commonest  site  of  the  swelling  is  at  the 
side  of  tlic  vagina  near  the  vulva.  The  size  of  the  tumor  also  varies.  Usually 
not  larger  than  an  egg  or  one's  fist,  the  tumor  may  be  as  large  as  a  cocoanut, 
or,  widely  distributed,  it  may  contain  a  very  large  (juantity  of  blood.  A 
hematoma,  polypoid  in  shape,  has  been  observed  hanging  from  the  vagina. 

The  formation  of  a  hematoma  is  generally  accompanied  by  pain  in  the 
region  affected,  this  pain  being  very  severe  when  a  large  tumor  is  formed. 
There  are  at  the  same  time  constitutional  evidences  of  hemorrhage  that  also 
vary  in  their  severity  in  direct  jirojjortion  to  the  volume  of  the  timior.  Should 
tiie  swelling  reach  its  fidl  volume  at  once,  and  burst — an  unusual  complication 
— the  loss  of  blood  may  rapidly  be  fatal.  In  some  instances  the  tumor  con- 
tinues to  enlarge  for  twenty-lour  hours.  Soon  after  its  formation  it  assumes 
a  livid  or  mottled  appearance,  at  first  giving  tense  fluctuation,  but  later  a  dot- 
Hke  firmness.  IJy  pressing  upon  the  bowel  or  the  bladder  the  functions  of 
these  organs  may  seriously  be  interfered  with,  and  when  the  swelling  reaches  a 
considerable  size  during  labor  it  may  impede  the  birth  of  the  child  or  the  pla- 
centa, and  later  may  obstruct  the  lochial  flow.  The  synn)toms  being  practi- 
cally characteristic,  tiie  (liaguo,si,s,  therefore,  is  generally  easy  when  the  tumor 
is  visible  or  is  easily  accessible  in  the  lower  parturient  tract.  The  tumor  might 
he  mistaken  for  prolapse  or  inversion  of  the  uterus  or  the  vagina,  for  varicose 
veins,  or  for  vaginal  enterocele.  AVhen  the  eff'usion  has  taken  ])lace  within  the 
jjclvis,  the  diagnosis  will  be  made  by  a  bimanual  examination,  together  with 
the  mode  of  onset  and  the  constitutional  signs  of  internal  hemorrhage. 

The  (erminafion  of  a  hematoma  may  be  any  one  of  the  following :  (u)  Ab- 
sorption ;  (b)  recovery  after  evacuation  of  its  contents ;  (c)  septic  infection 
Ijefore  or  after  ruptiu'e ;  (d)  hemorrhage,  wiiich  may  prove  rapidly  fatal  before 
rupture  or  at  the  time  of  rupture.  Rupture  niay  be  the  result  of  undue  or 
sudden  eflbrt,  or,  at  a  later  jieriod,  it  may  occur  spontaneously  from  slougliing. 
The  idtimate  result,  which  in  any  case  will  depend  ujion  the  size  and  situation 
of  the  tumor,  is  also  largely  influenced  by  the  treatment  pursued.  Small  tinnors 
not  larger  than  an  orange  are  usually  absorbed,  while  those  of  larger  si/e  fre- 
(|iiently  burst  spontaneously  and  thus  add  to  their  gravity.  Of  30  cases  col- 
lected by  Winckel,  twenty-three  spontaneous  ruptures  occurred  within  eight 
days.  If,  on  the  one  hand,  the  larger  tumors  are  opened  before  necrotic 
eliiuiges  or  renewed  hemorrhages  have  occurred,  the  prognosis  is  favorable,  and 
with  rigid  antiseptic  treatment  death  should  be  oxce])tional ;  if,  on  the  other 
hand,  delay  permits  such  changes,  the  mortality  is  12  jn-r  cent.  (Winckel). 

The  situation  of  the  tumor  influences  the  prognosis  to  the  extent  of  its 
being  accessible,  and  thus  being  more  readily  dealt  with.  Intrapelvic  tumors, 
therefore,  are  more  dangerous,  the  hemorrhage  being  less  readily  controlled 
and  the  danger  of  suppuration  being  greater.  Tumors  appearing  during  labor 
have  had  a  higher  mortality  than  those  occurring  after  delivery. 


^vr.f  I 


1r     i1 

1  'M?    *    I 


4 11 


n  .:  !* 


•S'i.;,!! 


It- 


'■.  It. 


'-tiivn 

iiii 

I  m, 


682 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


The  treatment  of  a  hematoma  varies  with  the  time  of  its  appearance,  its 
size,  and  its  situation. 

Should  the  swelling  occur  before  or  during  labor,  and  offer  a  serious  obstruc- 
tion to  the  passage  of  the  child,  the  tumor  should  be  laid  open  in  its  dejwndent 
portion,  to  favor  subsequent  drainage,  preparations  having  previously  been 
made  to  control  the  free  hemorrhage  almost  certain  to  follow  evacuation  at 
this  time.  Manual  compression  by  an  intelligent  assistant  can  be  utilized  to 
control  free  bleeding  while  the  bleeding  vessels  are  being  searched  for  and 
ligated.  If  this  cannot  be  done  readily,  forceps  should  be  used  to  draw  the 
head  into  the  vagina  until  by  the  pressure  of  the  head  the  bleeding  is  con- 
trolled. Even  when  the  tumor  is  not  large  enough  to  impede  the  passage  of 
the  child,  it  is  best  to  anesthetize  the  patient  to  prevent  excessive  straining  on 
her  part,  and  to  apply  the  forceps  and  to  employ  cautions  extraction  to  pre- 
vent further  bleeding  and  increase  in  the  size  of  the  swelling.  If  the  forceps 
is  not  employed,  or  in  case  the  swelling  first  appears  after  labor,  an  attempt 
should  be  made  to  control  the  hemorrhage  by  the  application  of  cold  and  by 
pressure,  both  of  which  can  conveniently,  and  usually  effectually  be  applied  by 
means  of  the  largest  Barnes'  bag  or  by  a  colpeurynter  placed  in  the  vagina  and 
filled  with  ice-water,  ice  poultices  being  placed  against  the  labium.  If  the  swell- 
ing ceases  to  enlarge — an  indication  that  bleeding  has  been  controlled — and  if 
the  tumor  is  not  larger  than  one's  fist,  efforts  should  be  made  to  promote  its 
absorption  by  cooling  applications,  such  as  compresses  wet  with  lead-and-opium 
wash  or  with  diluted  alcohol.  Meanwhile  the  vagina  must  be  kept  clean  by 
frequent  antiseptic  douches,  and  the  patient  should  be  cautioned  to  avoid  all 
ei;urts  at  straining.  It  is  therefore  desirable  to  use  the  catheter  and  to  keep 
the  stools  soluble. 

After  waiting  a  few  days,  if  there  are  no  signs  of  absorption,  and  if  the 
tumor,  which  had  been  hard,  now  becomes  soft,  and  the  overlying  skin  or 
mucous  membrane  is  tense,  discolored,  or  vesicated,  indicating,  as  these  changes 
do,  beginning  suppuration  or  threatening  spontaneous  rupture,  the  time  has 
arrived  for  prompt  evacuation  of  the  tumor.  An  incision  5  to  7.5  centimeters 
(2  to  3  inches)  in  length  should  be  made  along  the  inner  surface  of  the  labium, 
the  clots  turned  out,  bleeding  vessels  ligated,  and  the  cavity  daily  cleansed 
and  packed  with  antiseptic  gauze. 

When  symptoms  of  internal  bleeding  and  physical  examination  point  to 
the  occurrence  of  a  heniatoma  within  the  pelvis,  care  must  be  taken  to  exclude 
free  hemorrhage  in  the  peritoneal  cavity  from  a  ruptured  broad  ligament 
or  other  vein,  since  the  latter  condition  would  necessitate  opening  the  ab- 
domen, while  in  the  former,  if  the  hemorrhage  is  confined  within  the  con- 
nective tissue,  the  shock  and  collapse  should  be  combated,  and  effort  be  made 
to  limit  the  hemorrhage  by  cold  and  by  the  internal  administration  of  hemo- 
statics. Subsequently  the  tumor  should  be  watched,  and,  if  not  absorbed,  it 
is  best  to  evacuate  it  through  the  vagina.  If  not  extensive,  and  if  there  an' 
no  marked  constitutional  evidences  of  internal  bleeding,  the  condition  will 
probably  go  unrecognized  until  spontaneous  evacuation  occura  or  until  incision 


,M-;  M' 


PATiioLoay  OF  riiK  pverpeuivm. 


683 


learance,  its 


is  made  after  several  weeks  or  months,  as  in  a  case  of"  Terfj^rif^oriantz,  in 
wliicli  ease  a  broad-ligament  hematoma  through  pressure-necrosis  comnuini- 
(•at«l  with  the  posterior  vaginal  vault,  and  was  emptied  of  stinking,  blootly 
fluid  after  four  months. 

n.  Diseases  of  the  Sexual  Organs. 

1.    PlKRl'KItAI.     InKKCTIOX. 

By  "puerperal  iuf'eetion "  is  here  understood  all  the  manifold  diseases 
conditions  in  a  puerperal  woman  caused  by  microbes  except  eruptive  fevers ; 
iion-inflammatorv  diseases  of  the  nervous  system,  sucli  as  tetanus,  tetany,  and 
insanity  ;  and  inflammation  of  the  breasts, — all  of  which  are  discussed  in 
otlicr  parts  of  this  work. 

Puerperal  infection  in  almost  all  cases  is  a  wound-infection,  and,  just  as 
this  may  be  slight  or  be  serious,  puerperal  infection  may  be  a  local  affection  of 
the  external  genitals  of  little  importance;  or  it  may  be  a  more  serious  affection 
(if  the  internal  genitals,  especially  the  uterus;  or  the  whole  system  may  be 
drawn  into  the  morbid  process.  In  most  books  this  condition  is  treated  of 
iMider  the  name  "  puerperal  fever,"  a  denomination  from  which  the  writer 
entirely  abstains,  for  the  reason  that  it  is  absolutely  impossible  to  draw  a 
distinct  line  anywhere  on  this  field  as  a  limit  for  something  worthy  of  that 
name.  The  old  idea  of  puerperal  fever  as  an  essential  fever,  a  nosological 
entity  mi  generis,  is  given  up  by  all.  It  is  impossible  to  define  puerperal 
fever,  and  it  ought  to  follow  the  terms  dropsy,  lung  fever,  and  brain  fever, 
which  have  long  ago  been  relegated  to  the  scientific  lumber-room  for  terms 
fiillen  into  desuetude  and  given  way  for  definite  and  correct  expressions.  The 
term  "  puerperal  fever"  ought  the  less  to  remain  in  scientific  language  as  in 
some  of  the  worst  cases  there  is  no  fever  at  all. 

Of  late  years,  instead  of  "  puerperal  fever,"  the  term  "  puerperal  septi- 
cemia" is  used  by  many,  which  is  certaiidy  an  improvement,  in  so  far  as  it 
reminds  us  of  the  identity  of  puerperal  infection  with  wound-infection  ;  but 
the  expression  is  both  too  wide  and  too  narrow  for  our  purposes — too  wide, 
l)ecause  the  same  word  has  a  more  restricted  sense  of  a  certain  form  of  puer- 
peral infection  in  contradistinction  to  other  forms ;  too  narrow,  because  the 
word  by  its  etymology  means  a  condition  where  septic  material  circulates 
with  the  blood  through  the  whole  body,  and  because  the  term  cannot  projicrly 
he  made  to  encompass  many  diseased  cond!tit)ns  foutid  in  the  puerperal  woman, 
wliich  conditions  in  most  cases  never  lead  to  a  general  infection  of  the  whole 
system. 

The  term  "  puerperal  infection  "  is  open  to  the  criticism  that  it  means  a 
cause,  and  not  the  effect  producal  by  this  cause,  but  this  is  not  without 
analogy  in  common  parlance.  The  word  "  cold "  meant  originally  a  low 
ti'in])erature,  but  by  extension  it  has  been  made  to  comprise  as  well  the 
disturbance  in  the  human  body  caused  by  ex])osiire. 

Hy  using  the  expression  "puerperal  infection"  to  designate  the  diseased 


H    K'- 


i    <    I'M 


t  V 


/        ! 


'I  l^w 


mnm  " 


i! ;  „ 


'  n'x 


% 


'im'^': 


i  -'1   '■ 


ii 


t. 


(iS-l 


AMEIill'AX    TEXT-noOK    OF    OliSTF/riilVS. 


coiKlitioiis  produced  \>\  infection  diiriiij;  jn'c^niincv,  childbirth,  and  the 
pncrpcrid  state  \vc  have  tlie  advantage  of  liavin^  a  general  term  whieli 
covers  tlic  whoh-  groinul,  iniM  and  serions  ca>es,  local  and  general  distnrli- 
anccs  in  the  ct|iiilil)rinni  of  health.  We  are  furthermore  reminded  of  the  |>os- 
siltilitv  of  jfuardin^r  otn-  patients  a<>ainst  a  |)est  that  not  lonjr  aii'o  was  thouuht 
to  he  due  to  a  deterioration  of  the  atmosphere,  or  even  to  a  direct  retrihution 
of  an  irate  deity  ;  an<l  we  are  turned  in  the  right  direction  for  fmdiui;  thera- 
jH'Utieal  relief  for  evils  already  existin<r.  We  stand  also  on  |)urc  scientific 
fjround,  since  all  modern  n'scarch  proves  that  in  the  mildest  and  in  the 
severest  cases  the  morbific  element  is  the  same — namely,  the  presence  of  tlic 
diflcrcnt  species  of  stdfj/ii/lococcus  j)iio(/ciK'f<  {V'u^.  All)  and  the  slrcjitiH'niTiin 
pi/nffciir,^  (Fig.  418). 


FlH.  117.— StaiiliyliiiMMcus   iiycifiiius  lUl^l■ll^  in  |iiis 
(X  UKK))  (Kriiiikol  ami  riiillirl. 


I'll 


llx— Strtiitnccicc'.is  iiynnciifs  in  |ius 
(<  KHKli  (I'riinkt'l  lunl  I'fci fieri. 


The  celebrated  French  micnwopist  C'ornil'  states  that  the  streptococci 
found  inpatients  affected  witii  s(»-called  "puerperal  fever"  arc  the  same  as 
those  first  described  by  Fehleisen  as  the  cause  of  erysipelas.  He  fbimd  the 
.same  coccus  in  all  the  different  forms  of  |»uerperal  infection — pyemia,  septi- 
cemia, the  diphtheritic  and  thi'  ])lilebitic  form.  Only  once  did  he  find  a  rod- 
shaped  bacillus. 

Clivio  and  Monti  of  I'avia'  found  in  five  cases  of  ])ucrpcral  peritonitis  in 
the  fluid  contained  in  the  abdomen  a  strepto<'oceus  which  was  identical  willi 
Fehleisen's  streptococcus  of  erysi|)elas  au<l  with  Hosenbach's  streptococcus  of 
suppuration,  and  similar  streptococci  were  found  in  phlej>'monons  abscesses  in 
other  diseases.  Lust ii>- of  Turin  ^  found  this  same  streptococcus  in  the  blond 
of  the  spleens  and  the  hearts  of  women  who  died  from  puerperal  endouu'tritis 
and  peritonitis. 

Jiumm,^  who  made  extensive  researches  with  ample  material,  likcwi-e 
arrives  at  the  <'oiielusioii  that  the  streptococci  found  in  ])uer])eral  infection  an' 
identical  with  those  found  in  inflrted  wounds.  Mironow'^  also  identified  tin' 
streptococcus  of  erysipelas  with  that  jrathered  from  the  uterus  of  sick  puerperal 
women. 

Doyen,  rnshini>:,  Hunim,  and  others"  found  that  puerperal  infection  iiiny 
be  (bie  to  other  cocci.  J)oderlein  ^  found  the  streptococcus  ])vo<i;enes  to  be  the 
most    important,    but,  besides,    that   the    pyogenic   staphylococci    are   active 


>!i--  I 


'mli'rtidii   ini\y 


I'lKIM'KltAI.    INri:rTI(>N. 


I'l  All      II. 


> 


iviii-'i'iu's  in  I'lis 
ml  I'lcifU'D. 


.^ 


Spi'i'iiiifii  fniiii  a  inLtii'lit  wlm  ilU'il  soiitic,  sIkiwi'iiil:  tin-  mntcriiil  tliiil  wmilil  !»•  loimil  In  !»'  iriimviil  liy 
till  Tiinttf  (ir  the  liiiixiT  mi  the  "  nniiilu'iu'il  iiliHoiiliil  silo."  "fldts  in  tlii'  \Ut'iinr  ^.inn^o^  "  Aiiiiy  Micliciil 
Mii^ciini,  \Vii.sliiiii.'tnii,  II.  C.  .No.  10,(ily.i. 


W    ■             '-:■<:''' 

I 

1 

MkMm 

k.ul^ 

P  li 


t 


;l 


s? 


PATIlOUKiV    OF    Till':    I'l'h'h'/'h'If/f'M. 


<>85 


I'licriMTiil   fovor,  HO  cjillrd,   is  tlicrcforc  not    a    nosolojjjioul   entity,   but   is  a 
c'onipU'X  plicnoineiioii  (Ino  to  (litrcrciit  niiot'olirs. 

lHjf'n'nit  Fonm  of  Jtifcclinn. — First  oi'  all,  we  must  distin^iiisii  hctwt'cu 
iiKM'c  local  atlrctions  and  a  (jinvt'dl  infection  nactiin^  tlio  whole  sy.''tfin.  Tlio 
Hiriiicr  arc,  of Conrsc,  niiicli  less  danjjcrons  than  the  latter.  Next,  we  must 
separate  the  y>»^vV/  I'roni  the  jien nine  N<'y>//c'  inf'eetion,  hotii  oC  which  may  he 
local  i>r  he  jjcneral.  (Jcneral  putrid  iiitection  is!  calknl  Mprcmid,  and  general 
M'ptic  inteetion  is  called  xrittitrmia. 

I'ntrcf'action  and  sapremia  are  due  to  many  dillerent  sehizoinycetes,  the  so- 
called  xdpropliiftcs — minute  organisms  which  are  allied  to  algie,  and  are  found 
all  over  the  world  in  streams,  plants,  animals,  etc.  By  their  growth  and 
multiplication  these  organisms  produce  certain  cijcmieal  suhstanecs,  the  so- 
called  (oxiiiH,  a  kind  of  ptoma'ins  wiiich  give  rise  to  fever.  Ptoma'inx  are 
alkaloids  produced  in  dead  vegetable  and  animal  tissues  during  putrefaction  ; 
/i'iicor"i"niii  arc  similar  alkaloids  producotl  in  living  animal  tissues  as  a  result 
(if  their  activity.  Pt(»mains  are  only  pniduced  by  microbes.  Leueomai'ns 
arc  harmless  unless  their  excretion  is  interfered  with. 

The  changes  occurring  in  puerperal  infection  may  be  produced  by  ptouiains 
or  by  leueomai'ns  alone,  without  the  presence  of  microbes,  but  in  the  vast 
inajority  of  cases  the  microbes  are  present.  The  saprophytes  are  generally 
brought  into  the  interior  of  the  uterus  mechanically. 

8ej)ticemia  is  due  to  a  few  well-known  micrctbes  that  actively  enter  the 
tissues,  which  they  injure  through  their  growth,  and  by  their  distribution 
thronihout  the  body  may  so  change  the  chemical  processes  anil  normal 
{'imctions  that  death  ensues.  These  microbes  are,  as  we  have  stated,  almost 
exclusively  streptococci,  and  are  idcnti<!al  with  those  that  cause  wound- 
diseases;  and  in  the  second  line  come  staphylococci.  The  latter  two  varie- 
ties of  microbes  are  therefore  also  called  pafkof/oiic  microbes,  which  give  rise 
to  so-called  specific  puerperal  diseases,  and  which  are  dilferent  from  the  so- 
called  non-patliof/enic  microbes,  that  only  cause  putrefaction  and  non-apecific 
puerperal  disease. 

The  infection  starts,  in  the  vast  majority  of  cases,  from  the  endometrium, 
liuinm*  distinguishes,  in  accordance  with  what  has  just  been  said,  a  putrid 
iVom  a  nrptic  rndometrifis,  but  he  admits  that  in  some  cases  the  two  forms 
are  blended.  In  putrid  endometritis  there  is  found  in  the  uterus  a  super- 
ficial layer  of  necrotic  tissue,  under  which  is  a  layer  of  granulation-tissue 
filled  with  leucocytes,  those  formerly  ninch-raaligned  colorless  blood-cor- 
puscles that  have  since  the  advent  of  bacteriological  studies  ])rove(l  to  be 
our  truest  friends,  forming  a  bodyguard  that  protects  us  against  the  constant 
attacks  of  our  enemies,  the  miert>bes,  whom  their  miiMite  bodies  engulf  and 
ai)sorb.  Hence  they  have  received  the  name  of  "  phagocytes ;"  that  is, 
"devouring  cells,"  a  species  of  giant-killers  on  a  small  scale.  While  the 
nccr()bioti(!  layer  is  covered  with  all  kinds  of  saproi)hytic  bacilli  and  cocci, 
these  never  enter  the  granulation  layer. 

Septic  endometritis  differs  according  to  its  being  a  local  affection  or  an 


r 


II    <- 


' '.  < 


I  i- 


680 


AMERICAN  TKXT-nOOK  OF  OBSTKTIilCS. 


inflainination  I'ollowod  bv  gt'iirnil  iiifoctioii.  In  loml  .^cpllc  ('H(lometritii<  the 
oii(I()iiu'ti'iuiu  is  miicli  liko  tliat  in  putrid  eiuloinetriti.s,  except  that,  besides 
iiu)rc  or  less  nimierons  germs  oi'  putref'aetioii,  streptoeoeei  are  tbimd. 

(uiicral  septic  endoinctrififi  appears  under  two  (lillerent  I'ornis — the  /////;- 
plutth'  and  the  l/iroiiiho-jiltlchitic.  In  the  /ipiiplidtic  form  tiiere  is  a  mixture  nl' 
sapro[)liytes  and  streptoeoeei  on  the  necrotic  surface,  but  the  granuhition-wall 
is  much  thimier  than  in  putrid  endometritis,  and  in  the  worst  form  of  sepsi> 
it  is  altogether  absent.  On  the  placental  site  the  veins  are  well  closed,  their 
walls  being  in  contact  and  without  thrond)!.  In  the  severest  cases  the  infec- 
tion-carriers go  through  the  finest  lymph-spaces  between  the  tissue-element-. 
In  less  rapid  cases  they  generally  follow  the  larger  lymph-vessels.  From  the 
wall  of  the  lymph-vessels  they  enter  the  surrounding  tissue,  causing  necrosis. 
The  lymphatic  form  often  starts  from  injuries  of  the  cervix. 

Ill  the  ihvombo-plilchitic  form  of  general  intection  the  endometrium  is  like 
that  of  localized  endometritis,  the  germs  never  entering  the  layer  of  granula- 
tion tissue  filled  with  leucocytes  except  at  the  placental  site.  Here  the  veins 
have  not  been  closed  by  collapse  and  apposition  of  their  walls — the  normal 
process — but  are  ])lugge(l  with  thrond)i.  In  some  of  these  thrombi  we  find, 
superficially,  saprophytes  and  streptococci,  but  the  latter,  finding  a  favoraltle 
.soil  in  the  thrombi,  enter  into  their  interior,  while  the  saprophytes  remain  near 
the  surface.  The  invaded  thrombus  soon  forms  a  detritus,  a  process  that 
extends  into  the  broad  ligament.  The  thrombo-phlebitic  is  a  more  rapid  and 
a  more  dangerous  form.  In  septic  peritonitis  the  infection  is  not  propagated 
through  the  Fallopian  tubes,  but  it  takes  place  through  the  lymphatics  of  the 
walls  of  the  uterus. 

The  <llj)htli('riti('  form  of  ])uerperal  infection  begins  in  the  nuieous  mem- 
brane of  the  vulva,  vagina,  or  uterus,  or  in  a  tear  extending  into  the  sur- 
roimding  connective  or  muscular  tissue,  and  patches,  like  those  found  in  a 
diphtheritic  wound  or  in  the  throat  of  a  patient  affected  with  diphtheria,  arc 
formed.  Ft  is  again  tlu;  same  streptococcus  that  is  at  work,  and  the  affection 
passes  into  one  of  the  above-<lescribed  forms. 

The  difference  in  symptoms  and  in  th(>  danger  in  different  cases  of  puer- 
peral infection  may  be  accounted  for  in  many  ways.  The  different  power  of 
resistance  may  coiuit  for  something,  one  organism  succumbing  to  an  attack 
which  a  stronger  constitution  successfidly  resists.  The  mere  nund)nr  of 
microbes  seems  to  be  of  importance  in  all  infections,  the  invaded  body  beiiii:' 
capable  of  neutral./ing  a  small  munber,  but  losing  in  the  battle  with  the 
many. 

Tli(>  anatomical  structure  and  eonneetions  of  the  part  invaded  explain  maii\ 
peculiarities  in  the  result  produced.  An  infection  attacking  one  lymph-vesM'l 
leading  to  a  gland  may  be  cut  short  there,  while  if  the  infecting  material  enter- 
ai\other  lymph-vessel  it  is  carried  to  the  peritoneu'n,  thence,  perhaps,  throu'jli 
the  stomata  of  the  diaphragm  to  the  pericanlium  and  the  plenr;'.  ( )r  a  throm- 
bus in  !i  vein  breaks  down,  and  part  of  the  detritus  is  carried  away  with  tip 
blood-eurrent  through  the  vena  cava,  the  right  aui'icle,  the  right  ventricle,  anil 


IMKKrKHAI,   INTKCTION. 


ri.Aii:  to. 


Hhvm'tritiK  tlic 
t  that,  bosiiU's 

tbuiul. 
rms — the  ///'"- 
s  u  luixtmv  ol 
i-iumlnti()ii-\v;iU 

form  of  scepsis 
L'll  flosod,  tlioir 
oases  tlio  infi'c- 
tissiuM'UMncnts. 
;els.  From  tin- 
causing  noorosis. 

)niotriiim  is  \\\<v 
lyer  of  gramila- 
llerc  the  veins 
^Hh — the  normal 
hrombi  we  iiml, 
iliiig  a  favorable 
vtes  remain  near 
i,  a  proecss  tiiat 
X  more  rapi<l  aii<l 
s  not  propajrateil 


lym| 


iliatief 


of  til 


le  nnieous  mem- 
ig  into  the  sur- 

fhose  found  in  :i 
h  diphtheria. 


arc 


am 


1  tlie  atVection 


lit  eases  t^i'  pni'i- 
litVerent  po\v(>r  of 
linir  to  an  attack 
licre  mnnbiM-  <>l 
ided  body  beiii'j 
battle  with   tlu' 

od  explain  manv 
|)ne  lyniph-vesM'l 
material  eulcr- 
[•rhaps,  throu'ji 
.     Or  a  throiii- 
jd  away  with  the 
Iht  ventriele,  aii'l 


I 


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iiiin  lirii  «lin  iliiil  cii;!!!  iliiy^  |io«|  |.,ii  linn  v  (III  puniK  lal  |.ii  il.inli  i^  ,  \riii>  MnliiMl  Mu-ciiiii.  \\ii>liiiit;iii|i 
I'  I'.,  Nn.  y.i.'iTi. 


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l'i>l'li r  |il.lirlll;l  .n   t'llllllilliM'^    '"    "''  '■"■■    illlllll    IVnlll    v,.|,vi^    livi'   iImJ^    II  I'll  I    ilrliMiy   ill  II   l\  l.hiiiil  cnll- 

ililiuii.    I'nlurcil  uirl.  niiii'li'1'11  \ciii>  nl.l.  ^^  iilnlitic.  u  iili  iliinl  Ulu-  iii  u-.ii  i  ,\riii\  Mr.linil  Mu>.iMn,  \\a>li- 
iii'JI'ili.  li.  ('.,  No.  TTMl. 


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PATHOLOGY   OF    THE   PUERPKRIUM. 


687 


is  deposited  in  a  fine  brancli  of  the  pulmonary  artery,  torniing  an  abscess, 
from  which  the  microbes  are  carried  to  other  parts  of"  the  body  to  form  new 
foci  of  suppuration. 

Most  important  of  all  seem  to  be  the  different  degrees  of  virulence  of  the 
microbes  themselves.  Virulence  is  a  property  of  the  protoplasm  that  shows 
itself  in  energetic  proliferation  and  increased  { ower  of  resisting  the  influence 
of  the  cells  in  the  organism  invaded.  This  virulence  is  diminished  by 
artificial  culture,  and  is  increased  in  the  anin\al  body,  but  in  what  way  is 
unknown.     The  virulent  streptococcus  rapidly  invatles  the  tissues. 

Infection  starting  from  the  genitals  takes  place  through  a  wound,  many 
niii'robes  being  found  in  the  genital  tract  of  every  puerpera,  besides  the 
placental  site,  which  has  been  compared  to  the  stump  left  after  the  amputation 
of  a  limb.  It  is  not  so  in  animals.  AVith  animals,  as  a  rule,  the  process  of 
expelling  their  offspring  is  not  more  difficult  than  the  act  of  defecation,  and 
tlioir  placental  site  either  regains  its  epithelium  before  the  loosening  of  the 
placenta,  or  recovers  it  in  a  very  short  time  after  delivery,  almost  in  minutes. 
This  fact  explains  why  puerperal  infection  is  not  produced  in  an  animal  by 
tlio  injection  of  septic  fluid  into  its  vagina  and  uterus.  As  soon,  however,  as 
the  same  fluid  is  injectetl  under  the  mucous  membrane  infection  follows.® 

In  the  opinion  of  the  writer  the  so-called  "  puerperal  fever  "  is  nothing 
but  the  most  serious  form  of  puerperal  infection.  Localized  is  less  dangerous 
tiiiui  general  infection  ;  putrid  infection  is  not  so  important  as  septic  infection  ; 
but  any  local  infection  may  become  a  general  infection,  and  putrid  infection 
may  end  in  death. 

S.j/tk'cmia  in  Children. — Identically  the  same  disease  above  described  in 
puerperte  is  often  found  in  new-born  children.  The  mother  of  the  child  may 
or  may  not  have  the  disease.  Infection  in  the  child  generally  takes  ]>lace 
tiu'ough  the  navel,  but  it  may  enter  through  sores  in  the  mouth  or  through  an 
accidental  wound,  or  it  may  be  aspiretl  into  the  lungs  in  the  putrid  liquor 
amnii  or  be  inhaled  through  the  air,  or  it  may  even  pass  from  mother  to  child 
through  the  placenta.  If  not  acquired  from  the  mother  before  birth,  the  poi- 
son may  be  carrieil  to  the  child  by  doctors  or  by  nurses,  or  may  cling  to  any  object 
with  which  it  comes  in  contact,  or  niay  float  in  the  air.  The  sources  of  the  j)(>ison 
ill  children  are  the  same  as  those  we  shall  now  describe  in  regard  to  the  mothers. 

ExroiiOGY. — Experience  shows  that  a  ])uerpera  is  more  lial)le  to  disease 
tiian  is  a  woman  in  other  conditions,  and  it  is  not  difficult  to  give  many  good 
reasons  why  this  must  be  so.  The  causes  of  puerperal  infection  arc  prcditi- 
jiDfiinii  or  ex('iti)u/. 

I'lrditijio-sin;/  Cuuncs. — During  pregnancy  the  chemical  composition  of  the 
lilood  undergoes  considerable  change ;  the  total  amount  of  blood  circulating 
in  the  body  increases,  but  it  is  more  watery  than  in  the  non-pregnant  con- 
dition. In  other  words,  the  woman  suffers  from  plethora  and  hydremia. 
Tlie  red  blood-corpuscles  diminish,  while  the  colorless  corpuscles  increase  in 
number.  Hemoglobin,  albumin,  fat,  ])hosphorus,  and  iron  are  found  in  too 
small  amount,  whereas  thequautity  of  fibrin  is  considerably  greater  than  in  the 


:».•. 
■.P::] 


,r         >S 


688 


AJMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


ini 


f  \ 


non-prcgnaut  woman.     The  plethora,  liyperiiiosis,  and  leneocytheniia  predis- 
pose to  intlainmation. 

The  heart,  especially  the  left  ventricle,  becomes  hypertrophic.  The  walls 
of  the  blood-vessels  become  thicker  and  their  calibre  larger,  esi)ecially  those  in 
the  uterus  and  the  breasts.  The  lymphatics  of  the  pelvis  become  so  dilated 
that  they  look  like  veins.  This  dilatation  of  blood-  and  lynii)h-vessels  pre- 
disposes to  the  formation  of  thrombi,  which  not  only  constitute  a  fertile  soil 
for  the  pathogenic  microbes,  but  also  may  break  down  and  be  carried  away  by 
the  circulation  to  remote  parts  that  become  new  centres  of  infecfion.  The 
nniseular  tissue  of  the  uterus  grows  enormously  in  order  to  afford  room  fur 
sheltering,  and  force  enough  to  expel,  the  fetus. 

The  nervous  system  is  in  a  high  state  of  irritation,  as  may  be  concluded 
from  the  headache,  toothache,  neuralgia,  vertigo,  and  longings  and  aversions 
so  common  in  the  j)regnant  condition.  Parturient  and  puerperal  women  are 
highly  emotional.  The  ])resence  of  a  disliked  or  dreade<l  person  in  the  lying- 
in  room  may  arrest  labor-pains.  A  letter  containing  unpleasant  news  may 
cause  a  rise  of  several  degrees  in  temperature.  Shame  in  those  who  have 
"  loved  not  wisely,  but  too  well,"  fear  of  destituticm  in  the  poor,  indignation 
at  a  husband's  cruelty,  are  all  factors  that  lower  the  vitality  and  diminish  the 
power  ')f  resistance.  Since  every  muscular  contraction  and  all  secretory  func- 
tions are  controlled  by  nervous  action,  we  can  imagine  that  even  the  propaga- 
tion of  microbes,  their  distribution  in  tlie  body,  and  their  expulsion  from  it 
may  be  influenced  by  the  condition  of  the  nervous  system. 

At  the  end  of  labor  the  patient  is  exhausted  by  pain  and  loss  of  blood,  and 
the  genital  canal  is  full  of  tears  and  abrasions,  which  open  for  microbes  free 
access  to  the  tissues.  If  this  is  true  of  even  the  most  normal  delivery,  it 
applies  with  still  greater  force  to  tedious  deliveries  and  to  those  in  which  the 
accoucheur  nnist  resort  to  operative  interference,  necessitating  the  introduction 
of  fingers,  hands,  or  instruments  into  the  genital  canal. 

Xormally,  the  muscular  tissue  should  contract  forcibly  during  the  ex])ulsion 
of  the  child,  and  should  remain  contracted  until  all  veins  on  the  placental  site 
are  closed  by  simple  agglutination.  But  if  the  muscular  contractions  are 
defective,  the  woman  may  cither  bleed  to  death,  or  the  veins  may  be  i)luggwl 
nj)  by  the  formation  of  clots,  which  are  an  excellent  soil  for  streptococci  and 
sti'phylococci,  and  into  the  depths  of  which  they  therefore  rapidly  ])euetr;it('. 
The  separation  of  mother  an<l  child  outside  the  placental  site,  wliidi 
separation  ought  to  take  place  between  the  superficial  and  the  deep  layer  of  tlic 
decidua,  may  be  defective,  so  th.at  lari^er  or  smaller  pieces  of  membranes  are 
left  behind,  and  at  the  placental  site  a  cotyledon  may  be  torn  off  and  remain 
in  the  uterus.  Such  remnants  of  the  secundines  soon  become  covered  with 
saprophytes,  and  they  undergo  a  putrefaction  which  may  lead  to  more  or  Ic-^s 
serious  consequences.  The  entirely  normal  lochial  discharge  is  in  itself  ;iti 
excellent  medium  for  the  cultivation  of  all  sorts  of  microbes. 

After  the  birth  of  the  child  a  retrograde  process  begins.  The  hyperplastic 
and  hypertrophic  tissues  have  to  be  li(piefied  and  be  reabsorbed,  the  intii- 


PATHOLOGY   OF    THE  PUERPERIUM. 


689 


,;>  ■    ' , ! 


mediate  stage  being  fatty  degeneration.  While  before  delivery  there  is  a 
.-strong  current  of  plastic  material  toward  the  uterus  and  the  child,  after 
(k'livery  the  direction  is  reversed,  and  a  strong  current  carries  ett'ete  material 
tVom  the  genitals,  especially  the  uterus,  to  the  rest  of  the  body. 

Primiparffi  are  still  more  exposed  to  infection  than  those  who  have  before 
hcrne  children,  labor  being  longer,  the  canal  to  be  traversed  being  narrower, 
iiiid  the  parts  composing  it  being  softer. 

Delivery  in  general  hospitals  exposes  the  patients  to  greater  dangers  than 
delivery  in  special  lying-in  institutions  or  in  their  own  homes.  Parturient 
women  ought  not  to  be  in  the  same  room  with  pnerperte,  the  discharges  from 
tlio  latter  being  particularly  dangerous  to  the  former.  The  crowding  of  too 
many  puerperie  into  one  room  is  in  itself  dangerous.  The  less  the  space  the 
greater  becomes  the  difficulty  of  obtaining  absolute  cleanliness,  and  the  greater 
is  tlio  danger  of  noxious  substances  being  carried  from  one  patient  to  another. 

The  exciting  cause  of  puerperal  infection  is,  as  we  have  seen,  the  introduc- 
tion of  certain  microbes  into  the  body  of  the  woman,  as  a  rule  into  her  genital 
tract. 

Sources  of  the  Poison. — The  infection  may  come  from  a  woman  similarly 
affected,  from  suppurating  or  decaying  tissues,  from  putrefying  substances 
within  or  without  the  body,  and  from  zymotic  diseases,  especially  erysipelas 
and  diphtheria. 

Contarjion. — That  the  disease  may  be  brought  from  one  patient  to  another 
was  discovered  by  British  physicians,  and,  while  in  America  it  was  denial  by 
the  leading  obstetricians  of  the  day,  Hodge  and  Meigs,  nevertheless  it  was 
])roved  to  be  contagious  by  the  masterly  essay  of  Oliver  Wendell  Holmes, 
wlio  so  distinguished  himself  in  another  line  that  his  merit  as  a  physician  is 
apt  to  be  overlooked.'" 

N'ow-a-days  the  contagiousness  of  puerperal  infection  is  universally  admit- 
t(Hl,  and  the  only  mooted  point  is  whether  it  is  essential  that  the  microbes  be 
carried  from  one  patient  to  another  on  solid  objects  or  whether  they  may  float 
tliroiigh  the  air — a  point  to  which  we  shall  presently  return. 

Siipjmration. — That  the  source  of  puerperal  infection  may  be  suppuration 
was  pointed  out  as  early  as  1847  by  Semmelweis."  Students  who  had  examined 
a  patient  with  a  cancerous  ulcer  of  the  uterus  caused  puerperal  fever  in  and 
(leatii  to  fourteen  women. 

Ill  America  was  the  celebratal  case  of  Dr.  Rutter  of  Philadelphia,  who  in 
184!^  had  forty-three  cases  of  puerperal  sejjticemia  in  his  practice,  while 
neighboring  practitioners  had  none.  He  bathed,  changed  his  clothes,  shaved 
off  his  hair  and  wore  a  wig,  stayed  ten  days  away  from  the  city,  and  did  not 
take  with  him  to  his  next  patient  anything  he  had  before  worn  or  carried. 
She  had  an  easy  confinement,  yet  she  died  from  puerperal  fever.  The  groat 
Meigs  taught  his  students  that  such  a  fatality  was  God's  providence.'^  It 
remained  for  the  present  generation  to  find  the  solution  of  the  riddle  in  the 
taet  revealed  by  a  contemporary  of  Dr.  Rutter,  that  he  suffered  from  an 
obstinate   muco-purul  nt   coryza."     It   is   easy  to   understand   now  how  by 

44 


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690 


AMERICAN   TEXT- HOOK   OF   OBSTETRICS. 


toudiiiig  his  nose  with    his  fingers   Dr.   lluttor  hronglit   staphylococei   aiKi 
streptococci  into  the  vagina  or  the  uterus  of  his  unfortunate  patients. 

A  French  i)hysician  who  had  delivered  eight  hundred  women  without 
accident  was  seized  with  suppiu'ative  adenitis,  for  which  he  wore  a  draiuago- 
tube.  Witliin  three  weeks  he  had  three  cases  of  ))uerperal  septicemia." 
During  the  time  of  the  great  morbidity  and  mortality  in  the  New  York 
Maternity  Hospital  immediately  preceding  the  new  era  an  assistant  suffend 
frequently  from  pustulous  eczema  of  the  hands.  A  dentist,  Dr.  Pedlcv, 
called  attention  to  decayed  teeth  in  doctors  and  nurses  as  a  jiossible  source 
of  puerperal  infection.'* 

In  1889  there  was  in  the  Xew  York  Maternity  Hosjiital  a  paralytic  patient 
liaving  a  carbuncle  in  the  sacral  region.  There  were  two  puerperte  in  the  same 
ward,  and  all  were  in  the  hands  of  the  same  nurse.  One  of  the  two  puerjjenc, 
who  had  been  perfectly  well  up  to  the  eighth  day  after  her  confinement,  got  a 
chill  and  her  temperature  rose  to  105.6°  F.  On  the  cervix  was  found  a  di|)li- 
tlieritic  infiltration.  The  patient  with  the  carbuncle  had  no  puerperal  affection 
of  any  kind. 

Pat  refaction. — Semmelweis  showed  conclusively  that  the  enormous  mor- 
tality prevalent  in  the  lying-in  hospital  of  Vienna  was  due  to  cadaver-poison 
brought  by  the  students  from  the  dissecting-room  to  the  wards  in  which 
women  were  examinetl  and  delivered.  Tiie  hospital  has  tw'o  departments, 
one  for  students  and  one  for  niidwives,  admission  taking  place  to  eaci; 
department  on  alternate  days.  Nevertheless,  the  mortality  in  the  students' 
department  was  three  times  higher  than  that  in  the  midwives'  department. 
A  similar  instance  is  reported  from  private  practice.  A  Scotch  physioinn, 
Dr.  Renton,  and  a  friend  practised  in  the  same  place.  During  a  so-called 
"epidemic"  of  puerperal  fever  all  Renton's  patients  remained  healthy,  while 
all  those  of  his  friend  were  taken  sick.  The  difference  between  the  (wo 
was  owing  to  the  fact  that  Renton  did  not,  while  his  friend  did,  perinnn 
autopsies.'^ 

The  infection  may  originate  also  from  a  decomposing  part  of  a  liviiiif 
body.  Thus,  frequently  pieces  of  placenta  or  of  membranes,  left  behind  in 
the  uterus,  become  the  starting-point  of  ,.uerperal  infection.  The  writer  once 
had  a  patient  who  gave  birth  to  a  macerated  fetus,  and  from  whose  uterus  a 
decomposed  plai'cnta  was  removed  without  doing  the  least  harm  to  tlie 
parturient,  but  it  gave  rise  in  another  patient  to  one  of  the  worst  cases  of 
puerperal  infection  in  the  writer's  experience.  The  assistant  who  delivered 
the  first  woman  was  allowed  bv  his  colleague  in  charge  of  the  second  to 
examine  her,  and,  although  he  disinfected  his  hands  with  bichlorid,  lio 
doubtless  brought  on  his  fingers  the  germs  that  came  near  costing  the  woman 
her  life. 

Some  years  prior  to  the  date  of  the  writer's  coimection  with  the  New  Ymk 
Maternity  Hospital  there  was  erected  on  Blackwell's  Island,  N.  Y.,  a  new- 
building  designed  as  a  maternity  hospital.  The  building  had  scarcely  Ikih 
opened  before  such  a  so-called  "epidemic"  of  puerperal  fever  broke  out  in  it 


k:f  m 


vlocncci   aiiti 
ients. 

men  without 
■e  a  ilraina«r('- 

septiceniiii." 
a  New  York 
■itant  sutli'icd 

Dr.  Pedlcy, 
osrsible  source 

ralytic  patient 
•aj  in  the  same 
two  pucrperie, 
inement,  j^ot  a 
found  a  dipli- 
rperal  affeetion 

mormons  mor- 
eadaver-poison 
ards  in  whicli 
o  departments, 
phice   to  eacl-. 
n  the  students' 
es'  department, 
oteh  physieian, 
'insr  a  so-ealled 
healthy,  while 
'tween  the  two 
did,  peril  inn 

\rt  of  a  living; 
left  behind  in 
The  writer  once 
whose  nterns  a 
harm   to  tlio 
worst  cases  of 
who  delivered 
th(!  seeond  to 
biehlorid,  1k> 
ting  the  woniau 

the  New  Y"il< 

N.  Y.,  a  nrw 

Id  searcely  l^'cn 

1  broke  out  in  it 


PATIIOLOaV   OF    Tin-:   PCERPKniUM. 


4!' 


that  it  had  to  be  vaeated.  The  cause  of  tins  epidemic  was  probably  dnc  to  the 
iriiano  w^ith  which  the  surrounding  grounds  had  been  covereil  in  order  to  make 
a  garden. 

Feliling"  observed  an  epidemic  of  pue-;  ^ral  fever,  diphtheria,  and 
ciysipelas  as  the  consecjuencc  of  a  bursted  waste-pipe,  the  dirty  water  soak- 
ing into  the  ground  on  which  stood  the  hospital. 

Gustav  Braun'*  in  1889  had  so  serious  an  epidemic  in  the  Vienna  lying-in 
liospital  that  during  one  month  nearly  18  per  cent,  of  the  puerjiera;  were 
taken  sick,  and  nearly  9  per  cent.  died.  He  attributed  the  troid)le  to  the  fecal 
matter  from  the  hospital  and  that  of  a  neighboring  barrack  being  evacuated 
into  a  canal  flowing  past  the  hospital. 

The  immediate  contiguity  of  a  churchyard,  a  dunghill,  a  privy,  a  stable,  a 
slaughter-house,  a  cess-pool,  a  sewer,  a  pool  of  dirty  stagnant  water,  or  similar 
jilaees  where  organic  substances  are  imdergoing  decomposition,  is  therefore 
dangerous  to  a  parturient  woman. 

Zi/inotie  Diseases. — The  exact  relations  between  puerperal  infection  and 
zymotic  diseases  are  not  definitely  settled.  Since  it  is  now  known  that  it  is 
tlie  same  streptococcus  which  gives  rise  to  both  diseases,  there  can  hardly 
longer  be  entertained  any  donbl  of  the  jjossibility  of  puerperal  infection  being 
(hie  to  the  poison  brought  from  a  jierson  affected  with  erysipelas  to  a  jiuer- 
pera.  The  same  observation  applies  probably  to  diphtheria,  since  a  diphthe- 
riti(!  local  affection  entirely  like  that  which  occasionally  develops  in  a  woiuid, 
and  which  commoidy  appears  in  the  n])per  air-passages  in  diphtheria,  is  one  of 
the  commonest  forms  of  puerperal  infection. 

Scarlet  fever  may  attack  a  puerpera,  but  it  remains  scarlet  fever  and 
follows  a  similar  course  to  that  in  other  patients.  Typhoid  fever  is  so  well 
cliaracterized  by  the  intestinal  ulcers,  and  is  so  ditferent  from  puerperal  infec- 
tion, that  the  two  must  be  distinct  diseases,  but  this  fact  does  not  prevent  one 
disease  from  leading  to  the  other. 

\V(ti/s  by  v'hich  the  Poison  enters  the  Bodi/. — In  the  vast  majority  of  cases 
tlic  ]ioison  causing  puerperal  infection  is  brought  mechanically  into  the  genital 
tra(!t  by  the  fingers  or  by  the  instruments  of  doctors,  midwives,  or  nurses.  It 
may  lurk  in  a  lubricant  or  may  adhere  to  a  sponge,  a  rag,  or  to  any  other 
substance  coming  in  contact  with  the  genitals. 

]\[any  think  that  this  mode  of  entrance  is  the  only  one,  and  deny  inteclion 
through  the  air — a  view  which,  in  the  writer's  ojiinion,  is  contrary  to  many 
well-authenticated  facts.  There  have  already  been  quoted  on  the  precetling 
page  instances  where  e])idemics  in  hospitals  could  only  hv  traced  to  the  ground, 
tlio  walls  of  a  building,  or  the  air  near  it  being  infected  by  fecal  matter  and 
otlier  refuse.  Now,  it  does  not  seem  at  all  likely  that  the  doctors  and  luirses 
hronght  the  microbes  from  the  guano  lying  on  the  ground  outside  the  new 
hospital  on  Blackwell's  Island  referred  to,  nor  from  the  feces  floating  in 
tlie  canal  flowing  past  the  Vienna  hospital,  nor  from  the  wet  ground  that  was 
soaked  by  the  bursted  waste-pipe  described  by  Fehling.  It  is  certainly  more 
probable  that  the  streptococci  were  carrietl  through  the  air  into  the  hospitals 


I 

■1  ■.■ 


■h 


f1 


(\\)2 


AMimrcAx  Thxr-nooh'  or  oitsTF/nurs. 


aiul  woiH!  doportitt^l  on  clothing,  instnimciits,  drcssiiij^-inatcrials,  or  oven  on 
the  lianda  of  the  pliysii'ians  and  nni-scs. 

Soino  years  aj;o  tlu'iv  was  in  tlio  Now  York  Infant  Asylnm  <i  locul 
epidoinic  of  puerperal  infiH'tion,  the  eaiise  of  wliicli  was  found  to  he  a  dead  nn 
in  the  eeUar.  The  diM-tors  and  nnrses  never  visitinl  the  eelhir,  and  the  fin  - 
man  who  attended  to  tlie  fnrnaee  there  never  entered  tlie  wards,  fs  it  mil, 
then,  a  h>p,'ieal  eonehision  that  the  niierohes  (h'vehiped  in  tlie  dead  ho<ly  of  tli< 
rat  were  earried  hy  the  air  of  the  eeUar  from  t!t»or  t«>  floor  through  the  whnl,' 
bnihlinn?  This  methtxl  of  dissemination  is  so  nmeh  tiie  more  likely,  in!i>- 
mueh  as  we  have  exaet  observations  showinjj  the  existence  of  the  streptoeoci  i 
in  the  air.     Humm '"  fonnd  the  eoeei  in  the  dust  floating  in  the  air. 

Depaul*'  roportisi  the  ease  of  a  pupil-midwife  who,  while  wiishiufr  di,. 
genitals  of  a  patient  alfcH'tiHl  with  puerperal  fever,  felt  an  nnpleasant  seiisi- 
tion,  was  taken  siek  in  the  evening;,  and  died  on  the  third  day  "with  all  the 
symptoms  of  the  most  eharaeteristie  puerperal  fevr."  The  diajj;nosis  of  |)M(  r- 
peral  fever  was  eontirmed  by  the  autopsy  ;  she  was  found  also  to  be  a  vir^;in  and 
not  menstruatiuir.  The  natural  inference  is  that  she  inhahnl  through  the  huigs 
the  poison  that  eaustnl  her  death,  ('reik'-'  has  shown  that  puerperal  iidectidii 
in  children  may  start  from  the  mouth. 

The  theory  t)f  air-infv'ction  in  a  limitinl  space  is  also  borne  out  by  the  <'l1l(t 
of  sanitary  measures.  Before  the  present  syst«'m  of  antiseptic  midwifery  in  the 
New  York  Maternity  Hospital  was  practised,  patients  were  always  free  frmn 
fever  during  the  first  week  after  a  ward  had  been  fumigated  with  sulpiuir. 
Jiusch  ■"  fouuil  that  he  prevented  puerperal  fever  in  the  Herlin  lying-in  hos- 
pital by  heating  the  wards  before  using  them  to  (10°  Reaumur  (—  1<!7"  V.). 
In  many  iiospitals  a  great  im|)rovement  was  obtained  in  the  rate  of  mortality 
simply  by  introducing  a  better  system  of  ventilation. 

The  writer  firmly  believes,  therefore,  in  the  possibility  of  the  transmission 
of  the  morbific  agent  in  puerperal  infection  through  the  air,,  but  this  applies 
only  to  closed  rooms  or  to  short  distances.  The  atmosphere  in  general  is  not 
wtntaminatcHl,  and  epidemics,  in  the  old  sense  of  the  word,  do  not  cxi>(. 
They  can  always  be  traced  to  an  individual  carrier  or  to  the  ncighborhdiHl 
of  a  focus  from  which  the  di.scase  spreads. 

Att(oiiif<vtio)i. — Some  divide  puerperal  infW'tion,  in  regard  to  its  orifriii, 
into  two  classes,  called  (iKfo-f/eiuiic  and  lirtcro-ffrnctic  In  the  first  class  tlio 
puerpera  is  suppose*!  to  infect  herself;  in  the  second  the  infection  is  broimht 
to  her  from  without.  According  to  some  of  the  most  modern  bacteriologists, 
atitoinfcvtion  is  only  possible  as  sapremia.'^^  They  maintain  that  the  pallm- 
genic  cocci  are  never  found  in  the  healthy  vagina  nor  in  the  healthy  cervix.-' 
Diulerlcin  thinks  that  streptococci  brought  into  the  vagina  soon  disappear,  just 
as  he  proved  it  experimentally  for  staphylococci.  lint  other  authorities"'  cliiim 
to  have  found  both  streptococci  and  staphylococci  in  the  vagin.T  of  healthy 
pregnant  and  puorjx^ral  women.  When  we  take  into  consideration  that  at 
least  staphylococcus  pyogenes  abounds  on  human  liands,'^*  it  can  hardly  he 
doubtal  that  it  is  found  also  on  the  skin  of  the  penis.     Since,  now,  women 


j'AT/K )/.<)(,')'  or  Till-:  j'rrnrKitirM. 


i\\y,\ 


»,  or  ovou  on 

ylma  a  l<"':il 
bo  a  tloiul  nil 
imd  (lio  I'm  - 

S.       Is    it    Iln(, 

(I  body  of  till' 

llilll  tlio  wlloli- 
0  likely,  iiiM- 
iic  strcplot'ot'ii 
the  air. 
L>  wiishin^;  tlic 
)loasiu)t  sciisii- 
'  "with  all  \\w 
rnosis  of  pill  r- 
Ih'  a  virjiin  and 

t)U^h  tilt!  1  lilies 

•jHTal  infcctitiii 


ho  transmission 
but  this  api>ru's 
n  jfonoral  is  imt 

,  do  not  oxi>t. 

>  noinhborlitinil 


oOon  hiivo  Hoxual  intoroonrso  up  to  tlio  day  of  thoir  oonfnioniont,  tlu're  is  no 
liirticidty  in  supposing  that  fhoy  iiavo,  at  (ho  (iino  of  thoir  oonfnioinont,  suoh 
cocoi  in  tho  vagina,  and  that,  in  a  oortain  sonso,  tln'V  may  infoot  th«'insolvo«, 
not  oidy  with  saprophytos,  hut  also  with  patho^onic  oo(xm.  Fnrthornioro, 
|iiiorporal  iiifootion  may  Ih',  duo  to  disoascHl  ntorino  appondagos,  or  since  a 
woman  always  has  innnorous  sapro])hytes,  and  s(»inetimes  pathogenic;  eoooi,  in 
Ik  r  vajjina,  these  orfjanisms  may  Ix'  earried  honoo  by  a  perfectly  disinfected 
liiiircr  into  the  uterus  and  cause  infection,  which  in  a  certain  sonso  is  also  an 


Mil 


toinfection. 


Wo  must  also  remember  that  few  vafjinio  are  absolutely  healthy.  It  is 
<l,iimed^  that  normal  va^;iiial  secretion  contains  only  lUifillnH  V(i(/hi<i/!n  auA 
if'iilium  (i/hi('(tns,  hut  as  soon  as  the  soeretion  boiMimes  alkaline — which  it  easily 
(iocs  by  atlmixturo  of  cervical  secretion — saprophytes,  ])yojr(>iii<;  staphylococci, 
and  streptococci  find  a  favorable  soil,  and  autoinfection  boc(»mes  possible. 

Time  of  Infection. —  Infeetion  <'ommonly  takes  place  durin<j  delivery,  but 
it   may  occur  both  before  and  after. 

iMoK'rAlilTY. — I'uerperal  infection  is  one  of  the  most  important  of  diseases. 
I')(li>rc  the  introduction  of  antiseptic  treatment  puerperal  infection  often 
prevailed  in  so-oallod  "epidemics,"  of  which,  accordinj;  to  Fordyce  IJarker,"** 
iiinre  than  two  hundred  had  been  described  since  1740  ;  independently  of  suoh 
periods  of  a  conj;lomeration  of  fatalities  tho  number  of  those  carried  olf  by 
the  disease  was  and  is  very  lar^o.  Fn  the  nia<j;iiilieent  Lariboisii'^ro  Hospital 
in    Paris  tho    mctrtality   used   to    be    almost    8    per  cent,   of  all   tho  won 


ion 


(!.-••    h 


th 


(leiivered."  in  <me  ol  the  services  or  tho  iarfjjo  lyuifj-in  hospital  ni  V  K^nna  tlie 
mortality  for  six  years  (1841-40)  was  almost  10  per  cent.'"  In  tho  Maternity 
Hospital  of  I'aris  it  avorajjed  during  five  years  (1800-64)  11  per  oont." 
l)iirin<!;  seventeen  years  (18(51-77)  there  was  in  Berlin  one  death  from  "puer- 
peral fever"  in  every  178  <'onfinoments,  or  0.57  per  cent.,  and  a  total  mortal- 
ity in  childbed  of  1  in  152,  or  0.(55  per  cent.  Outside  tho  capital  the 
mortality  was  nnich  p;roator.  In  all  Prussia  there  <lie(l  durinj^  sixty  years 
(lSlO-75)  0.8  per  oont.  of  all  confined  women,  or,  more  exactly,  8322  out  of 
ev(>ry  1,000,00().'*2 

Injfiioiee  of  Antisepsin  on  Mnrta/ifi/. — The  above  very  important  and  con- 
villeins';  statistical  researches  have  boon  eontinued,  and  they  show  an  im))rove- 
iiient,  whieh  generally  is  attributed  to  the  oblijiatory  use  of  antisoptit!  druf^s 
in  the  manajijoment  of  conlinemont  oases.  Thus  tho  puerperal  mortality  from 
all  ciuises  was  in  Prussia  during;  the  eleven  years  followinj;  1875  (1S7(J-8G) 
0.0833  per  cent.,  an  improvement  of  27.5  per  oont.'^^  Jjimitinj^  the  investiga- 
tion to  the  child-bearing  age  (fifteen  to  forty-five),  tho  mortality  from  "puer- 
peral fever"  was  in  the  first  period  (1816-75)  12.01  per  cent.,  and  in  the 
second  (1876-8(5)  9.97  per  cent.,  an  improvement  of  16.9  per  cent. 

Similar  investigations  in  Demnark  load  almost  exactly  to  tli(>  same  results, 
both  as  to  the  groat  mortality  and  to  tho  improvomont  since  tlu;  introduction 
of  antiseptic  precautions.^*  Still,  with  the  sole  exeeption  of  tuberculosis, 
"l»uerperal   fever"  is  the  most  fiital  disease  for  women  between  fifteen  and 


■i"   ./<V 


(lilt 


AMKIiU'AX    TKXT-IKiOK    nl'    OIlSTr/miCS. 


M       ■ 


■•■i 


forty-five  years  of  ii<j:e,  and  if  we  tai\e  (lie  period  of  ten  years  l)et\veiii 
twenty-live  and  tliirty-five  yeai-s  of  age,  in  wliieli  most  eliildren  are  i)oni, 
one  death  in  every  six  is  dne  to  "puerperal  fever."  In  the  jjrand-diiehv 
of  IJaden,  liKWever,  tiie  pnerperal  mortality  has  remained  the  same  during 
the  last  forty  years — a  eireiimstanee  which  is  aeeoimted  for  l>y  the  inetlicieni  v 
of  the  midwives,  wiio  do  as  much  harm  as  good  by  their  way  of  using  ann- 
sepsis.'** 

I'a  I  iroi,(MiY. — A  peenliar  feature  of  puerperal  infeetion  is  the  great  diver- 
sity of  the  pathological  changes — a  circumstance  that  has  given  rise  to  nuirh 
perplexity,  hut  which  can  easily  he  accounted  fnr,  since  it  is  known  that  the 
true  agents  at  W(»rk  are  living  organisujs  or  a  poison  prodn<'ed  by  them. 

Vulvitis  and  Vaerinitis. — The  external  genitals  may  he  the  seat  of  ;i 
vdtdrrhdl  or  of  a  diphihcritii'  inflammation.  In  th<'  catarrhal  form  the 
mucous  UHMuhrane  is  swollen  and  red,  and  it  secretes  a  n»uco-purulent  fluid. 
In  the  diphtheritic  l()rm  small  whitish  or  yellowish  false  mend>raiies  appear, 
spread,  and  join  one  another  until  there  is  formed  a  more  or  less  thick  ami 
large  patch  intiuKitely  coiuKvtod  with  the  sm-rouuding  tissue,  which  is  sw»»lleii, 
infiltrattHi  with  serum,  and  of  a  dirty  greenish  or  a  brownish  color. 

Endometritis. — The  endometrium  is  the  chief  point  from  which  iul('<'- 
tion  spreads  throughout  the  body.  The  endouulrium  may  be  the  seat  nf 
a  catarrhal  inHammation,  when  it  is  red,  swollen,  covered  with  a  purideiit 
fluid,  and  sometimes  studded  with  small  roimd  pustules.  The  lips  of  the  os 
are  swollen  and  covered  with  gramdatious  that  easily  l)le<'d.  Other  forms  nl' 
endometritis  soon  implicate  the  deeper  layers  of  the  uterus,  and  need  no  speciiil 
description  apart  from  that  to  bo  given  under  MvtrUk. 

Metritis. — INfetritis  may  assume  four  (litfereut  forms — the  .simple,  the  diph- 
theritic, the  dissecting,  and  the  putrescent. 

Siuijifc  JfttrHiK. — In  the  simple  form  the  ntorns  is  much  enlarged,  its  walls 
are  thick,  the  tissue  is  soft  and  friable,  and  near  the  inner  surface  almost  dilllii- 
cnt,  cherry-colored,  and  bathed  in  a  dirty  greenish-brown  fluid.  The  cervix 
is  often  torn  or  bruised. 

Dijihthrrific  iiK'frids  is  characterized  bv  a  condition  similar  to  that  just  de- 
scribed in  the  external  genitals.  A-  ;i  rule,  the  process  begins  in  the  cervix. 
It  may,  however,  begin  als(»  at  the  uterine  ostium  of  the  tube,  and  spread 
through  the  wall  as  a  yellow  layer  out  to  the  peritoneal  coat  of  the  uterus, 
Diiisectinf/  nirlrHis  (Fig.  41i>)  is  a  form  that  has  been  little  heeded.*  In 
this  form  a  large  piece  of  the  uniscular  tissue  of  the  uterus  is  severed  from  its 
surroundings,  and  is  expelled  sometimes  so  long  as  seven  wwks  after  confmc- 
ment. 

Putrescent  Mrtritis. — In  the  putrescent  form  the  walls  of  the  uterus  are  so 


*Tlie  writer  has  personally  observed  and  describwl  eiglit  cases.  He  lias  given  the  aHiMtimi 
its  name,  ami  was  iliL' first  to  point  out  its  relation  to  the  puerperal  state  (AVic  York  Mt'il'md 
Jnuniiil,  188'2,  vol.  xxxvi.  p.  i)X~  ;  Arrhinv  iif  Mi<Hcini\  .\pril,  1883  ;  Medical  liirord,  Deo.,  Hs:!, 
vol.  xxiv.  p.  6C4).  A  few  eases  have  been  added  in  (Jerniany  (see  Iloechstenbach,  Arvhiifiir 
Gynakologii;  vol.  xxxvii.  p.  175). 


PATHOLOdV   O/'    Tin:   I'rHltl'KlilCM. 


68ft 


ihii)  that  thoy  show  irnprcssioiirt  of  the  iiitcstinc.     The  iitcriis  is  lar^c.     Tlio 

iiiiU'oiiH   iiicinlti'iiiir  of  \\\\'  iiit«>i'ioi'  Iimii^s   in  discolorctl  shrctls,  or   i(    is  casilv 

iiioviil)l('  over  the  subjacent  tissue.     Tlie  submucous  eonneetive  tissue  may  Ik; 

clian^'ed  to  a  wliitisli   mass,  and  tlu^  nuiseiilar  tissue  may  Im!  red  and  llal)l»y  ; 

lull  sometimes  the  (k'struetion  extends  deep  into  tlie  mus- 

iidar  tissue,  forming  irre^idar  cavities  tilled  with  a  choco- 

l.ite-coh)red   or  a  l)hicl\  pulp,  or  with  a  more  ichorous  or 

I'lU'idcnt  fluid.     It  is  particidarly  the  phutental  site  wiiieli 

i-allected  hy  this  deep  lanM'owinj;,  the  pathojieniv"  niierohes 

lindinj^  a  favorahh;  soil  in  th<>  thromWi  <-losin^  the  veins. 

In  oth«'r  eases  the  infection  follows  tho  lymphatic  vessels. 

Salpineritis. — The  Fallopian  tubes  are  more  rarely 
llic  road  followed  hy  tho  infcctinj^  microbes,  but  we  may 
iiave  lioth  catarrhal  and  diphtheritic  inflammation  ex- 
lending  from  the  endometrium  to  this  locality. 

Oophoritis. — The  ovaries  very  frecpiently  are  affect<'d. 
We  may  find  u.snperfi(Mal  inflammation,  the  so-calle<l  jtcri-      I'ni  iiu.^ssiMtiin,MMr- 
o<;/(/(oy///.s,  cond)ined  wiMi   peritonitis,  or  pdirnrlniiiKifotiH  "•His((iiirriKins);siK(iiri( n 

'  .    .        .  ,.  ,  ,'  .,11  1    "•''l"'ll<'lli.v  II.  II ntlh.. 

uoplioritis,   in  which  the  deeper  parts  an;  inrlamed,  and  n,»  v.nk  Mni.niiiy  iic.s 

wiiidi  mav  end  as  an  ornrian   (ihm;%'t.  '•""'  "" '"'  ;-^'.  '^•'.  "'"' 

Cellulitis. — The  connective  tissue  of  tho  pelvis  and   liiMMunt.     tiiIn  whs  iii^ 

!■  .  i         !■    ■!  1    I         •        I  11  I  III        I'iulilli   t'lisr   ipC  the   rriKirl 

iKljacent  parts  ot  tlie  ahdoiuinai  wall  may  be  swollen,  bo  ^ iisi„.,i  h,  iho  \iw  Vark 

iiililtrated  with  serous  fluid,  and  bo  the  seat  of  liemor-  ""'"■"'  av'(„v/,  vi.i,  xxiv. 
rli;i;;ic  thrombi,  lliis  intlammatioii  may  end  in  resolu-  iv,,!,,  ,i,,ii,,i(,nrniiii,  is  iwd- 
tion  or  in  suppuration,  the  abscess  opening:;  into  the  rec-  thirds  niiuirai  size.) 
tiiiii,  the  va}!;ina,  and  tho  bladder,  or  breakinjf  thi'oiij:;h  the  skin,  often 
after  lonjj;  wanderings,  espaiially  at  Poiiparf's  lij;ament  or  above  the  crest 
of  the  ilium. 

Lymphangitis. — The  lymphatic;  spaces  and  vessels  are  the  chief  roads  by 
which  puerperal  infection  reaches  the  deeiier  parts.  Those  of  the  vulva  and 
the  lower  fourth  of  the  vajrina  lead  to  the  superficial  inguinal  glands,  from 
wliirli  others  go  to  the  (h'op  inguinal  glands,  which  again  are  in  connection  with 
tlic  external  iliac  glands.  Thus  a  neglected  wound  on  the  labium  may  bccoiiK! 
the  starting-point  of  a  general  peritonitis. 

From  the  upper  three-fourths  of  the  vagina  and  tiio  cervix  the  lymphatics 
go  to  the  internal  iliac  and  the  sacral  glands.  TIk;  uterus  itself  is  a  network 
iif  lymph-spaces  and  lymph-vessels,  which  finally  lead  to  the  lumbar  glands 
( l''ig.  4"J()).  While  the  lym)»h-ves.sels,  normally,  are  so  small  as  to  be  invisible 
wiien  not  injected,  in  puerperal  lymphangitis  they  become  as  thick  as  a  goo.><e- 
(liiill,  and  they  may  form  prominences  (»n  the  surface  of  the  uterus  as  large  as 
clieiTios  and  tilletl  with  a  purulent  fluid.  From  the  finer  lymph-vessels  the 
iiiliction  extends  to  the  surroiindinj>:  connective  tissue. 

Peritonitis. — Peritonitis  is  the  commonest  atVection  in  the  graver  cases  of 
puerperal  infection.  The  abdomen  is  swollen,  the  intestines  being  distended 
with  gases.     The  inflammation  may  be  local — that  is,  limited  to  the  pelvis — 


m 


swrs- 


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AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 


or  ho  general,  exttnuliiig  over  the  whole  abdomen;  or  it  may  ho  adhesive  or  l)c 
jmt'ulent.  The  peritoneum  is  injected  ;  its  opitlielium  is  thrown  oif',  and  it  i> 
in  places  covered  with  plastic  lymph,  which  binds  the  knuckles  of  the  intostiiios 
together  or  to  the  other  pelvic  and  alxlominal  organs.    In  the  peritoneal  cavitv 


%     i 


Fin.  420.— Lyniplmtics  of  the  ntorus :  1,  lymphatics  I'nmi  the  hody  and  fundus  of  the  uterus;  2,  ovnrv; 
3,  vatfinii ;  1,  Kalloiiiaii  tube;  '>,  lymphatics  I'roiii  the  cervix  ;  li,  lymphatic  vessels  from  the  cervix  Koiiii! 
til  tlie  iliac  Kaniilia  ;  ".  lyiuphatii'  vessels  from  the  hody  and  fundus  Koiiid  to  the  lunitiar  KaiiKl'a ;  s,  aiuis- 
tonioses  of  cervical  and  uterine  vessels  ;  '.i,  small  lymphatic  vessel  in  the  round  ligament  Roins;  to  the  iMi;iii 
nal  glands ;  Kt,  11,  lymphatic  vessels  of  the  tubes  which  empty  into  the  large  lymphatic  vessels  from  llie 
body  of  the  titerus;  I'J,  ovarian  lis;unient  d'oirier). 

is  found  a  fluid  that  may  be  serous,  fibrinous,  or  jiurulent.  Often  this  fluid 
very  much  resembles  milk,  and  contains  large  clots  like  curdled  milk.  The 
inflammation  starts  in  most  cases  from  the  endometrium  and  spreads  through 
the  lymphatics. 

Pleurisy  and  Pericarditis. — From  the  peritoneum  the  microbes  find  o:i<v 
access,  through  the  stomatu  of  the  diaphragm,  into  the  lymphatics  of  tlic 
pleura  and  the  pericardiinn,  which  become  red,  swollen,  and  injected,  are  i'i>\- 
on'<l  with  false  membranes,  and  contain  a  sero-purulent  fluid. 

Phlebitis. — The  veins  also  often  ofl'er,  as  has  been  noted,  roads  for  tin' 
microbes  to  enter  the  system,  although  less  frequently  than  do  the  lymph- 
vessels.     Phlebitis  occurs  in  the  uterus  t»r  in  the  lower  extremity. 

Uterine  Phlebitis. — As  we  have  stated,  the  thrombi  (Fig.  421)  that  form  in 
the  uterine  sinuses,  where  the  contraction  and  retraction  are  imperfect,  arc  :i 
fertile  soil  for  pathogenic  germs.  From  the  sinuses  of  the  uterus  the  throiiilio- 
sis  may  extend  more  or  less  into  the  uterine  and  other  veins.  The  thronilnis 
may  become  tunnelled,  so  that  the  vessel  regains  its  lumen,  or  it  may  become 
organized  into  connective  tissue  and  form  a  permanent  plug.     A  piece  of  tlic 


PATHOLOGY   OF    THE   PUERPERIUM. 


697 


thrombus  may  l)C  torn  off  and  he  carried  llir  away  by  the  blood-current,  fonn- 
inj^  an  ombohis,  or  the  thrombus  may  become  disintej^rated  and  be  liquefie<l  to 
:i  ])uriform  fluid  which  mixes  with  the  blood  and  causes  the  condition  known 
as  pyemia.  In  this  way  the  microbes  may  be  carried  throughout  the  bodv, 
Ibrming  new  foci  of  disease  in  all  organs.  Thus  infarctions  appear  in  the 
hings  and  lead  to  pneumonia  and  to  pulmonary  abscesses. 
The  posterior  part  of  the  lungs  is  often  the  seat  of  hypo- 
static pneumonia.  The  spleen,  which  is  large  and  soft, 
may  contain  infarctions,  but  these  rarely  suppurate. 

The  kidneys  are  the  seat  of  hyperemia  and  infarctions, 
llie  latter  often  forming  abscesses.  In  cases  with  a  more 
clironic  course  amyloid  degeneration  niay  set  in.  Some- 
times the  loose  connective  tissue  around  the  kidneys  is 
inflamed,  and  there  may  form  a  perincphritic  abscess.  The 
liver  may  become  the  seat  of  hepatitis  and  hepatic  abscesses. 
The  nuicous  membrane  of  the  intestines  is  swollen,  but  no 
ulcers  form.  The  heart  is  frequently  affected  by  endocar- 
ditis, often  of  the  ulcerous  variety,  by  myocarditis,  or  by 
|K'ricarditis. 

The  eyes  may  be  destroyed.    The  brain  and  its  meninges 
are  rarely  inflamed.     The  breasts,  the  parotid,  the  tonsil, 
and  the  thyroid  body  may  become  inflame<l  and  suppu- 
rate.    On  the  skin  appear  erythematous,  erysipelatous,  ves- 
icular, or  pustular  eruptions.     The  articulations  are  often 
art'octed,  and  they  may  fall  a  prey  to  pyavthrosis,  ending      kki.  i2i.-(iuts  in  si- 
iii  ankvlosis.      The  subcutaneous  and  intermuscular  coi,-  "l'*""*  ""^  '"••'■i'l''  "»"« 
noctive  tissue  may  be  infiltrated  extensively  with  ])us,  and   Army  Modicni  Museum, 
form  large  shreds  of  mortified  tissue.         '  w,.siuu,'t..u,  i...m. 

IVilchitis  of  tilt'  Ler/. — The  dise-ise  kno\  n  as  ph/ci/mrifia  alha  (loloitf  may  be 
due  either  to  phlebitis  or  to  cellulitis.  (  'ffen  both  conditions  are  c(mil)in('<l. 
The  phlebitis  may  begin  primarily  in  the  leg,  or  it  may  come  on  as  a  second- 
ary afl'ection  alter  the  iliac  and  ovarian  veins  have  become  inflamed.  In  some 
cases  the  inflamrtiation  of  the  vein  may  be  secondary  to  thrombosis,  and  may 
again  lead  to  pen{)hlebitis  and  cellulitis.  In  other  cfses  the  process  takes  an 
inverse  course,  the  inflammation  of  the  connective  tissue  leading  to  phlebitis 
and  thrombosis.  The  thrombi  are  subject  to  the  san.e  'hanges  as  stated  above. 
In  the  ])hlebitic  form  one  or  more  veins  form  ,.!.d  strings,  and  below  the 
ol)struction  the  extremity  becomes  edematous  an<'  swollen.  In  tlie  cellulitic 
lurni  the  skin  is  w'  ite  or  pink,  tense,  and  hard  ;  one  or  both  legs  swell,  and 
the  epidermis  may  be  liftinl  l)y  a  seron-  .\  ad,  tbrming  large  vesicles.  The 
inguinal  glands  swell.  Suppuration  ml  i..,)rtifieation  may  spread  destruction 
ill  the  coimective  tissue  mulor  the  ,s'k'u  or  between  the  muscles.  This 
pernicious  form,  howev(>r,  is  rnre. 

Acutest  Septicemia. — In  the  sevcie  ^  .-ases  of  puerperal  infection  the 
ahove-menti»med  inflammations  hardly  find  time  to  develop  before  tiie  patient 


698 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


Ufl  i| 


I ' 


r  if 


m 


iii 


succumbs.  Still,  there  are  traces  of  lymphangitis  or  phlebitis  of  the  uterus, 
swelling  of  the  connective  tissue,  and  a  little  blootly  fluid  in  different  cavities ; 
the  glandular  organs  of  the  abdomen  are  large,  sofl,  and  friable,  the  micro- 
scope showing  their  cells  to  be  in  the  condition  called  "  cloudy  swelling;"  the 
blood  is  dark,  thin,  and  only  slightly  coagulable. 

SYMPTO>ts,  Diagnosis,  and  Procjnosis. — In  treating  a  case  of  puerperal 
infection  one  would  first  like  to  know  if  he  has  to  deal  with  pathogenic  or 
with  non-pathogenic  bacteria.  In  some  particularly  well-appointed  clinics 
an  expert  bacteriologist  makes  daily  microscopical  examinations  and  pure 
cultures,  but  most  physicians  have  to  form  an  opinion  by  the  phenomena  ob- 
servetl  in  the  patient  herself.  In  this  respect  three  points  are  of  great  import- 
ance, namely :  If  the  infection  is  caused  by  pathogenic  microbes,  the  disease 
begins  earlier,  perhaps  within  a  few  hours  after  delivery,  and  certainly  within 
a  few  days;  the  general  condition  of  the  patient  suffers  much  more,  and  sh  ' 
soon  becomes  somnolent;  and,  finally,  the  frequent,  weak  pulse  and  the  l!it>li 
temperature  bear  witness  to  the  presence  of  higher  fever.  But  even  an  infec- 
tion that  begins  as  non-pathogenic,  or  a  condition  that  originally  is  not  lausod 
by  infection  at  all — for  instance,  a  marantic  thrombosis — may  later  change  in 
character  and  end  in  sepsis. 

Some  groups  of  cases  arc  so  well  marked  in  many  respects  that  it  facilitates 
the  description  to  point  them  out.  Thus  there  are  localized  cases,  where  the  dis- 
turbances are  limited  tt)  the  genital  canal  and  hardly  affect  the  system  in  genernl. 
There  is  a  lyiaphatlc  form,  in  which  the  invasion  takes  place  through  tlio 
lymph-vessels,  and  which  begins  early  and  implicates  the  serous  !i,embrancs, 
causing  j)eritonitis,  pleurisy,  and  pericarditis.  There  is  a  phlehiflc  form,  in 
which  the  microbes  enter  through  the  thrombi  in  the  uterine  sinuses.  Tlic 
latter  form  begins  later,  progresses  more  slowly  than  the  preceding  form,  and 
it  is  characterized  by  repeated  chills  and  metastases  in  remote  organs.  Finally, 
there  are  cases  of  <ici(f('-'<f  scptiectiiin,  in  which  the  ])atient  succumbs  before  tlic 
usual  inrtammations  are  well  developed.  But  all  cases  cannot  be  divided  into 
these  groups:  sometimes  two  forms  are  combin(Hl,  such  as  lymphangitis  and 
phlebitis;  and  often  one  passes  into  the  other,  as  when  an  affection  seemin<ilv 
local  in  the  course  of  its  development  ends  by  becoming  generalized.  The 
writer  prefers,  therefore,  to  follow  the  anatomical  distribution,  and  to  describe 
the  symptoms  observcnl  in  each  organ,  adding  remarks  in  regard  to  diagnosis 
and  prognosis  as  he  progresses  from  one  to  another. 

Vulvitis  and  Vaginitis. — Si/mptoms. — In  the  cahurhal  form  of  vulvitis 
and  vaginitis  smarting  occurs  during  micturition. 

The  nlceratlve  form  is  accompanied  by  slight  rise  in  temperature,  tlic 
labia  being  swollen  and  tender,  and  the  ulcers  being  slow  to  heal,  the  process 
of  reparation  recpiiring  so  long  as  three  weeks.  The  lochia  are  ot"ten  fetid ; 
the  patient  complains  of  smarting  when  she  urinates,  and  sorif  times  she  sutlers 
from  retention  of  urine. 

The  fliphfhcrltic  form  is  much  more  serious.  It  t»ejiiiis  ofKr,  with  a 
chill,  followed  by  high  temperature,  which  may  reach   107°   F.     This  fevii' 


B 


PATHOLOGY   OF    THE  PUERPERHM. 


G99 


the  uterus, 
mt  cavities ; 
,  the  micro- 
2l!ing;"  the 

of  puerperal 
athogenic  or 
inted  elinics 
;is   and  pure 
lenomena  oh- 
great  iniport- 
s,  the  disease 
•tainly  within 
more,  and  sli  ^ 
and  the  l.ii''' 
even  an  iiit'et  - 
'  is  not  caused 
iter  change  in 

at  it  facihtatos 
where  the  dis- 
tem  in  general, 
•c  througli  the 
IS  hiembranes, 
(ebitie  form,  in 
sinuses.     The 
ing  form,  and 
rans.    Finally, 
nbs  before  tlu' 
ic  divided  into 
iphangitis  and 
ti(m  seemingly 
icralized.     'V\w 
luid  to  doseribc 
rd  to  diagnosis 

Irm  of  vulvitis 

iperature,  tlic 

cal,  the  procerus 

often  fetid ; 

he  sutl'cr-' 


im^H  s 


Olltl. 


with   ii 
This  fev.r 


l)egins  generally  from  two  to  four  days  after  delivery.  It  has  no  typical 
temperature-curve,  except  that  there  is  a  rise  every  evening.  The  pulse 
is  rapid  and  weak,  and  the  resj)iration  is  accelerated.  The  i)atient  has 
iK^  appetite,  the  tongue  is  coated,  the  bowels  are  often  loose,  and  she  is  fre- 
ijnently  troubKnl  with  nausea  and  vonuting, 

.\s  a  rule,  the  uterus  is  implicated.  It  is  large  and  tender,  and  the  lochia 
i»ocome  scanty,  grayish,  and  offensive.  The  secretion  of  milk  does  not  begin 
or  the  secretion  ceases.  The  patient  complains  of  pain  in  the  hypogastric 
region,  sometimes  extending  down  to  the  legs.  She  has  severe  headache,  and 
soon  becomes  stupid  and  delirious.  These  signs  of  general  affection  may  pre- 
cede the  appearance  of  the  diphtheritic  exudation  For  several  days  new 
])atches  form  and  the  old  ulcers  spread.  Fi'om  the  time  the  infiltration  ceases 
'.uitil  the  scabs  produced  by  the  treatment  recommendetl  below  are  cast  off  and 
the  sores  healed  about  a  week  elapses.  The  labia  are  swollen  and  are  coveral 
with  the  above-described  patches.  Erythema  or  erysipelas  may  start  from 
them  and  spread  more  or  less  over  the  body.  Sometimes  the  tissues  become 
gangrenous.  Cicatrices  may  cause  considerable  shortening  and  narrowing  of 
the  vagina. 

Diagnosis. — With  a  little  care  diphtheritic  ulcers  cannot  be  confounded 
with  pus-covered  tears  in  healthy  tissue.  These  tears  give  rise  to  no  general 
or  local  disturbance. 

Prognosis. — In  the  catarrhal  and  ulcerative  forms  of  vulvitis  the  prognosis 
is  good.     The  diphtheritic  form,  however,  shows  considerable  mortality.* 

Endometritis  and  Metritis. — Symptoms. — The  simple  form  of  metritis  is 
characterized  by  moderate  fever,  often  begimiing  with  a  chilly  sensation  ;  some 
pain,  espet^ially  severe  after-pains;  headache,  anorexia  r\d  a  coated  tongue. 
The  lochial  discharge  is  fetid,  continues  red  longer  than  usual,  or  becomes  so 
lisain  after  having  been  yellow.  Tiie  uterus  is  enlarged  and  tender.  In  regard 
to  the  (Jiplitheritic  form  the  reader  is  referral  to  what  has  been  said  above  under 
Viilritis.  JJissccting  metritis  (Fig.  419)  gives  rise,  as  a  rule,  to  a  protracted 
(Mirnlent  discharge.  The  jnitrcsccnt  form  shows  symptoms  similar  to  those 
I'  ina  in  the  most  severe  diphtheritic  cases,  and  it  is  accompanied  by  a  par- 
ticularly offensive  discharge. 

J'rognosis. — In  the  simple  form  of  metritis  the  prognosis  is  good.  The 
disease  lasts  a  week  or  two.  In  the  di])htheritic  form  the  prognosis  is  doubt- 
t'lil.  the  disease  often  ending  fatally.  The  dissecting  form  has  a  better  prog- 
nesis.t     The  putrescent  form  is  nearly  always  fatal. 

Salpingitis  and  Oophoritis. — These  affections  apj)ear  only  together  witii 
emlonietritis  or  peritonitis,  and  their  symptoms  are  merged  in  those  of  the 
ivilanunation  of  the  uterus  or  of  the  peritoneiuu. 

Cellulitis,  or  Parametritis. — The  inflammation  of  the  pelvic  connective 
tissue  in  general  begins  with  a  chill  or  a  chilly  sensation,  followed  by  fever, 

*  0{  27  oases  of  puerperal  diplitlieria,  forming  the  base  of  a  |ia|ier'"  l)y  tiie  writer,  five  died, 
t  Of  14  cases  known,  tiiree  ended  fatally.     Of  the  writer's  8  cases  oidy  one  died,  wiiieh 
(Uatli  was  due  to  rupture  of  the  uterus  in  consequence  of  an  error  committed  by  an  assistant. 


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AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 


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anorexia,  weakness,  and  headache.  The  temperature  rises,  the  pulse  and  tlio 
respiration  become  more  frequent,  tlie  patient  complains  of  pain  at  the  side  ol' 
the  uterus,  and  by  bimanual  examination  we  find  the  fornix  of  the  vagina  tendci' 
and  a  swelling  extending  from  it  in  the  direction  of  the  iliac  fossa.  When  the 
swelling  increases,  it  pushes  the  uterus  over  to  the  opposite  side.  As  a  rule,  onlv 
one  side  is  affected,  but  sometimes  a  similar  condition  is  found  on  both  sides. 
The  uterus  is  hardly  movable.  Severe  neuralgic  pains  may  extend  down  tlic 
lower  extremities  or  up  to  the  lumbar  region,  which  condition  nuiy  be  due  to 
simple  pressure  on  the  nerve-trunks  in  the  pelvis  or  to  an  implication  of  tlic 
nerves  in  the  inflammation.  If  the  inflammation  attacks  the  connective  tissiio 
of  the  iliac  fossa,  the  corresponding  extremity  is  drawn  up  and  adducted,  so  that 
the  affected  kneo  'xsts  on  the  other  extremity.  The  extremity  swells  and  Ix^- 
comes  edematoi.  Sometimes  thrombi  may  be  felt  in  the  veins  of  Scarpa's 
triangle,  of  the  \  j  '  space,  or  of  the  calf. 

Usually  the  inti.  ,  .ntion  ends  in  resolution.  If  pus  forms,  the  patient 
has  repeated  chills,  the  swelling  becomes  softer,  and,  finally,  fluctuation  may  bo 
felt.  The  pus  may  be  evacuated  through  one  of  the  hollow  organs — vagina, 
rectum,  or  bladder — or  may  break  through  the  skin  in  more  or  less  reniiito 
places,  especially  near  Poupart's  liganaent  or  at  the  crest  of  the  ilium.  Tlio 
abscess  may  now  close,  but  often  suppuration  goes  on,  es])ecially  if  the  abscess- 
cavity  conununicatcs  with  the  intestine,  and,  finally,  the  patient  may  die  from 
exhaustion.  In  very  rare  cases  the  abscess  ruptures  into  the  peritoneal  cavitv, 
causing  general  and  speedily  fatal  |KM*itonitis. 

DiuffnoHls. — It  maybe  difficult  to  decide  whether  an  exudation  begins  in  tlic 
coiuiective  tissue  or  in  the  jieritoneal  cavity.  Cellulitis  nearly  always  starts 
from  a  torn  cervix.  The  swelling  is  found  on  the  side  of  the  uterus,  not  behind, 
or,  if  so  found,  then  only  as  a  comparatively  thin  projection  or  bridixe. 
When  it  reaches  the  pelvic  wall  it  follows  the  latter  closely,  while  in  perito- 
nitis the  fingers  may  be  inserted  between  the  swelling  and  the  bones.  If  the 
inflammation  spreads  in  cellulitis,  it  often  goes  down  on  the  side  of  the  vaghia 
to  the  vulva  ;  a  peritonitic  exudation  can  only  increase  in  the  direction  of  the 
other  side  or  upward,  and  it  implicates,  as  a  rule,  Douglas's  pouch,  pushing 
the  uterus  forward. 

Pi'ognoiilH, — As  a  rule,  the  jirognosis  is  good.  Generally,  the  process  ends 
in  resolution  within  two  weeks.  IJut  it  may  be  very  protracted,  even  witiioiit 
suppuration.  If  an  abscess  is  formed,  the  prognosis  as  to  life  and  duration 
is  less  good,  but  even  then  with  ]>ro])er  treatment  the  patient  generally  re- 
covers. Rupture  into  the  peritoneal  cavity  is  fatal,  unless  laparotomy  is  per- 
formed. If  cellulitis  appears  as  part  of  the  general  infection,  the  result  is 
very  doubtful. 

Lymphangitis. — livmphangitis  may  start  from  the  vulva  and  the  lower 
part  of  the  vagina  or  from  the  uterus. 

Vufvar  lipnf)ha)i(jith  is  of  little  importance  if  it  is  arrested  at  the  superlieial 
inguinal  glands.  The  patient  presents  the  usiud  fever-symjUoms,  and  rod 
lines  may  be  seen  on  the  skin  extending  from  the  vulva  to  the  groin.     Tlio 


t  .3 


'■  •Tf"  ■    ■ 


ion  beo-ins  in  tlu> 


a  and  tho  lower 


PATHOLOGY   OF    THE  PUFAIPERIUM. 


701 


labia  swell  and  smart.  The  glands  very  rarely  snppuratc.  If  the  inflamma- 
tion implicates  the  deeper  inguinal  glands,  it  may  lead  to  peritonitis. 

Uterine  lymphangitis  (Fig.  420)  is  the  most  common  beginning  of  general 
puerperal  infection,  but  it  may  also  continue  as  a  local  process.  The  patient 
-liows  the  usual  fever-symptoms.  The  uterus  is  enlargetl  and  tender,  cspe- 
rially  near  the  cornua.  The  pulse  is  full.  There  may  be  a  little  vomiting 
and  some  tympanitis. 

Diagnosis. — Uterine  lymphangitis  differs  from  cellulitis  and  local  perito- 
nitis in  the  absence  of  swelling  at  the  vaginal  roof;  from  general  peritonitis 
ill  the  limitation  to  the  lower  part  of  the  abdomen,  the  full  pulse,  and  the 
absence  of  green  vomit. 

Peritonitis. — On  account  of  the  diffp'-enoe  in  the  severity  of  the  symptoms 
and  the  prognosis  it  is  expedient  to  consider  local  and  general  peritonitis 
s('|)arately. 

Local  peritonitis,  like  tiie  other  localizations  hitherto  described,  begins  with 
a  cliill,  but  this  is  much  more  protracted,  lasting  from  ten  to  twenty  minutes, 
and  it  is  accompanied  or  is  followed  by  a  peculiarly  intense  pain  in  the  lower 
part  of  the  abdomen,  which  is  extremely  tender  to  the  touch.  The  tempera- 
ture rises  suddenly  to  103°  or  104°  F.  The  pulse  beats  from  100  to  120 
times  per  minute,  and  it  is  small  and  hard.  The  respiration  is  rapid.  The 
t'over  is  continuous,  with  an  exacerbation  toward  night.  The  patier.t  has  no 
appetite,  but  has  an  umiuenchable  thirst.  The  tongue  is  coated.  The  bowels, 
at  first  constipated,  later  become  loose.  There  is  usually  some  vomiting  of 
food,  nniciis,  and  bile,  and  sometimes  moderate  hiccough.  Tiie  lower  half  of 
the  abdomen  is  distended,  and  in  order  to  lessen  the  tension  the  patient  lies  on 
licr  back  and  draws  up  her  knees.  The  secretion  of  milk  is  normal  or  is 
<('ant.  The  lochial  discharge  is  diminished,  is  of  a  dirty  color,  and  often  is  of 
utVensive  odor. 

In  the  coui-se  of  a  week  or  two  a  distinct  tumor  is  felt  in  the  pelvis  and  the 
lower  part  of  the  abdomen,  which  tumor  is  composed  of  the  uterus,  the  append- 
ages, the  intestine,  the  omentum, — all  mattetl  together  with  exudation  and  new- 
t(  iined  adhesioi.s.  Below,  the  exudation  is  usually  situated  in  Douglas's  jwuch, 
jMisliing  the  uterus  forward,  but  it  may  also  be  plai'tnl  more  laterally,  pressing 
the  uterus  over  to  the  other  side,  and  at  the  same  time  canting  it  forward.  The 
I'xndation  pushes  the  fornix  of  the  vagina  in  front  of  it,  so  that  the  cervix  seems 
to  disappear,  and  together  with  the  corpus  uteri  it  forms  a  pear-shaped  body, 
witliout  distinction  between  the  two.  The  abdominal  siu'tiice  of  the  swelling  is 
iMU'ven,  and  it  offers  a  different  degree  of  resistance  in  different  parts.  Often 
a  peculiar  sensation,  much  like  that  experienced  in  pressing  a  snowball,  is 
felt  on  slight  pressure,  due  to  fresh  adhesions  being  torn,  as  can  be  inferred 
from  what  we  find  in  laparotomies  performed  after  this  crepitation  has  been 

i\'h. 

The  swelling  usually  ends  in  resolution  in  the  course  of  two  or  three 
weeks.  Pain,  fever,  and  swelling  subside  and  the  patient  gradually  regains 
her  health.     But  the  swelling  may  end  also  in  suppuration,  in  which  event 


^if'  -.^i; 


*'  :'»■ 


702 


AJflJIilCAiY   TEXT-BOOK   OF   OBSTETRTCS. 


W. 


the  fever  increases;  tlu- patient  lias  repeated  chills;  the  swelling  softens  and 
b(Hx)nies  boggy,  and  sometimes  fluctuating.  If  the  alxscess  tends  toward  the 
vagina,  fluctuation  may  here  be  felt.  If  it  progresses  to  the  bladder,  tlic 
patient  feels  a  frequent  desire  to  emjity  this  organ,  and  the  act  of  niicturifiou 
is  more  or  less  painful.  If  the  rectum  is  being  imjjlicated,  the  patient  com- 
plains of  tenesmus.  Wherever  the  abscess  breaks  a  large  amount  of  offensive 
pus,  mixed  with  grumous  masses,  is  evacuated.  The  most  common,  and  at 
the  same  time  the  most  fortunate,  place  of  evacuation  is  through  the  vagina. 
In  some  cases  after  breaking  the  abscess  may  close  at  once,  but  in  other  cases, 
especially  if  there  is  a  communication  with  the  rectum,  it  may  refill,  or, 
if  the  pus  is  found  in  separate  foci,  the  ]>rocess  of  elimination  may  be  very 
protraetetl  and  exhaust  the  patient's  strength.  The  pus  may  also  follow  tiw; 
vagina  downward  and  oi)en  in  the  ischio-rectal  fossa.  Enteritis,  cystitis,  or 
pyelo-nephritis  may  develop. 

PrngnoHis. — As  a  rule,  local  peritonitis  ends  in  recovery,  but  it  may 
become  general  and  speetlily  end  the  patient's  life,  or  it  may  take  so  pro- 
traete<l  a  ..'ourse  that  she  succumbs  to  exhaus^tion.  As  to  complete  restoration 
to  health,  the  \>vi  ino  tlcation  should  be  guard  k1.  Peritonitis  leaves  a  ]>redis- 
positioii  to  new  attacks.  It  often  causes  chronic  oophoritis  and  salpingitis, 
makin*;"  the  patient  more  or  less  an  invalid,  and  it  is  a  frequent  cause  of 
sterility  ;  or,  if  she  again  conceives,  she  is  more  apt  to  have  trouble  in  subse- 
quent confinements. 

General  periton  if  is  has  symptoms  similar  to  those  of  local  peritonitis,  but 
nuu'h  intensified.  It  appears,  as  a  ride,  from  two  to  four  days  after  delivery, 
but  it  may  also  begin  immediately  after  parturition.  The  chill  lasts  from 
half  an  hour  to  several  hours.  The  pain  is  excruciating,  and  it  sjireads  over 
the  entire  abdomen.  The  pulse  beats  from  120  to  160  per  minute.  The 
temperature  is  104°  F.  or  higher.  The  respiration  ranges  from  26  to  56  per 
minute,  and  it  is  shallow  on  account  of  the  pain  produced  by  the  movements 
of  the  diaphragm  and  on  account  of  the  compression  of  the  lungs  by  the  inflated 
intestine.  The  patient  lies  on  her  back,  with  the  knees  drawn  up.  Siie  shuns 
every  movement  and  dreads  every  approach.  Even  the  weight  of  the  bed- 
clothes may  be  intolerable.  Her  face  expresses  tiie  greatest  anxiety  and  pain. 
Her  features  are  pinched,  the  corners  of  her  mouth  drawn  down  ;  the  eyes 
sink  deep  into  their  sockets,  a  black  streak  showing  under  each  lower  lid. 
The  skin  is  ])ale  ;  the  tongue  is  dry,  red  at  the  point  and  the  edges,  and  brown 
in  the  middle.  The  thirst  is  Jinquenchable.  The  patient  vomits  continuously, 
and  the  vomit  soon  has  the  peculiar  appearance  of  chopped  spinach.  Com- 
monly the  patient  has  diarrhea,  and  is  often  racketl  by  hiccoughs. 

The  urine,  which  is  scant  and  often  contains  albumin,  must  frequently  Ih' 
drawn  with  a  catheter.  The  milk-secretion  soon  ceases.  The  lochia  are 
scant,  often  fetid,  or  disappear  altogether.  The  abdomen  is  enormously  di>^- 
tended  ;  the  percussion  sound  is  tympanitic  in  front,  dull  at  the  dependent 
parts  ;  and  the  pectoral  organs  are  |iMs!ied  up  and  compressed. 

The  patient  often  suffers  from  insomnia,  and  at  the  same  time,  as  a  rule, 


PATHOLOGY   OF    THE  PUEllPERIVM. 


703 


g  softens  and 
s  toward  the 

hUuWor,  the 
)t'  micturitiim 

patient  coin- 
it  of  offensive 
iiinion,  and  at 
srh  the  vagina. 
in  other  eases. 
may  refill,  or, 
1  may  be  very 
ilso  follow  the 
tis,  cystitis,  or 

y,  but  it  may 
,y  take  so  pro- 
)lete  restoration 
leaves  a  pre<lis- 
and  salpingitis, 
[■qnent  cause  of 
rouble  in  subso- 


she  is  in  a  somnolent  condition,  is  slow  to  answer  questions,  or  is  completely 
delirious.  From  her  li.stless  lethargy  she  sutldeidy  starts  up  as  if  scared  by 
;i))palling  dreams  and  visions,  and  looks  around  with  a  pitiful  expression  of 
dismay  and  horror.     In  some  cases  the  intellect  remains  clear  "^o  the  last. 

Pror/nosis. — General  peritonitis  is  one  of  the  most  dangcioi.3  forms  of 
puerperal  infection,  but  the  patient  may  recover.  Favorable  signs  are  the 
ileercase  in  the  frecjucncy  of  ihe  pulse  and  the  respiration,  the  fall  in  tempera- 
tnrc,  the  disappearance  of  j)ain,  tiie  cessation  of  tympanitis  and  vomiting,  the 
return  of  the  appetite,  the  increase  in  strength,  the  return  of  mental  clearness, 
and  a  cheerful  disposition. 

Unfavorable  signs  are  an  irregular  pulse  or  one  beating  more  than  140;  a 
temperature  above  104°  F. ;  a  laboriotjs  respiration,  over  40 ;  a  copious 
diarrhea ;  cold,  clammy  extremities ;  the  appearance  of  red  blotches  on  the 
skin  ;  a  profuse  perspiration  ;  the  subsidence  of  ])ain,  while  the  distention  of 
the  abdomen  remains  the  same  or  increases.  Death  ol;„,  ""s  usually  in  nine 
or  ten  days,  except  where  an  abscess  ruptures  into  the  peritoneal  cavity,  when 
life  becomes  extinct  in  a  day  or  two.  What  has  been  said  above  about  the 
doubtful  return  to  perfect  health  applies  still  more  to  general  peritonitis. 

Pleurisy. — Pleurisy,  as  a  rule,  is  secondary  to  peritonitis  or  to  phlebitis, 
but  it  may  be  a  primary  lesion.  The  fluid  is  sero-purulent,  like  that  in  peri- 
tonitis, except  when  it  is  due  to  an  infected  embolus.  In  such  cases  the  fluid  is 
])in'ident.  When  pleurisv  supervenes  in  the  course  of  periton  'is  it  is  easily 
overlooked — so  much  more  so  as,  on  account  of  the  patient's  sufferings,  we 
often  cannot  make  a  ])hysical  examination.  Its  advent  may  be  marked  by  a 
now  chill,  by  increased  fever,  and  by  still  more  embarrassed  respiration. 

Prof/noHis. — Pleurisy  is  a  very  serious  complication  in  childbed. 

Pneumonia. — Pneumonia  appears  as  hypostatic  jmeumonia  in  the  most 
dependent  part  of  the  lungs  or  in  disseminated  I'oci  due  to  embolism  in  any 
jiiirt  of  the  organs.  It  is  generally  combined  with  pleurisy.  The  usual 
syni])toms  of  the  disease — pain,  cough,  bloody  expectoration,  and  dyspnea — 
may  be  missing,  when  it  can  only  be  diagnosticated  by  the  stethoscopic  signs 
— ere]>itant  rales,  bronchial  respiration,  and  dull  or  flat  j)ercussion-sound. 

l*rof/nnsiK. — Pneumonia  is  a  dangerous  affection  in  a  puerpera. 

Pericarditis. — Pericarditis  may  be  pro]>agated  through  the  lymph-vessels 
of  the  diaphragm  from  peritonitis,  or  may  be  due  to  emboli  from  a  venous 
thrombus. 

Tlie  Kj/mpfoms  generally  become  merged  into  those  of  other  inflammations. 
Siiinetime,s,  however,  a  friction-sound  or  an  increased  dull  area  reveals  the 
presence  of  false  membranes  cm*  of  exudation  aroinid  the  heart. 

Phlegmasia  Alba  Dolens. — Tlie  thromho-ph/chitic  form  of  phlegmasia 
may  begin  during  ]>regnancy,  and  is  accomjianied  by  fever  and  a  sensation  of 
heaviness  in  the  limb.  Commonly  the  inflanunation  begins  in  the  .second 
week  after  confinement.  Sometimes  the  local  affection  is  preceded  by  anorexia, 
a  l>a(l  taste,  a  coated  tongue,  constipation,  and  eructations.  The  phlegmasia 
begins  with  fever  and,  perhaps,  a  chill.     The  urine  is  concentrated.     If  the 


704 


AMERICAN   TEXT- HOOK   OF  OBSTETUICS. 


fi    li. 


!, 


thrombosis  begins  in  tlie  leg,  tlie  latter  swells  from  the  foot  upward ;  but  if 
the  leg  is  seeondarily  att'ected  after  tlie  pelvic  veins,  the  swelling  spreads  in  tli(! 
opposite  direction.  The  extremity  is  painful ;  the  skin  is  white,  tense,  hard, 
sometimes  covered  with  blisters,  or  it  may  become  red  and  be  perforated  l)v 
an  abscess.  The  Jift'ecttHl  veins  may  be  felt  as  hard  strings.  Both  extremities 
may  be  atl'ecteil,  the  thrombosis  passing  from  one  side  to  the  other  through  the 
vena  cava,  or  beginning  independently  in  cither  extremity.  The  phlegmasia 
usually  runs  its  course  in  from  three  to  six  weeks,  and  ends  in  resolution. 
It  may  pass  into  suppuration  and  the  patient  still  ret^over.  Sometimes  gan- 
grene sets  in  anil  leads  to  death,  or  sejjtici'mia  may  develop. 

Varicose  veins  are  more  lial)le  to  the  formation  of  thrombi  than  healtiiv 
veins.  If  the  deeper  veins  are  affected,  the  skin  luis  a  peculiar  purple  color, 
which  variety  has  been  distinguished  under  the  name  of  phlegnmsia  ccemlva 
dolena.  As  a  rule,  the  thrombus  is  reabsorbed,  and  the  swelling  subsides.  In 
other  cases  there  ibrms  a  periphlebitic  al)scess  that  breaks  on  the  skin  ;  and  in 
still  others  the  thrombus  may  become  infectetl  and  give  rise  to  metastases  just 
like  those  which  will  ]>resently  be  described  under  Uterine  Phlebitis. 

The  celluUtiG  form  of  phlegmasia  is  characterized  by  high  fever,  by  con- 
siderable pain,  by  redness  of  the  skin,  by  the  appearance  of  bullae,  and  by 
extensive  suppuration  and  mortification  of  the  subcutaneous  and  intranuis- 
cular  connective  tissue.  Large  shreds  of  connot'Jve  tissue  may  be  expelled 
and  the  sores  heal,  but  there  is  great  danger  of  the  patient  falling  a  ])rev 
to  gangrene  or  to  septicemia,  or  of  being  exhausted  by  the  protracttnl 
suppuration. 

Uterine  Phlebitis. — The  veins  of  the  uterus  may  be  blocked  by  simple 
thrombosis,  which  may  extend  more  or  less  into  the  pelvis.  If  the  iliac  vein 
becomes  implicated,  j)hlegmasia  alba  dolens  supervenes.  If  pathogenic 
microbes  find  their  way  into  the  uterine  simises,  there  develops  infectious 
uterine  phlebitis — one  of  the  severest  forms  of  puerperal  infection. 

Uterine  phlebitis  begins  with  a  long  and  severe  chill,  followed  by  similar 
attacks  at  irregular  intervals,  and  it  is  characterized  by  metastases  in  one  or 
more  organs.  The  chills  are  due  to  the  entrance  into  the  blood  of  microbes 
or  of  their  chemical  products.  During  the  chills  the  temperature  rises  to 
from  104°  to  108°  F.,  the  pulse  beats  from  140  to  160  per  minute,  the  res- 
piration becomes  as  frcfpient  as  from  36  to  o6.  Rarely  the  patient,  instead  of 
real  chills,  has  oidy  chilly  sensations.  In  the  interval  between  the  chills, 
especially  after  the  first  chill,  she  feels  great  relief,  the  temperature  sinking  to 
100°  or  101°  F.,  and  the  pulse  and  respiration  betHMuing  less  frequent,  in 
this  form  of  puerperal  infection  there  is  no  pain,  little  tenderness,  and  no 
tympanitis. 

After  the  lull  of  the  first  interval  new  chills  follow,  and  the  more  meta- 
stases are  developed  the  more  the  fever  becomes  contiimous.  The  skin  turns 
yellowish,  and  sometimes  complete  jaundice  develops.  The  nose  becomes 
pinched;  the  eyes  lie  deep ;  the  cheeks  are  hollow;  the  tongue  is  dry  and 
coated.     The  patient  has  no  appetite,  but  has  great  thirst,  headache,  insonmia, 


PATIlOlJHi  V    OF    THE   PI  ERPERIL'M. 


705 


ard ;  but  it' 
jreuilrt  ill  th(i 
tense,  hanl, 
ortbratal  l)y 
li  extremities 
[•through  the 
c  phlegmasia 
in  resohitiuu. 
iiuetimes  gau- 

than  heaUliy 
r  purple  color, 
rnuisJrt  ccendca 

subsides.  In 
c  skin  ;  and  in 
metastases  just 

bit'iH. 
lever,  by  con- 
l)»dl«,  and  by 
and  intramus- 

lay  be  expelled 
foiling  a  prey 
the   protracted 

,eke<l  by  simp'" 

f  the  iliac  vein 

If    pathogenic 

relops  infections 

'ection. 

)wed  by  similar 
istases  in  one  or 
)od  of  microbes 
leratnre  rises  to 
minute,  the  res- 
tient,  instead  of 
,vcen  the  chilis, 
ature  sinking  to 
3,  frequent.     In 
derness,  and  no 

the  more  meta- 

The  skin  turns 

|e   nose  becomes 

Lgue  is  dry  aii»l 

[lache,  insonmia, 


sometimes  diarrhea,  and  less  fre(|U('ntly  von>iting.  Frequently  the  breath  has 
;i  peculiarly  disagreeable  smell,  designated  as  "sweet."  The  urine  is  scant, 
iiiul  it  almost  always  contains  albumin. 

The  secondary  infection  appears  first  in  the  lungs,  then  in  the  pleura, 
tlie  heart,  the  liver,  the  kidneys,  the  spleen,  the  intestine,  the  meninges,  the 
brain,  the  eyes,  the  articulations,  the  skin,  and  the  connective  tissue.  Pneu- 
monia, pleui  Isy,  and  pericarditis  have  already  been  describetl,  and  the  other 
!(l(•alizatitnl^  will  presently  be  noticetl. 

J)i(i(/nosL'i. — Uterine  phlebitis  in  the  beginning  is  somewhat  like  malarial 
J'cvcr,  but  the  chills  are  repeatetl  at  irregular  intervals  and  the  fever  soon 
becomes  continuous.  Swollen  veins  may  be  felt  in  the  pelvis,  and  phlegma- 
sia alba  dolens  may  supervene.  There  is  often  metrorrliagia.  The  appearance 
of  metastases  is  characteristic. 

If  adynamic  and  ataxic  symptoms  develop,  the  disease  may  be  mistaken 
for  fiiphoid  fever.  First  of  all,  we  must  know  if  the  patient  is  or  is  not  a 
piu'i'pera.  If  she  denies  having  recently  given  birth  to  a  child,  it  can  easily 
be  proved  by  the  presence  of  milk  in  the  breasts,  by  the  flaccidity  of  the 
abdominal  wall  and  the  presence  on  it  of  purple-colored  strioe,  by  the  large 
size  of  the  uterus,  by  tears  in  the  cervix,  in  the  vagina,  or  in  the  vulva,  and 
l»y  the  presence  of  lochia. 

Typhoid  fever  may  develop  in  the  puerperal  state,  but  that  is  a  very  rare 
occurrence.  It  is  ciiaracterized  by  the  continuous  fever,  by  ochre-eolortnl 
stools,  by  tenderness  on  pressure  in  the  right  iliac  fossa,  and  by  the  appear- 
ance of  a  few  discrete,  small  pink  spots  on  the  abdomen.  Visceral  complica- 
tions are  rare,  and  at  the  end  of  the  third  week  a  decided  change  takes  place 
for  the  better  or  the  worse. 

In  uterine  phlebitis  there  may  be  gargouillement,  but  no  tenderness,  in  the 
right  iliac  fossa.  There  may  be  cutaneous  eruptions,  but  they  are  spread  over 
larger  surfaces  as  erysipelas,  general  erythema,  large  blotches,  papules,  or 
pctc'chite.  There  is  no  regular  fever- curve.  The  disease  begins  with  very 
high  temperature  and  a  pronounced  chill.  The  temperature  then  falls  sud- 
denly nearly  to  normal,  to  rise  again  with  the  next  chill.  Complications  in 
ditterent  organs  are  a  chief  feature  of  the  disease. 

The  distinction  between  iiter'nia  lipnphauf/itis  and  phlebitis  is  more  of  scien- 
tific than  of  ])ractical  interest,  and  frequently  the  two  are  combined.  Lym- 
phangitis usually  begins  from  two  to  five  days  after  delivery  ;  phlebitis  usually 
begins  at  the  end  of  the  first  week.  In  lynqihangitis  there  is  pain  in  the 
lower  ]>art  of  the  abdomen  ;  in  phlebitis  there  is  hardly  any  pain.  In  lym- 
phangitis there  is  great  tenderness  on  pressure ;  in  phlebitis  there  is  none  of 
the  abdomen  and  little  in  the  pelvis.  In  lymphangitis  the  uterus  is  large ; 
phlebitis  has  less  influence  on  the  involution.  Ijymphangitis  spreads  rapidly 
upward,  and  may  cause  peritonitis,  pericarditis,  pleurisy,  hypostatic  pneumo- 
nia, but  it  does  not  affect  the  head  or  the  limbs  nor  cause  pyemia  with  infarc- 
tion and  abscesses  in  the  viscera.  Lymphangitis  may  begin  with  a  chill,  but 
this  is  not  so  severe  as  in  phlebitis,  and  it  is  not  repeated.     In  lymphangitis 

45 


U.'!,      1 


i' 


TOO 


AMKIiJVAX  TEXT-BOOK  OF  OBSTETRfCS. 


'm 


l;i 


I; »» 


I  , 


'il 


tlio  fever  is  more  coiitinuoiis;  in  phlelntis  there  are  very  niarketl  fever  intcr- 
luissions  or  r('inis.si()iis. 

Endocarditis. — Eiulooarditis  appears  late  in  the  piiorperiuin — from  ten  u> 
fifteen  days  after  delivery.  It  is  ac(;ompanie(l  by  an  inerease  in  fever  ainl 
somnolence,  and  jjives  rise  to  a  rasping  sound,  especially  at  the  apex,  more 
rarely  at  the  base.  This  nun'inur  is  jjenerally  synch rolious  with  the  fii>t 
heart-sound,  but  it  may  also  be  heard  with  the  second.  It  shows  a  peculiiir 
mobility,  beiiifj  heard  one  day  at  the  apex,  the  next  at  the  base,  or  vice  irrmi. 
Endocarditis  iscommoidy  ulcerons.  When  the  small  abscesses  in  the  cndo- 
cardinm  break,  they  empty  their  contents — pus,  microbes,  and  their  cheniicil 
products — into  the  blood-current,  which  carries  them  throuj^h  the  entiic 
system,  causing  new  localizations  of  the  infection  ;  but  the  symptoms  of  (licsc 
abscesses  are  so  merged  into  those  already  |)resent  that  they  camiot  be  distin- 
guished. The  supervention  of  endocanlitis  in  uterine  phlebitis  makes  the 
pro(/)wsix  still  more  unfavorable. 

The  (dlmentdrij  cantil  does  not  suffer  much  in  uterine  ]>hlebitis.  We  have, 
however,  mentioned  the  complete  anorexia,  the  unquenchable  thirst,  the  pro- 
fuse diarrhea,  and  the  occasional  vcmiting.  Sometimes  thrush  appears  on  tlie 
dry  tongue.  In  rare  cases  abscesses  are  formed  in  the  parotid,  the  tonsil,  or 
the  thyroid  body,  the  appearance  of  which  abscesses  makes  the  prognosis 
more  unfavorable. 

Hepatitis. — The  liver  is  very  frequently  implicated  in  puerperal  metro- 
phlebitis. There  is  pain  in  the  right  hypochondriura.  The  organ  is  eidargcd, 
as  can  be  found  by  percussion  and  ]>alpation,  and  it  is  tender  on  pressure. 
The  skin  has  a  yellow  tint,  and  often  real  jaundice  develops.  The  serous  coat 
is  often  implicated  in  peritonitis,  and  then  sometimes,  on  slight  pressure,  tliero 
can  be  felt  the  crepitation  characteristic  of  new-formed  adhesions. 

Nephritis. — Intlamination  of  the  kidneys,  which  is  a  very  frequent  occin-- 
rence,  is  characteri/ed  by  the  presence  of  albumin  and  casts  in  the  tu-itie, 
whereas  the  other  symj)toms,  such  as  headache,  somnolence,  disturbed  eye- 
sight, vomiting,  and  ])ain  in  the  lumbar  region,  are  so  covered  by  the  general 
condition  that  they  lose  their  diagnostic  importance.  An  inflammation  of  tlip 
loose  coimective  tissue  in  which  the  kidtiey  is  imbedded  may  cause  constant 
tenderness  on  ]>ressure  in  the  lumbar  region. 

Splenitis. — An  inflammation  of  the  sj)leen  may  sometimes  be  diagnosti- 
cated by  palpation  and  an  increase  in  the  normal  dull  area  in  the  left  liypo- 
chondrium.  The  patient  may  com])lain  of  pain  and  tenderness  in  this  locality. 
If  an  abscess  ruptures  into  the  peritoneal  cavity,  she  collapses  and  dies. 
Generally  the  symptoms  due  to  localization  in  the  spleen  are,  however,  so 
blended  with  those  due  to  other  localizations  and  the  general  condition  that 
they  are  not  recognizable. 

Nervous  Disturbances. — Manifold  distiu'bances  occur  in  the  nervous 
system  during  the  puerperal  state,  such  as  neuralgia,  paralysis,  convulsions, 
tetanus,  tetany,  insomnia,  delirium,  etc.,  and  need  not  be  due  to  infection,  but 
to  anemia  or  hyperemia  of  the  brain,  hysteria,  pressure  on  a  nerve-trunk,  or  a 


nrn, 


/'AT/lO/J)(,'y   or    Till':   PVEItPKHltM. 


707 


li 


ii-^ 


I  fever  intci- 

— from  ton  tn 

in  fovcr  iiixl 
nc  aiH>x,  move 
with  the  tiiM 
,()ws  a  pcculiiir 
?  or  t'KV  cccs". 
ort  in  the  ciulu- 

tlioir  ehcmitiil 
ujvli  the  entire 
iptoms  of  these 
uuiot  he  (hstin- 
Ditis  makes  the 

hitis.  We  have, 
;  thirst,  the  i)ro- 
\\  appears  on  tlie 
id,  the  tonsil,  or 
es  the  prognosis 

puerperal  nietro- 

DVgan  is  enlar>r;e»l, 

uler  on  pressure. 

The  serous  ooat 

it  pressure,  there 

ions. 

k-  frequent  oecnr- 
ists  in  the  urine, 
:e,  disturbed  eye- 
•ed  by  the  general 
flammation  of  the 
lay  cause  constant 

,iics  be  diagnosti- 
in  the  left  hype- 

.ss  in  this  loeulity. 

Dllapses  and  dies. 
are,  however,  so 

L-al  condition  tbut 

Ir   in  the   nervous 

Ilvsii*,  convulsions, 

|,e  to  infection,  but 

,  nerve-trunk,  or  a 


reflex  action.     Severe  affcH'tions  of  the  nervous  svsteni  niav  be  due.  however. 

»  •  7  / 

to  tlirond)osis  of  the  cerebral  veins  or  to  purulent  meningitis,  produced  l)y 
metastasis  from  an  infected  endometrium. 

Arthritis. — Sometin.es  the  infecting  agents  in  metro-phlebitis  are  carried 
lo  the  joints.  At  the  beginning  nuuiy  articulations  may  be  allectod,  but  wliilp 
I  lie  inflammation  subsides  in  most  of  them,  it  may  remain  in  one  or  two, 
i'-|)e('ially  tlioise  of  the  knee  and  shoulder.  Of  the  articidations  of  the  trunk, 
the  symphysis  pubis,  the  sacro-iliac,  and  the  .steru»)-clavicidar  are  most  fre- 
quently affected. 

Puerperal  articidar  inflammation  differs  from  rheumatic  inflammation  by 
its  .stability,  and  from  both  this  and  the  gonorrheal  type  by  its  pronounced 
tendency  to  suppuration.  The  aflected  joints  become  ])ainful,  the  j)ain  being 
ninch  increa.sed  by  movements  or  by  pressure.  The  skin  becomes  red  and  hot, 
and  if  there  is  an  abscess  in  the  artietdation,  the  joint  may  i)e  perforated.  All 
tlic  tissues  composing  tlie  joint,  even  the  cartilage  and  bone,  may  be  destroyed. 
If  the  patient  survives,  the  afTected  joint  may  remain  ankylosed. 

Abscess  and  DiflFuse  Cellulitis  of  the  Limbs. — lioth  the  subcutaneous 
and  the  intenuuscular  connective  tisstie  may  become  the  seat  of  localization  of 
puerperal  infection.  The  lind)  swells  and  is  painfid.  The  skin  be<;omes  nnl 
and  hot.  Cireinuscribed  ab.scesses  may  form,  or,  especially  in  the  sid)fascial 
form,  a  diffuse  phlegmon  may  extend  over  a  large  area — a  form  which  is  very 
tiangerous,  and  which  may  cost  the  patient  her  life  or  it  may  leave  her  in  a 
crippled  condition. 

Skin  Diseases. — A  puerpera  may,  as  well  as  another  per.son,  be  attacked 
l)y  eruptive  fevers,  such  as  measles,  .scarlet  fever,  small-pox,  or  erysipelas,  as 
an  accidental  complication.  She  may  likewise  have  .some  kind  of  eruj)tion 
in  consequence  of  the  use  of  certain  drugs — for  example,  copaiva,  quiniu 
salicylic  acid,  or  iodoform. 

A  milUwy  eruption,  consisting  of  small  white  vesicles,  sometimes  each  sur- 
rounded by  a  red  ring  or  springing  front  a  red  skin,  is  often  found  in  an 
otherwise  well  woman,  and  is  only  due  to  increased  perspiration.  This  eru])- 
tion  is  generally  found  on  the  trunk.  Sometimes  an  eruption  of  red  macula) 
or  papuhe,  or  a  general  erythema,  accompanied  by  more  or  ''■>■  s  'ever,  appears 
on  the  skin  in  pue-pera?  who  present  no  other  sign  of  disea.se. 

Ihit  in  othe»'  cases  the  skin-eruption  accompanies  other  symptoms  of  severe 
puerperal  infection,  and  it  must  then  be  regarded  as  ])art  of  the  infection.  An 
erythema  may  spread  more  or  less  far  from  the  genitals,  or  large  erythema- 
tous blotches  may  apjiear  on  any  part  of  the  body.  Small  dark  hyperemic 
spots  of  the  size  of  a  hempseed — so-called  "petechite" — that  do  not  vanish 
on  jtressure,  may  appear  in  very  severe,  generally  fatal,  ca.ses.  Sometimes 
there  is  a  pemphigu.s-like  eruption,  the  epidermis  being  rai.sed  by  a  serous 
exudation,  forming  large  vesicles.  In  other  cases,  again,  bullte  fillet!  with 
pus  develop,  rupture,  and  leave  sores. 

Finally,  infected  puerperre  are  very  liable  to  have  bed-sores,  especially  on 
the  sacrum  and  the  heels.     In  all  those  cutaneous  aflections  that  appear  as 


7(W 


AMinni'AX  riLXT-nnoK  of  oiisTirntics. 


part  ul"  a  griiiTal  iiil'wtit»ii  the  syiuptorns  <(t'  the  latter  cover  thoae  (»1'  tin 
Ibrmcr. 

Acutest  Septicemia. — Tlii.s  form,  the  iiutst  (laiij^erourt  of  all  forms  ul 
Ijiierperal   infection,  lias,  fortunately,  become  very  rare,  and  lias  entirely  (li>. 
appeared  from  well-conducted  lyiiifj-in  hospitals,  institutions  where  it  formerly 
raged  in  the  so-called  ''epidemics"  of  puerperal  Jvrcr. 

It  l)e<iin.s  soon  after  ilelivery  with  a  long  and  severe  chill.     The  pi  1 

the  respiration  are  rapid.  The  temperature  in  some  cases  may  be  hi^n,  ami 
may  remain  so  without  the  remissions  characteristic  of  puerperal  phlebitis, 
but  in  other  cases  it  is  normal  or  even  sidmormal.  The  features  are  pinched, 
the  skin  pale  or  purplish,  and  the  tongue  dry  and  brown.  The  patient  is  in  a 
somnolent,  comatose,  or  delirious  condition.  She  has  fre(pient  involuntarv, 
copious,  dark,  and  offensive  evacuations  from  the  bowels.  The  urine  is  scant, 
nnd  it  contains  nnich  albumin.  The  course  of  this  form  is  rapid  and  ends  in 
«leath  in  a  day  or  two. 

Tkkatmkntuf  Pikui'KRAL  Infection. — Puerperal  infection  being  a  biic- 
terial  disease,  its  treatment,  preventive  as  well  as  curative,  must  chieflyj)e  germi- 
cidal.    Asepsis  and  antisepsis  are  the  watchwords  in  the  warfare  against  it. 

It  is  an  interestip,:.^  historical  fact  that  the  great  discoveries  which  form  tlio 
base  of  all  antisi-ptic  surgery  were  made  by  obstetricians  long  befor  tin  y 
were  independently  made  by  surgeons,  but  that  the  obstetrical  discov  lid 

not  succeed  in  changing  the  treatment  of  puerperal  disetise  by  oth^.  ^.ac- 
titioners  until  the  surgeons  stirred  up  the  entire  world  by  their  wondeil'iil 
achievements  by  means  of  antiseptic  measures. 

The  father  of  antiseptic  midwifery  was  Senn.solweis  of  Vienna,  who  as 
early  as  1847  understood  that  so-called  "puerperal  fever"  was  due  to  infec- 
tion, and  who  used  chlorin,  one  of  the  best  germicides,  in  the  sha|)e  of  chlo- 
rinated lime  as  a  disinfectant.  But  his  g;'eat  discovery  remained  an  uncut 
diamond,  lying  despised  in  a  corner,  for  a  whole  generation,  the  discoviTur 
meanwhile  dying  in  a  mad-house.  It  was  when  the  Scotchman  Lister,  apply- 
ing the  discoveries  of  the  French  chemist,  Pasteur,  to  surgery,  had  laid  tliu 
foundation  of  antiseptic  surgery  (1866),  that  the  Danish  obstetrician,  Stad- 
feldt,  and  the  Swiss  obstetrician,  Bischoff,  simultaneously  (1870)  introdiiml 
the  use  of  carbolic  acid  in  midwifery.^^ 

In  1881  the  French  obstetrician,  Tarnier,  read  a  paper  before  the  Iiitor- 
national  Medical  Congress  assembled  in  London  on  his  use  of  biehlorid  of 
i.ercury  as  a  local  remedy  for  puerperal  fever,  but  no  one  seems  to  have  paid 
any  attention  to  it  until  the  German  bacteriologist,  Robert  Koch,  published 
his  experiments  with  this  drug,  and  the  German  surgeon,  Schede,  introdiicod 
its  use  in  surgery.  The  biehlorid  of  mercury,  as  a  preventive  and  curative 
agent,  was  then  (in  1883)  introduced  in  many  lying-in  hospitals.  In 
America  it  was  first  introduced  in  the  New  York  Maternity  Hospital  by 
the  writer  on  the  1st  day  of  October,   1883. 

While  the  revolution  in  the  residts  as  to  morbidity  and  mortality  iVom 
puerperal  infection  dates  from  the  introduction  of  biehlorid  of  mercury,  it 


PATiiouxn'  o/'  Till-:  rrHni'iinnM. 


im 


thtwo  of  till' 

all  tonus  111 
^  I'lttiivly  <li" 
ero  it  tuni»oily 

The  \Y  1 

y  be  l»i^",  »'>'l 
i>onil  phlebitis 
I'Orf  are  {)ii»el>i<l, 
e  pntient  is  in  ii 
nt  involuntiuy, 
le  urine  is  seant, 
ipiil  and  ends  in 

stion  being  a  bm- 
chiefly.be  genui- 
are  against  it. 
s  which  t'onu  the 
long  betbr  they 
al  discov  h'l 

ic  by  otl.--    .■■•"■- 
J  their  wonderful 

Vienna,  who  as 
was  due  to  infk- 
|je  shape  of  cliVi- 
l.iuainetl  an  uncut 
,n,  the  discoverer 
lan  Lister,  apply- 
gery,  had  laid  tlie 
|obstetrician,  Stad- 
1(1870)  introiluml 

before  the  Inter- 
ne of  bichlorid  of 
seems  to  have  vaid 
It  Koch,  publisluHl 
Ischede,  introduood 
Intive  and  (nuativo 
Lin   hospitals.     1" 
Irnity  Hospital  l>y 

nd  mortality  fn"" 
[rid  of  mercury,  it 


lia^s,  however,  been  proved  that  tlic  true  <'anso  of  the  improved  result-;  i:«  not 
1)  be  .sought  in  the  drug,  but  in  its  application  ;  that  is,  the  xtfift  disinf«>etion 
i)f  hands,  instruments,  dressing-material,  etc.  Some  large  clinics,  such  as 
those  of  Copenhagen  and  \'icuna,  yet  cling  to  the  use  of  carbolic  acid,'*^  and 
obtain  just  as  goo«l  results  as  tluwe  in  which  this  drug  has  been  supplanted  by 
liiehlorid  of  nwreury. 

If  ever  a  medical  fact  has  been  proved  by  figures,  the  latter  have  proved  ti»e 
value  of  the  antiseptic  trciUment  in  midwifery.  The  testimony  from  over  the 
entire  world,  inde|)endently  of  geographical  position  or  climatic  ditt'erenccs,  is 
unanimous.  Counting  by  thousands,  hundreds  of  thousands,  and  millions,  the 
liiiures  are  too  large  to  be  vitiated,  the  new  treatment  l)eing  now  in  the  elev- 
enth year  of  its  probation. 

It  would  be  tiresome  and  unprofitable  to  enter  deeply  into  statistics,  but 
the  writer  can  hardly  begin  the  discussion  of  the  treatment  of  puerperal  in- 
t'retious  diseases  in  a  better  way  than  by  showing,  in  a  few  lines,  what  the 
mortality  formerly  was  and  what  it  now  is  in  the  institution  to  which  he 
iiail  the  honor  of  being  a  visiting  obistetric  surgeon  for  a  period  of  over  ten 
years  (1881-02),  and  with  which  he  is  yet  connected  as  consulting  obstetric 
surgeon. 

The  records  of  the  New  York  Maternity  Hospital  .show  the  following 
mortality  before  and  after  the  introduction  of  strict  antiseptic  treatment  with 
bichlorid  of  mercury  : 


Year. 

Dt'UviTli's. 

Deaths. 

I'cr  t'lMil. 

IST.'i          

570 
5S6 
480 
255 
254 
149 
,S82 
431 
447 

15 
20 
32 

7 
11 

8 

9 
14 
30* 

2fi3 

1876 

1S77          

3.73 
6.67 
2  75 

1878 

1870 

4.33 

1880 

1881 

5.37 
2  3(5 

1882 

1883 

3.25 
6.71 

Total 

3504 

14G 

4.17 

*  All  during  the  first  nine  months  of  the  year. 

During  the  last  six  months  before  the  change  in  treatment  was  made  there 
wore  delivered  237  women,  nineteen  of  whom,  or  8  per  cent.,  die<l,  and  of 
those  seventeen,  or  7.17  per  cent.,  succtimbed  to  sojisis.  During  the  last 
month  the  total  mortality  reached  even  ten  out  of  fifty,  or  20  per  cent.,  and 
tiiat  from  sepsis  15.69  per  cent. 

During  the  first  three  months  after  changing  the  treatment  there  were  102 
(lolivories,  without  a  single  death — a  circumstance  which  then  apjjcared  almost 
miraculous,  but  which  lias  become  quite  a  common  event,  and  has  later  been 
oxtoudcd  over  much  longer  periods.  The  following  list  shows  the  mortal- 
ity in  the  Xew  York  Maternity  Hospital  since  the  introduction  of  strict  anti- 
sepsis : 


710 


AMERICAX    TEXT- BOOK   OF   OBSTETRICS. 


■\l\ 


l'< 


W. 


m 


Delivcrifs. 

Mortiility. 

Per  cent. 

Yonr. 

Total. 

From 

Hi'psi.s. 

Total 
Mortiility. 

1.53 
0.5t> 
1.12 
1.30 
0.79 
0.32 
1.13 
0.42 
0.32 
O.OG 

0.87 

From 

St-psis. 

1884 

522 
537 
44ti 
389 
377 
314 
345 
240 
314 
305 

3789 

8 
3 
5 
5 
3 
1 
4 
1 
1 
2 

33 

4 
0 

1 
1 
0 
0 

1 

0 
0 
0 

0.70 

1885         

0.0 

188() 

0.22 

1887 

1888     ...    

1889 

0.2(j 

0.0 

0.0 

1890 

18<ll 

0.29 
0.0 

1892 

1893 

0.0 
0.0 

Total 

7 

0.18 

uu 


^. 


I 


Thus,  dwimj  the  last  {lure  i/earx,  out  of  10o9  padiwient  ivomen,  only  four  dial, 
or  O.o7  per  cent.,  and  not  one  of  them  from  injection. 

By  comparino;  the  jiroccdiiij;!;  lists,  awh  ctjiuprising  nine  years,  we  find  a 
decrease  in  mortality  from  4.17  to  0.87  per  cent.;  that  is,  the  mortality  has 
been  reduced  nearly  to  one-fifth  of  what  it  used  to  be. 

In  regard  to  morbidity  a  .similar  change  lias  taken  place,  but  the  writer  has 
no  exact  statistical  material  to  otl'cr  as  proof  He  must,  therefore,  contiiie 
himself  tc  an  e.xample.  During  the  six  months  from  October  1,  1882,  to 
April  1,  188."),  a  period  for  whicii  ho  ha.s  exact  notes  respecting  tlie  whole 
service,  192  women  were  delivered,  forty-six  of  whom,  or  nearly  o)ie  out  of  ft-ir, 
tvere  fierious/y  ill,  and  thirty-nine,  or  nearly  one  in  five,  sutfered  from  puerperal 
inflammation,  wliich  now-a-days  is  looked  upon  as  due  to  infection.  A  sick 
puerpera  has  now  become  a  rare  sight  in  the  wards  of  the  Maternity 
Hospital. 

A  certain  class  of  ca,ses  is  particularly  interesting,  because  all  the  symptoms 
of  cellulitis — namely,  pain,  tenderness,  and  swelling  in  one  of  the  iliac  fo.ssa^ — 
were  present,  and  still  there  was  no  rise  in  temperature — a  phenomenon  which 
can  be  accounted  for  oidy  in  this  way  :  that  the  condition  was  due  to  bruis- 
ing of  the  tissues,  and  that  our  antiseptic  treatment  prevented  the  infection 
which  so  easily  develops  under  such  circum.stances. 

Passing  to  an  exposition  of  the  treatment  of  puerperal  infection,  we  nuist 
distinguisii  between  (1)  hospital  practice  and  (2)  private  practice,  (3)  lU'cvciit- 
ive  and  curative  treatment,  and  (4)  surgical  treatment. 

1.  Prevention  of  Pferperai.  iNFFirnoN  in  H()spit.\i,s. — Parturient 
women  ought  to  be  provided  for  in  institutions  exclusively  designed  for  ob.stetiic 
purposes,  and  not  in  general  hospitals.  Before  the  introduction  of  antisepsis 
the  mortality  was  much  greater  in  the  wards  of  general  hospitals  devoted  to 
obstetric  cases  than  in  special  lying-in  asylums  ;  even  after  the  introduction  of 
anti.septic  j)rophylaxis  it  exposes  parturient  women  to  increa.stHl  risks  to  l)o 
treated  by  the  same  doctors  and  nui'ses  who  have  charge  of  the  sick, 

A  lying-in  hospital  ought  to  have  a  fi'ce  .supply  of  pure  air,  which  onulit 
to  circulate  freely  under  the  building,  whether  there  be  a  cellar  or  thebniM- 
ing  be  erected  on  pillars.     If  possible,  there  ought  to  be  in  the  wards  artilirial 


U'    t 


<!        i  0 


PATHOLOUY   OF    THE   PUERPERIUM. 


711 


1M  ; 


I'or 

cent. 

itnl 

\       From 

ality. 

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53 

0.7 1) 

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0.0 

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0.22 

.30 

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.79 

0.0 

).32 

0.0 

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).42 

1       0.0 

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0.0 

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0.18 

n,  only  four  dial, 

years,  we  find  u 
he  mortality  has 

)ut  the  writer  has 
therefore,  conlino 
tober  1,  1882,  to 
leetitij?  the  wholo 
rlij  one  ouf  ofjo'ir, 
ed  tVoiu  puerpi  ral 
infection.  A  sick 
)f    the   Maternity 

all  the  symptoms 
if  the  iliac  fossio— 

henomenon  whicli 
ivas  due  to  briiis- 

uted  the  infection 

liiifection,  we  nuist 
jctice,  (3)  prcNout- 

L^,,s. — Parturient 
liirned  for  obstet  ric 
lotion  of  antisepsis 

kspitals  devoted  to 
(he  introduction  o( 

K'ased  risks  to  l)o 
of  the  sick, 
air,  which  ouiilit 

tellar  or  the  bnilil- 

Ihc  wards  artili'ii»l 


ventilation,  which  can  only  bo  obtained  in  the  hij^hest  degree  of  perfection  by 
large  fan.s  revolving  under  the  building  and  throwing  pure  air  into  the  wards. 
During  the  season  of  cold  the  air  is  heated  before  being  forced  into  the  wards 
liy  the  fans. 

Where  there  is  no  artificial  ventilation  the  windows  must  be  kept  more  or 
less  open  at  the  top  day  and  night  the  year  round.  Although  this  proc  lure 
iiitcrteres  souujwhat  with  the  normal  persj)iration  in  childbed,  the  writer  has 
never  observed  any  harm  arise  from  it  in  the  Maternity  Hospital  :  this  inuuu- 
uity  probably  is  due  to  the  habitual  exposure  of  the  special  class  of  women 
there  confined,  for  in  private  practice  the  writer  has  seen  coryza,  bronchitis, 
;iiid  pneumonia  originate  from  a  similar  procedure. 

The  building  should  preferably  be  so  situated  that  the  patients  may  get  the 
morning  and  evening  sun  ;  at  all  events,  a  northern  exposure  should  be  avoided 
ill  the  tcniperate  zone,  and  a  southern  exposure  in  very  hot  climates.  EvcJi 
tlie  smallest  lying-in  hospital  sliould  have  one  or  more  special  rooms  for  isola- 
ting sick  |)atients  from  the  other  puerpera). 

There  ought  to  be  a  regidar  and  rapid  rotation  in  the  use  of  wards.  Ju 
tlic  fraternity  there  are  nine  beds  in  each  ward,  and  as  soon  as  th<}  last  patient 
has  becii  there  nine  days  the  ward  is  temporally  abandoned  and  disinfected, 
tli(>  same  bed  never  being  used  by  more  than  one  and  the  same  patient  before 
liciug  throughly  disinfected.  On  the  ninth  day  the  patient  is  transterred  to 
the  convalescent  ward,  where  she  .stays  until  well  enough  to  leave  the  hospital. 

Pregnant  women  ought  to  be  kept  in  special  waiting  wards  apart  from  partu- 
rient and  puerperal  patients.  The  former  often  stay  for  months  in  the  Maternity 
lli.spital,  and  it  is  more  difiicult  to  keep  discipline  among  them.  Pregnant 
women  need  other  food  and  regimen  ;  they  are  less  clean  and  less  (piiet ;  they 
would  be  exposed  to  mniecessary  anxiety  by  witnessing  the  suHerings  of  the 
]>artin"ient  or  sick  puerperal  women  ;  and  they  might,  perhaps,  even  become 
iiifccteil  before  their  delivery. 

The  parturient  woman  ought  to  be  delivered  in  a  spe(;ial  delivery-room,  a 
so-called  "  j)ony-room."  *  As  the  infection  most  tmpieutly  takes  place  dur- 
ing parturition,  the  woman  shoidd  be  delivere<l  in  a  room  where  everything  is 
kept  strictly  a.^eptic,  and  by  all  means  not  in  a  room  where  there  are  sick 
pncrpene. 

riiere  should  be  an  easy  eomnnmication  between  the  d(>liverv-room  and  the 
wards,  so  that  patients  need  not  be  carried  far  or  be  expo.sed  to  inclement 
weather;  yet  there  shonhl  be  no  direct  eomnnmication.  In  the  Maternity 
Hospital  this  condition  is  obtained  by  having  small  covere<l  corridors,  open  on 
one  side,  between  the  delivery-room  and  the  wards. 

The  wards  shoidd  likewise  be  separated  from  one  another.  They  should 
liavc  plenty  of  light,  preferably  from  two  opposite  sides.  Light  from  above 
is  only  needed  in  an  operating-room.     .\11  cross-bea'us  and  projections  should 

*'riie  writer  bclit'Vi's  this  singular  I'-xpreasion  comes  from  a  small  luni,  a  kindof  ont,  wliicli  was 
(mIIciI  a  "pony,"  and  wliiiii  wius  useil  for  (lelivories  in  olden  times,  as  it  yet  is  in  some  countries 
-  lor  example,  Belgium. 


.■r*T. 


I':.' 


P  V  " 


12 


AM E  It  I  VAX   TEXT-BOOK    OF   OJiSTETRIVS. 


bo  avoiclod,  as  tlioy  hocome  reccptaclo!;  for  dust,  which  may  become  a  oarriin- 
of  germs.  Tlie  floor  and  walls  should  be  hard,  smooth,  and  not  porons,  so 
tliat  they  can  easily  be  kept  clean  by  scrubbing  and  be  disinfected  with  fluids 
or  with  vapors.  It  is  well  to  have  separate  rooms  provided  for  patients  who 
have  undergone  serious  operations. 

The  (piestion  of  heating  is  important.  It  is  best  to  have  a  combination  of 
different  systems.  Warm  air  may  be  thrown  into  the  wards  by  fans ;  steam 
may  circulate  in  pipes:  both  these  methods  ensure  a  steady  supply  of  heat, 
and  prevent  the  water  from  freezing  in  the  supply-pipes  in  cold  weather. 
0|)en  fires  are  cheerful ;  they  give  a  very  pleasant  radiating  heat,  contribnt(>  to 
ventilation,  and  offer  an  easy  way  of  disposing  of  small  unclean  substances, 
which  otherwise  mav  accumulate  and  vitiate  the  air  in  tlr  a1.  Stoves  com- 
bine  to  some  extent  the  (pialities  of  a  radiator  and  an  op.  ii  flrc,  and  they  are 
more  economical.  IJy  the  evaporation  of  water  the  air  should  be  prevent(>(l 
from  becoming  too  dry. 

The  isolating  department  should  be  separated  entirely  from  the  eomtnoii 
wards,  and  each  patient  should  exclusively  cMxnipy  a  room.  This  departnunt 
should  have  a  special  doctor  and  special  mirses,  who  are  not  allowed  to  enter 
the  wards.     The  physician-in-chief  alone  shotdd  see  the  whole  service. 

Water-closets  should  be  of  the  very  best  kind,  and  never  be  situated  in  the 
wards  or  in  the  rooms.  They  should  not  even  comnHuiicate  directly  witii  the 
wards  or  the  rooms,  but  should  hv  separated  from  them  by  vestibules  with 
two  doors.  In  the  space  between  the  doors  a  window  should  constantly  Ix' 
open,  and  tlie  doors  should  close  automatically, 

There  shoidd  be  a  place  where  all  linen  and  bed-clothes  used  by  sick 
puerperse  can  be  disinfected  by  immersion  for  an  hour  in  bichlorid  solution 
(1  :  1000)  before  they  are  washed  ;  if  mattresses  are  used,  there  should  be  a 
room  where  they,  as  well  as  the  blankets,  can  be  fumigated  with  sulphurous 
acid  by  burning  sidphur  or  be  disinfected  in'  exjxtsure  to  sujx'rheated  stcaii). 

No  visitors  should  be  admitted  to  the  wards,  as  they  often  come  fnnii 
crowded  tenement-houses  in  which  there  \\\i\\  be  cases  of  measles,  scarlet  f'cvd', 
small-j)ox,  or  diphtheria. 

The  members  of  the  house-staff  shoidd  not  be  allowed  to  enter  the  wards 
occupied  by  otlier  patients,  the  isolating-rooms,  the  dead-house,  and  still  Ic^s 
be  permitted  to  make  autopsies  or  to  handle  anatomical  or  pathological 
specimens. 

DlsiXKrxTlON. — To  niake  the  all-important  point,  disinfection,  as  clear  as 
possible,  the  writer  will  first  simply  describe  how  it  is  carried  out  in  the  Ma- 
ternity Hospital,  and  postjione  for  the  time  being  all  the  mooted  points  that 
are  being  discussed  in  tlie  medical  journals. 

The  principle  upon  which  the  disinfection  is  based  is  the  belief  that  puer- 
peral infection  is  due  to  bacteria  foinid  on  the  patient,  on  doctors  and  muses. 
on  all  surrounding  objects,  on  everything  brought  in  contact  with  the  genitals, 
and  in  the  air  of  the  room.  We  will,  therefore,  have  to  consider  the  disiiil'ic- 
tion  of  the  wartl  with  its  furniture,  of  the  patient  and  of  those  who  minister 


iiiiJ  IMP' 


PATIIOUXIV   OF    THE    Pf!i:iil'i:iiJ(M. 


71;^ 


to  hor,  of  all  instruments  and  materials  that  come  in  contact  with  her,  and  of 
the  air  that  reaches  her  genitals. 

Ward  Dmufccfiou. — When  the  last  patient  has  been  nine  days  in  a  ward 
it  is  not  used  again  until  thoroughly  disinfected.  The  bed-clothes  are  taken 
oil"  the  beds,  the  linens  are  sent  to  the  laundry,  and  the  blankets  are  s[)read 
nver  the  ends  of  the  bedsteads.  All  windows  and  doors  are  closed.  Thirty 
jxHuids  of  sulphur  are  placed  in  an  iron  utensil  composed  of  an  upper  and  lower 
pan  connected  by  three  uprights.  The  sulphur  is  ])ut  in  the  upper  pan  and  is 
moistened  with  alcohol.  The  lower  pan  is  filled  with  water,  which  would 
cxtitiguish  the  fire  in  case  the  upper  pan  was  burnt  through.  After  lighting 
the  alcohol  the  ward  is  left  closed  for  at  least  six  hours.  Afler  that  time  all 
doors  and  windows  are  opened,  and,  if  the  ward  is  not  needed  immediately, 
they  are  left  open  for  several  days.  The  walls,  the  floors,  and  the  furniture 
are  scrubbed  with  soap  and  water,  and  thereafter  with  a  solution  of  bichlorid 
ol"  mercury  (1  :  1000).  So  long  as  straw  mattresses  were  used  the  straw  was 
burned ;  the  patients  now  lie  on  woollen  blankets  spnuid  over  a  woven-wire 
mattress. 

All  iKHl-clothcs  used  by  sick  puerpene  an;  first  immersed  for  an  hour  in 
the  solution  of  bichlorid  of  mercury,  and  are  then  preliminarily  washed  before 
sending  them  to  the  hospital  laundry,  where  they  are  mixed  witii  the  other 
iMMl-linen.  Patients  and  nurses  wear  only  such  clothes  as  can  be  washed. 
The  clothing  of  the  doctors,  when  required  to  be  disinfected,  is  suspended 
ill  a  small  room  and  fumigated  with  sidphur. 

Dwnfcsthif/  the  Patient. — When  a  patient  is  taken  in  labor  she  is  given 
a  lull  bath  of  tepid  water,  being  thoroughly  scrubbed  witii  soap,  and  dressed 
ii!  clean  clothes.  She  is  next  place<l  on  the  delivery-bed  on  a  riil)ber  blanket 
tliat  has  iK'en  disinfected  with  bichlorid  (1  :  1000),  and  the  lower  half  of  her 
hixly  is  washed  with  bichlorid  of  inen^ury  (1  :  2000),  taking  particular  can;  to 
(lean  every  furrow  at  and  near  the  genitals  and  the  umbilicus.  The  vagina  is 
irrigated  with  two  quarts  of  an  emulsion  of  creolin  (1  :  100),  using  metal  irri- 
ixators.  In  case  bichlorid  is  used,  the  irrigators  are  painted  with  an  incor- 
rodible substance. 

Disinfection  of  the  Docfom  and  NurxeN. — The  accoucheur  takes  off  his  coat, 
vest,  necktie,  collar,  and  cuffs,  rolls  up  the  sleeves  of  his  shirt  and  iiiider-wcar 
til  tlie  middle  of  the  arm  above  the  elbow,  and  covers  himself  with  a  large 
nihlter  apron  reaching  from  the  shoulders  to  a  little  above  the  ankles.  He 
next  anoints  his  hands  and  arms  with  soft  potassa  soap,  and  scrubs  them 
tliin'oiighly  witli  warm  water  and  a  stiff  nail-brush,  taking  particular  care  to 
clean  the  sj)aees  under  the  nails  and  at  their  roots.  He  (hen  wii)es  his  hands 
and  arms,  and  scrapes  his  finger-nails  with  a  stecil  nail-sciaper,  and,  finally,  he 
scrubs  all  these  parts  while  holding  them  for  at  least  three  minutes  in  a  solu- 
tion of  bichlorid  of  mercury  (1  :  2000).  He  is  now  ready  for  work,  and  must 
iKit  wipe  his  hands  or  arms.  JJut,  as  it  is  next  to  impossii)le  to  avoid  touching 
(lill'cront  objects  from  which  new  disease-germs  may  be  transferred  to  the  hands 
of  the  physician,  a  basin  with  a  warm  solution  of  creolin  (1  per  cent.)  is  kept 


.■r^ 


I      ] 


!   < 


1  y 


i     K 


f^  '■•  ■ 


i  ! 


714  AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 

at  the  bedside,  and  with  this  sohitioii  he  rinses  his  hands  at  the  moment  before 
touching  the  patient.  Tiie  nurses  disinfect  themselves  witli  the  same  care  and 
in  the  same  manner  as  the  doctor. 

If  the  accoucheur  has  had  a  patient  affected  with  puerperal  infection,  ery- 
sipelas, scarlet  fever,  suppuration,  or  other  tlisease  likely  to  cause  puerperal 
infection,  he  must  take  special  precautions.  If  possible,  he  should  stay  a 
quarter  of  an  hour  in  a  full  warm  bath  containing  two  drachms  of  biehlorid 
of  mercury,  washing  the  hair  and  beard  carefully  while  in  the  water.  At  all 
events,  he  should  scrub  his  hands  with  greater  care  than  under  ordinary  circiuu- 
stanees,  and  should  inunerse  them  a  longer  time,  say  five  mimites,  in  a  stronger 
solution  (1  :  1000),  or,  what  is  claimed  to  be  still  more  efficacious,  in  alcohol. 

Dmnfvctimi  the  Mnteriah. — All  materials  coming  in  contact  with  the  gen- 
itals, such  as  absorbent  cotton,  lint,  etc.,  are  thoroughly  soaked  in  the  creolin 
solution. 

Dmnfedhuj  the  Imtruments. — All  instruments  are  disinfected  by  means  of 
immersion  for  at  least  five  minutes  in  a  5  per  cent,  solution  of  carbolic  acid, 
or  by  boiling  them  in  a  solution  of  washing-soda  (a  tablespoonfid  to  each 
quart  of  water),  and  they  are  cleaned  very  carefully  after  having  been  used. 
All  instruments  composed  of  several  parts  are  taken  apart,  the  tubular  oiks 
being  l)oiled.  For  axis-traction  forceps  it  is  necessary  to  have  a  key,  so  as 
to  be  able  to  take  off  the  traction-rods  every  time  the  instrument  has  been 
used.  Sajxtlio  used  with  a  brusii  is  excellent  for  scrubbing  instruments.  Xd 
sponges  are  used.  They  have  been  replaced  by  absorbent  cotton,  absorbent 
lint,  or  sterilized  gau/e. 

Sutures  and  ligatures  arc  of  course  carefully  disinfected.  Silkworm  ;)iit 
stands  boiling  in  water  and  is  kejit  in  alcohol.  The  writer  disinfects  catgut 
by  boiling  it  in  alcoiiol  in  a  closed  vessel.*  Silk  is  boiled  for  iialf  an  hour 
in  water,  immersed  for  half  an  hoiu'  in  biehlorid  (I  :  1000),  and  is  kept  in 
alcohol.  If  a  sterilizer  is  available,  it  suffices  to  expose  the  silk  to  the  eU'cd 
of  circulating  steam  for  an  hour. 

Aiifisfptic  t'oHitnct  of  fjdfjor. — Very  few  r(t(/iu(f/  examhmtiom  are  ma<l('  at 
the  Maternity  Hospital,  and  the  person  making  them  disinfects  his  hands 
immediately  before  tlie  procedure.  In  ordinary  cases  the  examining  finger 
should  not  be  brought  beyond  the  external  os.  We  know  that  pathogenic 
nn'crobes  may  be  found  in  the  vagina,  and  even  in  the  cervix,  and  they  are  hy 
no  means  sure  to  be  removed  l)y  the  preliminary  douche.  If,  therefore,  the 
finger  is  brought  from  the  vagina  into  the  cervix,  or,  still  worse,  into  the 
uterine  cavity,  it  may  carry  disease-germs  into  the  uterus. 

No /«/>/'/can/.s  are  used.  Tlie  creolin  a<lhering  to  the  finger  or  the  forceps 
is  all  that  is  needed.  The  only  exception  made  by  the  writer  is  when,  in  tlio 
operation  of  version,  the  whole  hand  is  introduced  into  the  womb,  in  which 
ease  the  dorsal  surface  of  the  hand  is  smeared  with  mollin  containing  o  |»i  r 

*This  iiu'tliod  (if  (icorKc  H.  FowUt  has  liceii  inade  easy  and  ocmiomical  hy  tlie  inliinliic- 
tidti  of  Charles  N.  D(nv(f's  ooiidensci'.  In  liospitals  it  siilllcos  to  Iniil  the  calgiit  iinnu'di.ilcly 
liefore  the  oiieration  in  a  casserole  with  cover  at  the  same  time  instruments  "re  lieing  Imilcil. 


ml 


J'ATIIOlJX.y   OF    THI-:    PrERPERIUM. 


i  10 


cent,  of  carbolic  acid.  In  protracted  cases  the  vajfiiial  douche  is  repeated 
every  three  hours. 

When  the  head  bcfjins  to  open  the  vulva  the  latter  is  covered  with  a  piece 

it"  lint  wruu}^  out  ot"  bichlorid  solution.     This  is  done  partly  to  prevent  the 

I  iitrance  of  microbes  from  the  air  in  the  room,  and  jiartly  because  it  facilitates 

all  manipulations  calculated  to  protect  the  perineum  by  obviating  slipperiness. 

C^reolin  would,  therefore,  not  be  so  appropriate  for  this  purjiosc. 

Tlic  placenta  is  removed  by  Cirde\^  ccprcsKion  method  (Fi^.  204);  that  is, 
ill  ordinary  cases  not  even  a  Hngcr  is  introduced  into  the  genital  canal  after  the 
itirth  of  the  child,  the  placenta  being  s(|ueezed  out  by  compressing  the  uterus 
through  the  abdominal  wall.  The  writer  docs  not,  however,  remove  the 
placenta  so  soon  as  recommended  by  Crede,  rarely  removing  it  earlier  than 
fifteen  miinites  after  the  birth.  The  membranes  should  be  removed  very 
slowly  and  cautiously,  as  they  adhere  to  the  iimer  surface  of  the  uterus ;  other- 
wise they  would  be  torn  off  and  remain  in  the  uterus,  thus  giving  rise  to 
puerperal   infection. 

If  on  inspection  any  part  of  the  placenta  is  missing,  the  well-disinfected 
hand  of  the  j)hysician  should  be  introduced  into  the  uterine  cavity  and  the 
missing  part  scraped  off  with  the  nails.     As  a  ndc,  the  writer  does  the  same 


I'll..  l'JJ.-(iiin-if.'iH's's  liiiiiilatif^. 'limrlii'-cini,  aii.l  iiiua-utci-iiif  luln':  1,  (lnuclif-can  ;  '.',  iutra-ulrriiR' 
lulir;  ;!.  pffitiriil  piul ;  I,  hcUy-liiiiiliT ;  .".,  ktu'c-liiiuU'r ;  f.,  mis|icH(Kts  in'i'ViMiliiiK  kiU'c-liiiiiUT  Iimih  sliiliim' 
ilnwii ;  7.  hicast-liiiiiltT  (from  a  iihotonriililO. 

t'nr  larger  portions  of  mcn»brancs.  If,  however,  the  rope  formed  by  tiie 
inciiibranes  breaks  and  the  uterine  end  is  witiiin  reach,  the  writer  sometimes 
tics  a  silk  thread  to  il,  since  the  retained  piece,  as  a  rule,  can  easily  be  reni<»ved 
the  following  day  by  pulling  on  this  ligature. 

Iidrn-utcrinc  injcctioitx  are  used  if  the  fingers,  the  hands,  or  the  instruments 


/"    1 


„iv 


ii 


716 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


liavc  been  introduced  into  tlio  litems.  The  fluid  injected  is  a  1  per  cent,  emul- 
sion of  creolin  at  a  temperature  of  from  110°  to  115°  F.  Tlie  apparatus  used 
for  the  injection  ccMisists  of  a  douclie-can  (Fig.  422/),  and  a  ghiss  tube  (Fii;. 
422,^),  having  a  iiole  at  the  end  and  several  on  the  sides  near  the  end.  Before 
introducing  the  tube  into  the  uterus  the  vagina  is  irrigated.  Great  care  should 
be  taken  in  introducing  the  tube.  The  distance  from  the  fundus  uteri  to  the 
rima  pudendi  should  be  mej'o.iiod  by  holding  the  tube  over  the  abdomen  and 
noting  how  far  the  tube  is  to  be  inserted.  The  left  index  and  middle  fingers 
are  introduced  into  the  cervical  canal  and  the  tube  is  inserted  between  tlKtm. 
It  should  be  ascertained  if  the  tube  goes  in  the  direction  of  and  reaches 
the  fundus  ;  this  can  be  done  by  feeling  the  resistance  offered  by  the  latter,  or 
frequently  by  feeling  the  end  of  the  tube  through  the  abdominal  wall.  If 
any  difficulty  is  met  with,  the  tube  should  be  withdrawn  a  little  and  reintro- 
duced in  another  direction.  The  douche-can  should  be  held  not  higher  than  a 
foot  above  the  uterus.  At  the  end  of  the  injection  the  fluid  remaining  in  the 
uterus  should  be  pressed  out. 

Dressing. — After  the  removal  of  the  placenta  the  patient  is  again  washed 
with  bichlorid  and  the  coagula  removed  from  the  pubic  hairs,  or,  if  the  latter 
are  long  and  matted  together,  they  should  be  cut  ofl*.  It  is  the  routine  prac- 
tice in  the  Maternity  Hospital  to  hold  the  uterus  compressed  for  half  an  hour 
after  delivery.  At  the  end  of  this  time  an  occlusion  bandage  (Fig.  422,^)  is 
laid  over  the  genitals  and  fastened  to  the  binder  (Fig.  422/).  Tliis  bandage 
consists  of  a  piece  of  absorbent  lint  (12  by  8  inches,  folded  twice,  so  as  to  be 
3  inches  wide)  reaching  from  the  genito-femoral  furrow  on  one  side  to  that 
on  the  other  side  and  covering  the  vulva  and  the  anus.  Tliis  pad  is  first 
wrung  out  of  the  creolin  emulsion,  and  after  being  applied  is  covered  with  a 
piece  of  oiled  muslin  measuring  an  inch  more  than  the  pad  in  both  directions. 
This  oiled  muslin  is  washed  with  creolin  and  is  turned  forward  on  the  inner 
side  of  the  thighs.  Outside  of  the  muslin  is  placed  a  somewhat  larger  pad 
of  dry  cotton  batting,  which  is  held  in  place  by  a  piece  of  unbleached  muslin 
half  a  yard  square  and  foldetl  like  a  cravat  (5  inches  wide),  which  in  front 
closes  a  A-shaped  opening  left  at  the  lower  end  of  the  binder,  and  which 
is  fastened  to  the  binder  with  four  pins.  Behind  only  two  pins  are  needed. 
This  dressing  is  changed  every  six  hours  and  every  time  the  patient  urinates  or 
has  a  movement  from  the  bowels.  On  making  the  change  a  bed-pan  is  pushed 
in  under  the  patient,  and  the  outer  surface  of  the  genitals  is  irrigated  witli 
creolin.     No  vaginal  injection  is  usetl.     The  genitals  are  not  even  touched. 

Erc/nt. — Contraction  and  involution  being  great  preventatives  of  puerperal 
infection,  a  drachm  of  fluid  extract  of  ergot  is  given  three  times  a  day  until 
an  ounce  has  been  used. 

Pirincnrrhaphy. — All  lacerations  of  the  perineum  are  repaired  immediately, 
the  best  material  for  suture  being  silkworm  gut. 

Catheterization. — AVhen  the  jiatient  is  unable  to  urinate,  the  vestibule  is 
washed  with  creolin  emulsion  and  a  well-disinfected  catheter  is  introduced.  The 
common  flexible  catheters,  made  of  some  woven  fabric  covered  with  varnish,  are 


■'     ,i\ 


[•  cent,  eiunl- 
paratus  used 
is  tube  (Fig. 
?nd.     Before 
t  care  should 
IS  uteri  to  tlic 
abdomen  and 
iiiddle  fingers 
letween  th(!ni. 
;■  and  reaches 
the  latter,  or 
nal  wall.     It" 
e  and  reintro- 
higher  than  a 
uaining  in  the 

!  again  washed 
)r,  if  the  latter 
e  routine  prac- 
r  half  an  hour 
(Fig.  422,^)  is 
This  bandage 
ice,  so  as  to  be 
le  side  to  that 
is  pad  is  first 
covered  with  a 
)oth  directions, 
■d  on  the  inner 
Ihat  larger  pail 
lleached  muslin 
livhich  in  front 
ler,  and  whieh 
lins  are  needed, 
lent  urinates  or 
ll-pan  is  pushed 
irrigated  with 
even  touched, 
es  of  puerpeial 
jnes  a  day  until 

(d  immediately, 

Ihe  vestibule  is 
Itroduced.  TIh' 
lith  varnish,  are 


PArilOLOGY   OF    THE  PrEnrEIilVM. 


717 


strictly  prohibited,  as  they  cannot  be  kej)t  clean.  The  best  catheters  are  of 
metal  or  of  glass,  which  can  be  boiled  and  be  kept  aseptic  in  a  solution  of 
ctu'bolic  acid  (5  per  cent.).  If,  exceptionally,  a  flexible  catheter  is  neetled,  it 
should  be  of  soft  rubber,  which  is  disinfecteil  with  the  5  per  cent,  solution 
(if  carbolic  acid. 

Si/riiiff('.s. — If  injections  are  used,  great  care  should  be  taken  to  disi'ifect 
the  syringe  nozzle  by  boiling  and  immersing  it  in  a  solution  of  corrosive 
sublimate.  Nozzles  employed  in  a  serious  case  should  preferably  be  destroyed, 
as  glass  nozzles  only  arc  used,  and  they  are  quite  inexpensive. 

Very  much  has  been  written  during  the  last  ten  years  respecting  preven- 
tion of  puerperal  infection,  and  opinions  concerning  it  differ  greatly  among 
leading  obstetricians ;  for  instance,  regarding  the  use  of  ergot,  which  some 
extol  and  others  look  upon  as  a  direct  promoter  of  infection ;  vaginal  injec- 
tions, which  in  the  eyes  of  some  are  superfluous  or  harmful  ;  and  vaginal 
examinations,  which  some  fanatics  would  abolish  altogether.  Bnt  since  none 
have  had  better  results  than  the  Xew  York  Maternity  Hospital,  with  a  total 
mortality  of  4  in  1059  cases,  and  few  as  good,  the  writer  does  not  recognize 
any  reason  for  changing  a  treatment  that  has  .served  so  well  for  over  ten 
years.  The  only  change  made  by  the  writer  is  to  substitute  creolin  (1  jier 
cent.)  for  corrosive  sublimate  for  vaginal  and  intra-uterine  douches,  on  account 
of  its  greater  safety,^'  and,  so  far  as  known,  some  of  his  colleagues  yet  use 
biehlorid  (1  :  4000). 

II.  Pkeventiox  of  Pierperat.  Infection  in  Private  Practice. — 
The  benefit  of  the  antiseptic  treatment  in  hospitals  has  been  so  enormous  that 
all  criticism  has  been  silenced  and  every  doubt  has  vanished.     From  one  end 
of  the  civilized  world  to  the  other  the  treatment  is  essentially  the  same.     But 
how  ditterent  is  it  when  we  come  to  private  practice !    So  recently  as  1875  the 
International  Congress  of  Physicians  and  Surgeons  assembled  at  Brussels, 
Helgium,  adopted  resolutions  to  the  effect  that,  on  account  of  the  great  mor- 
tality in  Ivintj-in  asvlums,  all  such  institutions  should  be  abolished.     Since 
that  time  the  tide  has  turned.    The  hospital  is  now  the  safe  place  for  a  woman 
to  be  delivered  in  ;  it  is  in  private  dwellings  that  the  danger  lurks.     The  poor- 
est, the  dirtiest,  and  the  most  dissolute  women  are  safely  confined  in  a  lying-in 
asyhun  ;  the  richest,  the  youngest,  the  purest,  and  the  loveliest  sometimes  suc- 
cumb in  giving  birth  to  a  child  in  their  own  homes.     In  the  private  obstetric 
practice  of  the  writer  there  is  neither  death  nor  sickness  referable  to  infection, 
wiiile  in  consultation  practice  he  frequently  sees  death  follow  childbirth  or 
abortion.     What  is  the  cause  of  the  difTcrence?     It  is  only  that  the  writer 
n<es  strict  antisepsis,  and  that  many  general  practitioners  do  not.     Some  smile 
henigidy  at  the  mere  thought  of  using  such  superfluous  measures  in  private 
praetice ;  others   have  a  little  mercuric  chlorid   or  carbolic  acid  around  the 
house,  but  use  it  without  system  or  jierseverance.     Still,  there  is  nuich  greater 
danger  of  the  ]>atient   being  infected  by  the  doctor  or  the  nurse  in  private 
practice  than  in  a  well-appointed  lying-in  asylum.   The  young  men  composing 
the  house-staff  of  a  Iving-in  asvlum  are  strictlv  forbiilden  to  enter  the  wards 


,';      fli 


!?;:■ '.1 


I '  /""  ■■! 


718 


AMFJilVA.y  TKXT-nOOK  OF  OliSTETlilCii. 


mi 


of  a  hospital ;  tlicy  lia^'c  no  ])rivat('  practicT ;  tliov  do  not  .see  an  antojisy  ;  and 
if,  nnt'ortunatcly,  the  asylum  is  a  dt'|)iirtnK'nt  of  a  jfcni'ral  hospital,  the  elothcs 
and  the  bodios  of  tiie  nurses  before  goinj;  from  one  ilepartnient  to  another  arc 
subjected  to  thorough  disinfection  under  the  supervision  of  their  superiors. 
In  private  practice,  on  the  contrary,  the  physician  nuiy  have  treated  a  case 
of  diphtheria  or  of  erysipelas  a  n\oinent  before  being  called  to  a  continenient  ; 
and  nearly  all  private  inirses  take  prouiiscnonsly  medical,  surgical,  and  obstet- 
rical cases,  disinfecting  themselves  as  best  they  know  how  or  according  as  (he 
combat  between  innate  laziness  and  acquired  conscientiousness  ])rompts  them. 

As  a  matter  of  fact,  the  mortality  in  ])rivate  |)raetice  is  twice  as  large  as 
that  in  hospital  |)ractice,  or  larger.  Out  of  cvcri/  hiimlird,  viiivti/-Jin',  or  crrn 
ei(//iti/-iii)U'  ii'oincn  (Itlirtird  i>i  \cw  York  or  other  hirr/e  ciflcs  in  j>rivatc  })raf- 
ticc,  one  tliea;  that  is,  up  to  1.12  per  cent,  against  O.G,  O.o,  or  even  0.4  per 
cent,  in  the  best  lying-in  establishments. 

Country  practitioners  are  still  greater  opponents  of  antiseptic  midwiferv 
than  their  jjrofessional  brethren  in  the  cities,  the  country  practitioner  relying 
on  the  purity  of  the  atmosphere  in  which  he  works  and  on  the  robust  constitu- 
tions of  his  patients.  If,  however,  these  conditions  niay  help  the  women  to  get 
well,  they  cannot  to  any  great  extent  prevent  thenj  from  being  taken  ill.  In 
many  respects  country  |>ractice  exposes  the  patient  even  more  to  infection  than 
does  city  life.  In  most  places  there  is  no  drainage.  Manure  is  spread  over  the 
fieltls  or  the  garden  close  to  the  house  in  which  live  the  fanner  and  his  wife. 
The  village  butcher  kills  his  cattle,  lets  the  blood  soak  into  the  ground,  and 
nails  the  skins  to  the  barn-doors,  whence  their  odor  can  be  smelt  far  awav. 
The  country  practitioner  cannot  go  home  and  change  clothes  and  bathe :  lie 
must  make  his  round  or  he  would  never  get  through  with  his  work  ;  and  thus 
it  happens  that  the  same  hand  that  was  thrust  into  a  ju'rineal  abscess,  that  per- 
formed tracheotomy  on  a  child  sutl'ering  from  diphtheria,  or  that  dressed  a 
patient  attacked  by  bullous  erysipelas,  at  the  next  house  is  brought  up  to  the 
fundus  of  the  uterus  in  order  to  take  away  an  adherent  placenta. 

The  same  antiseptic  precautions  that  have  revolutionized  lying-in  asylums 
should  be  used  as  well  in  ])rivatc  practice,  be  it  in  the  city  or  in  the  coimtry. 
On  October  27,  1892,  the  Obstetric  Section  of  the  New  York  Academy  of 
Medicine  unanimously  passed  the  following  resolution  : 

"  W/inrcui,  Experience  both  in  this  country  and  abroad  shows  that  by  strict 
antisej)tic  measures  the  total  mortality  in  lying-in  hosj)itals  may  be  reduced  to 
a  few  per  thousand  ; 

"  ]yhere<(s,  Deaths  due  to  childbirth  or  to  abortion  are  yet  common  in  private 
practice ; 

"  Bemlred,  That  in  the  opinion  of  the  Obstetric  Section  of  the  New  York 
Academy  of  Mwlicinc  it  is  the  duty  of  every  physician  practising  niidwitcry 
to  surround  such  cases  in  private  practice  with  the  same  safeguards  that  :ire 
being  used  in  hospitals." 

In  practice  in  well-to-do  families  we  should  choose  a  large,  airy,  sunny 
room,  situated   as  far  as  possible  from  the  water-closet.     Should,  howevtr, 


\^ 


PATlIOIAUiV   OF    THE   VVKUPElilVM. 


719 


finion  in  private 


tlio  lyiiig-in  room  bo  close  to  the  watc'r-(!lo.st't  with  a  door  leading  direc-tly 
from  the  one  totiie  otiier,  this  door  shoidd  he  locked,  and  some  of  Piatt's  chlo- 
lid  or  other  powerful  disinfectant  should  be  poured  frequently  into  the  basin. 

Instead  of  lint,  the  writer  uses  for  the  pad  in  private  practice  absorbent 
cittton,  and  instead  of  oiled  iiuislin  he  uses  gutta-perclia  tissue.  The  pad  is 
not  changed  in  tiie  middle  of  the  night.  The  patient  is  directed  to  have  two 
liasins,  two  pitchers,  and  a  Ibuntain  syring(!,  which  articles  are  personally 
cleanseil  by  the  writer  before  bringing  them  intt)  use. 

In  the  dwellings  of  the  poor  tiie  antiseptic  precautions  may  bo  nnich  sim- 
pliHcd  and  yet  be  (juite  elective.  Tiic  perineal  pad  may  be  made  of  common 
<()tton  batting,  and  the  gutta-j)ercha  tissue  may  be  disj)enscd  with.  A  tin 
basin  may  be  nswl  instead  of  a  bed-pan.  Tiie  do(!tor  can  easily  carry  in  his 
satchel  some  tablets  of  corrosive;  sid)limate  and  a  couple  of  ounces  of  creolin, 
and  thus  be  prepared  to  disinfect  himself  and  his  patient  at  slight  expens<!  to 
Iiiniself  and  none  to  his  patient.  Intra-uterine  douches  can  be  made  with  a 
soft-metal  catiieter  costing  fifty  cents,  or  with  a  nvw  flexible  catlieter  costing 
twenty  cents.  The  uterine  sound  used  as  a  stylet  greatly  facilitates  the  intro- 
duction of  a  flexible  catheter. 

No  one  can  ftyresee — the  average  general  practitioner  least  of  all — whi'*^  ci)m- 
plications  may  arise  during  labor.  Where  an  easy  delivery  has  been  ]iromise<l 
the  iicalthy  primipara,  it  may  become  necessary  to  perform  version,  symphvsiot- 
oniy,  or  craniotomy,  the  result  of  either  of  which  oj)erations  depends  almost 
entirely  on  the  aseptic  or  septic  condition  of  the  patient  at  the  time  of  its 
performance,  taking  for  granted  that  tlie  operator  uses  all  antiseptic  precau- 
tions. The  (h)cfor  and  the  imrxc  should  k)iow  (hat  thci/  jrojuirdize  their  patieiit'a 
life  by  Introdumng  into  her  vmjina  (t  fiiu/er  fh<tf  /.s  not  dmiifeeted.  During  labor 
dangerous  microbes  will  not  be  destroyed  by  phagocytes  or  by  the  chemical 
composition  of  the  secretions,  as  wo  arc  told  they  are  under  other  circumstances. 
Upon  the  whole,  labor  in  private  practice  should  be  conducted  essentially  in 
the  same  way  as  that  described  for  lying-in  hospitals. 

III.    ClTUATIVK  TUKATMENT   OF    PlTElJPKIlAL  Im'KCTIOX. — Thc  CUrativo 

is  much  less  effective  than  the  preventive  treatment.  Since  infection,  in  the  vast 
majority  of  cases,  takes  place  in  the  genital  canal,  the  first  indicated  procedure 
is  the  removal  of  the  microbes  that  have  not  yet  entered  the  tissues,  which 
removal  is  effected  by  ablution  and  injection  with  antiseptic  fluids.  The 
second  procedure  is  to  seal  the  entrances,  which  is  done  by  means  of  cauteri- 
zation. A  third  procedure  is  to  clean  the  intestinal  canal  by  an  aj)ericnt  or 
by  enemas.  A  fourth  procedure  is  to  sustain  the  strength  of  the  patient  in 
oid(>r  to  give  her  a  chance  to  throw  off  the  poison  that  already  has  entered  her 
tissuos  or  that  circulates  in  her  blood.  Stimulants  are  therefore  usc<l  freely  ; 
as  much  food  is  given  as  it  is  possible  for  the  patient  to  digest ;  and  tonic 
urngs  are  administered.  A  fifth  procedure  is  to  cond)at  pain,  which  indication 
is  met  by  narcotics  and  ice.  The  sixth  and  final  procedure  is  to  redu<!e  the 
l)aticnt's  temperature  if  it  becomes  dangerously  high,  which  is  done  by  ice-bags, 
by  an  ice-water  coil,  by  refreshing  ablutions,  or  by  cooling  baths. 


'  1j 

!' 

{ 

\ 

720 


AM/CRIt'AX    TEXT- no  OK    OF   OBSTETRICS. 


In  describing  the  details  of  tlie  treatment  followed  in  combating  puerperal 
infection  the  same  anatomical  categories  will  be  used  as  in  the  preceding  pages, 
but  the  reader  must  bear  in  mind  that  what  is  described  under  ditl'erent  head- 
ings is  really  one  and  the  same  disease,  modified  only  by  tiie  intensity  of  liic 
affection  or  by  the  nature  of  the  tissue  affected.  To  avoid  endless  repetitions, 
a  mode  of  treatment  will,  as  a  rule,  only  be  mentioned  under  that  organ  in  the 
alfeetions  of  which  it  is  chiefly  employetl,  but  with  the  understanding  that  a 
similar  condition  in  another  organ  calls  for  similar  measures.  Thus  the 
means  of  reducing  the  temperature  are  discussed  under  Peritonitis,  but  what 
is  saitl  there  applies  as  well  to  eases  in  which  there  is  a  high  temperature  with- 
out peritonitis. 

Sometimes  the  lochial  discharge  becomes  fetid,  there  is  a  moderate  rise  in 
the  temperature  not  exceetling  102°,  some  acceleration  of  the  pulse,  but  no 
tenderness,  no  swelling,  and  no  ulceration.  This  condition  is  probably  due  to 
a  veri/  mild  degree  of  infection  with  saprophytes.  Often  a  blootl-clot  hidden  in 
the  deep  pouch  at  the  posterior  fornix  or  in  the  interior  of  the  uterus  is  the 
cause  of  such  a  condition.  Health  is,  as  a  rule,  soon  restored  bj-  using  dis- 
infectant vaginal  injections  of  creolin  or  of  carbolic  acid  every  three  hours, 
by  moving  the  bowels,  and  by  administering  5  grains  of  quinin  three  or  four 
times  a  dav. 

Vulvitis  and  Vaginitis. — The  catarrhal  inflamniation  of  the  external  gen- 
itals calls  only  for  the  above-mentioned  vaginal  douches  three  times  a  day. 
Simple  ulcers  may  besides  advantageously  be  dusted  with  iodoform,  with  der- 
matol,  or  with  stearate  of  zinc,  or  be  covered  with  iodoform  ointment : 


^.  Iodoform!, 

Balsami  peruviani, 
Vaselini, 


3j; 
3ij; 

5i).— M. 


If  the  sores  become  diphtheritic,  it  is  the  practice  of  the  writer  to  touch  thcin 
with  a  solution  of  chlorid  of  zinc : 


I^.  Zinci  chloridi, 
Aqufe  destillatse, 


ad    3j, 


which  is  applied  by  means  of  a  stick  wound  with  absorbent  cotton.  The 
caustic  should  be  applied  very  thoroughly,  and  be  held  in  contact  for  a 
minute.     The  vagina  is  then  syringed  with  creolin  or  with  carbolic  acid. 

If  the  perineum  has  been  stitched,  the  sutures  should  be  removed,  as  the 
torn  surface  is  already  or  will  be  infected,  and  it  must  be  treated  in  the  ubovi'- 
mentioued  way.  Tears  in  the  deeper  part  of  the  vagina  are  exposed  by  means 
of  a  speculum.  The  application  of  zinc  being  very  painful,  the  parts  should 
be  made  insensible  with  a  10  per  cent,  solution  of  cocain,  or  general  anesthesia 
must  be  produced.  The  vaginal  injections  are  repeated  every  three  hours. 
Once  in  twenty-four  hours  the  parts  are  inspected,  and  if  new  patches  have 
formed  the  same  procedure  is  repeated. 


h 


PATlIOIJKiV    OF    THE    VVEUPKUUM, 


721 


ng  puerperal 
w'tling  pagf>, 
itVcrent  hcad- 
teii!*ity  of  tlif 
srt  rcpetiticnis, 
t  organ  in  tlu' 
Hiding  that  a 
•s.     Thus  tlu- 
mii»,  but  what 
iperature  with- 

loderate  rise  in 
pulse,  but  no 
)rol)ably  due  to 
l-clot  hidden  in 
e  uterns  is  the 
I  bj-  using  dis- 
?ry  three  hours, 
lin  three  or  four 

he  external  geu- 
•ee  times  a  day. 
otbrm,  with  dor- 
intraent : 

y; 

kij.— M. 

ler  to  touch  thcin 


tnt  cotton.     The 
gn   contact  for  a 

carbolic  acid. 
I  removed,  as  the 
led  in  the  ahnvc- 
Ixposed  by  means 
Ithe  parts  should 
leneral  anestlu^sia 

[cry  three  hniu's. 

liew  patches  have 


The  application  of  chlorid  of  zinc  brings  out  the  diphtlicritic  infiltration 
lauch  more  distinctly,  the  atlccted  part  l)econiing  milk-white.  Fiatcr,  there  is 
lormed  a  grayish  slough  wiiich  is  very  nuich  like  a  diphthcriti(!  patch.  To 
listinguish  old  slouglis  from  iicn*  patches  the  physician  must  remember  where 
lie  has  cauterized  the  preceding  day,  and  pay  attention  to  the  contour  (»f  the 
iill'ected  place.  A  slough  produccil  by  cauterization  has  a  plain  curved  outline, 
while  that  of  a  new  diphtheritic  patch  has  a  scalloped  outline,  the  infiltration 
-preading  more  rapidly  at  one  point  than  at  ^Mother. 

The  object  to  be  attaiue<l  by  cauterization  is  both  to  kill  the  nucrobes 
(iiimd  in  and  near  the  woiuul,  and  to  seal  lymphatics  and  veins  leading  from 
tlic  ulcer  to  the  deeper  parts.  The  writer  has  found  chlorid  of  zinc  nnich 
niore  eflectivc  fi»r  this  {)i;rpose  than  tincture  of  iodin,  iodofi)rm,  licpior  ferri 
subsulphatis,  or  li(pior  fcrri  chloridi. 

The  general  treatment  consists  in  giving  an  aperient  if  the  bowels  have 
not  moved  freely,  5  grains  of  quiniu  every  four  hours,  half  an  ounce  of 
l)i'andy  or  of  whiskey  with  e(pial  parts  of  milk  or  water  every  two  hours. 
For  a  change  egg-nog  may  be  substituted  two  or  three  times  a  day.  If  strong 
li(luor  is  not  well  borne,  it  may  be  replacf!  by  a  corresponding  amount  of 
port,  sherry,  tokay,  or  angelica  wine,  but,  :»s  a  rule,  alcohol  can  be  taken  in 
large  amounts  without  producing  intoxication. 

rf  there  is  (/aur/rene  of  the  vulva  or  of  the  vagina,  the  stimulant  treatment 
should  be  pushed  still  more,  the  dead  tissue  should  be  removed  with  knife 
and  scissors  as  soon  as  feasible  after  the  formation  of  a  line  of  demarcation, 
and  healing  be  promoted  with  iodoform  or  with  camphor  emulsion  (see  under 
Bed-mrrs). 

Endometritis  and  Metritis. — If  the  large  size  of  the  uterus,  its  tenderness, 
anil  the  discharge  of  a  dirty  and  offensive  Huid  show  that  the  uterus  itself  is 
tiic  scat  of  inflammation,  the  (piestion  to  be  decmled  is  whether  it  is  emj)ty  or 
whether  it  contains  parts  of  the  secundines.  If  there  is  the  slightest  doubt  in 
tills  respect,  the  first  thing  to  be  done  is  to  anesthetize  the  jiatient,  place  her  on 
a  table,  in  the  dorsal  posture  with  elevated  bent  knees.  The  physician  then 
lubricates  his  hand  and  introduces  it  into  the  vagina,  thrusting  one  or  two 
fingers  into  the  interior  of  the  womb.  If  necessary,  the  whole  hand  may  be 
introduced.  In  either  case  the  operator  should  examine  systematically  the 
whole  endometrium,  and  especially  be  sure  to  reach  both  ostia  uterina  of  tlu; 
Fallopian  tubes,  where  often  a  piece  of  placenta  is  retained.  The  finger-nails 
are  used  as  scrapers.  The  other  hand  of  the  physician  is  laid  fiat  on  the 
fnndns,  steadies  the  uterus,  and  brings  the  fundus  within  easier  reach.  If 
possible,  it  is  of  great  advantage  to  enter  the  finger  at  one  edge  of  the  part  to 
be  rc.iioved  and  to  take  away  the  part  in  one  piece.  Often,  however,  we  nuist 
remove  the  part  piecemeal.  It  is  not  necessary  to  withdraw  the  hand.  By 
pressing  the  loosened  part  between  the  fingers  and  the  palm  of  the  hand  the 
ii.'-siie  to  be  removed  is  made  to  follow  the  inner  surface  of  the  arm  down  to 
the  OS. 

If  the  uterus  has  contracted  too  much  to  allow  the  hand  to  be  introduced^ 

46 


'k : 


if 


J^ 


722 


.lJ//;/.'/r.LV   THXT-liOOK  or  <)l{STi:Tlil(\S. 


and  the  ohstotriciaii  caMiiot  reach  tlio  fiiiuliis  witli  (lii>  (iiipTs,  (>v(>ii  hv  prcssin'^' 
well  on  it  fVoiii  tlic  outside,  lie  may  oiiiploy  instead  a  lar^c  didl  wire  eiiredf. 
This  instnunent  is  14  iiieiies  lon^,  lias  a  shank  a  <|n:irtei'  of  an  in<;h  thick, 
and  an  eve  lar^c  enou;j;h  to  admit  the  tip  «)t'  the  thnmb.  In  nsing  the  eurettc 
the  writer  as  a  ride  prei'ers  to  place  the  patient  in  the  Sims  position,  lie 
has  iisetl  the  wire  curette  as  early  as  the  end  of  the  sihioiuI  month  ol'  prcif- 
nancy  ip  abortion  eases,  alter  having  dilated  the  cervix  with  IlanUs's  and  lii> 
own  dilators.  At  a  still  earlier  period  the  writer  uses  the  Simon  sharp  spoon. 
Whenever  it  is  possible  ilie  let't  Ibrelinfier  should  be  introduced  beside  the 
large  curette,  so  as  to  be  able  to  teel  the  part  to  be  r(>inove<l  and  to  s<'i/c  it 
between  the  linker-tip  and  the  eye  of  the  curette,  which  is  safer  than  any  kind 
of  placental  forceps.  The  curette  is  not  only  used  to  remove  swiindiiies,  bin 
may  also  be  used  to  scrape  away  sponjiy  tissu(>  beloiij;inji  to  the  uterus  itself. 

Many  obstetricians  are  ojiposed  to  the  use  of  the  curette  in  obstetrit;  cases, 
n)aintainiii}r  as  an  arffiimcnt  that  new  wounds  are  produced  by  it,  and  that 
blood  accumulates  and  forms  a  fertile  soil  for  bacteria.^"  In  the  writer's 
experience  the  cnrett*'  is  of  j;rcat  value — nay,  indispensable — in  abortion  cases, 
but  after  ct)iilinement  he  always  uses  the  hand  if  possible,  f f  the  instrunieiit 
i.s  first  uswl  after  the  poison  is  no  lonjier  localized  and  iXw.  ])atient  is  pru- 
foiindly  septic,  the  cuiette  can  accomplish  very  little. 

When  the  internal  surface  is  smooth  tli(>  uterus  is  washed  out  with  two  or 
three  pints  of  ereolin  (1  per  cent.)  or  of  carbolic  acid  (2  per  cent.),  the  patient 
beinjif  in  the  dorsal  decubitus.  If  there  is  much  bleediii};,  this  intra-iiteriiie 
douche  sluMild  be  }>;iven  (piite  hot  (11')°  F.).  If  an  anesthetic  is  not  adiiiin- 
istered,  hot  water  is  very  painful,  and  lukewarm  water  is  preferred,  except  to 
check  liemorrhaije. 

St)me  obstetricians  pack  the  uterine  cavity  with  iodoform  jjau/e.  In 
obstetric  cases,  which  alone  concern  us  here,  the  writer  prefers  the  introduc- 
tion of  an  iodoform  suppository  : 


I^   Todoibrmi, 
Amyli, 
(ilycerini, 
Acaciie, 
Ft.  siippositoria  Xo.  iij,  of  the  .size  and  shape  of  t 


.'5ss; 
f.^s^  : 


tintrer. 


The  use  of  such  a  suppository  renders  fre(|iient  repetitimi  of  ilie  iiitia- 
uterino  douches  siiperHuous.  As  a  rule,  the  suppositories  are  usini  only  (Hiic 
in  twenty-four  hours. 

The  suppository  is  introduced  through  a  bivalve  speculum  by  means  df  a 
forceps  having  a  curvature  like  that  of  the  uterine  sound.  A  coiiiiiion 
dressing  forceps  is  unsuitable  for  this  purpose,  as  it  does  not  penetrate  liir 
enough  and  it  is  apt  to  wound  the  uterus.  Sometimes  it  is  iinneeessaiy  to 
repeat  the  intra-uterine  treatment,  the  condition  of  the  patient  being  satisfac- 
tory.    Vaginal  douches   are   usetl    instead,  and   they  are   also   einj)loye(l  as 


j'ATj/o /.()(,)'  or  Tin:  i'ri:ix'i'i:iii(M. 


T'J.l 


n  by  prcssiiv^ 

win'  <'Uirtti . 

m  inch  thitk, 

Hjr  tll«'  i'UlVtti 

|)(»s\tit>n.     Hi 
loiith  of  prc^j;- 
anUs's  iuul  hi> 
I)  sliiirp  spoon. 
rd   lu'sidi"  till' 
ami  to  seize  it 
than  any  kiiul 
secundini'Si  l>'it 
lie  uterus  itself, 
obstetrics  eases, 
l)y  it,  and  tliat 
In  the  writer's 
1  ab«)rtion  oases, 
'  tlio  instnuiieiit 
I  patient  is  pm- 

ont  with  two  or 
out.),  the  patient 
his  intra-utcM-iiie 
ic  is  not  admin- 
-ferred,  exeepl  to 


form  puize. 


In 


L'rt  the  introdnc- 


,r  tiuiier. 

,,„  of    the  intr;»- 
Jir  ust'd  only  uiiiv 

Itn  by  moans  ol'  u 
id.  A  eoiniiioii 
Lot  penetrate  I'm' 
lis  unntH-'Ossary  to 
Int  boinjj;  satisliu'- 
ilso  cmphiyed  a^^ 


;i  supplement   to  the   intra-nterino   injeetioii.s.     They   are  jjivon   every  three 


hiiiirs, 

Moforo  omptyinj;  the  nterns  it  Is  a  j;«m)<1  plan  first  to  wash  it  out  with 
several  liters  of  boiled  water,  which  washinj^  removes  a  ^jreal  many  microbes 
I lial  otherwise  ini};ht  be  carried  into  the  ti.ssnes  with  the  nails  or  the  <'iirette, 
(aiisMifjj  a  chill  lidlowed  i)y  I'evor.  The  elTcct  Is  merely  mechanical,  and  the 
ivsidt  in  preventing?  chills  ami  fever  is  just  as  ^o(»d  with  plain  Hterlllzed  water 
a.-  with  solntions  of  bichlorid  ol"  niercnrv,  carbolic  acid,  or  lysol." 

If  .several  days  have  elapsed  since  the  Ini'cction  took  |)laco,  Unmm  recom- 
mends the  use  of  the  <'nrotto.  Under  snch  circumstances  he  stales  that  pack- 
in};  with  lod(»form  gauze  is  nnich  to  be  preferred  to  injoetionH.  The  gauze 
keeps  the  uterus  dry  and  proviMits  the  propagation  of  putrefaction.  In  .septu; 
infection — that  is,  when  the  microbes  at  work  are  of  the  pathogenic;  k I ntl — 
these  measnros  become  much   more  unr(>llable. 

The  Intra-uterlne  Injections  reached  their  acme  when  junndiinif  irri(/<ifi<»i. 
was  reconunench'd.  The  uterus  was  first  washed  out  with  a  5  per  cent,  .solu- 
tion of  carbolic  add,  after  which  wa.shing  a  <u)ntlinu)us  .stream  of  INIInnich's 
.stilntlon — that  is,  water  containing  K)  per  cent,  of  sulphite  of  .sodium  and 
h  per  cent,  of  glycerin — was  kept  circulating  through  the  uterus  by  means  of 
two  ruliber  ttdx's  introduced  up  to  the  fundus.  This  treatment  has,  however, 
heen  abandonetl,  even  In  (Jermany,  where  it  orlgliuited,  as  it  does  no  good,  but, 
on  the  contrary,  does  a  great  <leal  of  harm.^'' 

Even  in  regard  toconunon  intra-uterino  injections  opinions  vary  very  nuich 
among  leading  obstetricians,  and  upon  the  whole  the  tendencry  is  rather  to 
re,>;trict  their  u.se  considerably.  Pippingskold  of  Ilelsingfors,  Finland — who 
has,  or  at  least  diu'ing  four  years  from  1884  to  1887  had,  the  smallest  mor- 
tality the  writer  ev(>r  saw  mentioned,  namely,  O.'Ji)  per  cent. — uses  them 
only  once  or  twice  a  year  in  a  service  varying  from  five  hundred  to  eight 
liinidred  patients  jwr  annum.'''  Sehrader  condemns  them  altogether,  because 
tliey  provoke  Jiterlne  contractions,  and  thereby  a  rapid  circulation  of  lymph, 
wliieh  ])romote,s  general  infection.'*  According  to  Humm,  the  intra-uterlne 
injections  are  good  In  putrid  endometritis,  and  even  in  the  septic  form  if  the 
iiiierobes  have  a  low  degree  of  virulenc(>,  in  which  (!asc  the  process  remains 
Ideal  ;  but  in  other  cases  they  do  more  harm  than  good. 

The  virulent  microbes  rapidly  invade  the  ti.ssnes.  Jn  cases  of  infection 
from  another  pnerpera  or  from  a  patient  atTeeted  with  erysipelas,  diphtheria, 
]ilil('irmon,  etc.,  the  local  treatment  comes  too  late.  When  there  are  clinical 
-ii;ns  of  abs()r])tion — pelvic  ]»eritonitis  or  metastases — local  treatment  is  use- 
less, and  it  may  do  haruj  by  inflicting  new  wounds,  by  tearing  open  aggluti- 
nated ones,  by  disturbing  beginning  encapsulation  of  septic  foci,  by  causing 
tluMlisplaeement  of  infected  thrombi,  etc.''''  Fraidv  uses  G  to  8  liters  to  wash 
lint  a  utern.s.*''  Kroenig  found  that  in  septic  Infection  there  were  as  many 
stre|)ti)coeei  a  few  hours  after  Intra-uterlne  anti.septic  Injections  as  before,  and 
that  their  virulence,  te.«ted  on  rabbits,  was  undiminished."^ 

'Painj)onage  with  Iodoform  gauze  may  occaslomdly  be  valuable.     Thus  a 


I 


724 


AMERICAN    TEXT-BOOK  OF   OBSTETRICS. 


case  is  reported  in  wiiich  the  placenta  had  been  retained  for  eight  days.  When 
the  doctor  found  lie  could  not  remove  it  he  tainponetl  the  uterus.  The  fol- 
lowing day  he  removed  a  part  of  the  placenta  with  the  curette,  tamponed 
again,  and  the  next  day  removed  the  remainder  of  the  placenta  with  tho 
curette/"  The  gauze  ought  to  be  removed  soon,  but  not  all  at  once,  since  the 
uterus  cannot  contract  in  proportion.^" 

Involution  is  promoted  by  the  administration  of  ergot  and  the  application 
of  the  faradic  current,  both  poles  being  api)lied  externally,  one  at  the  fundus, 
the  other  alternately  at  botli  sides  just  above  the  pelvic  brim. 

Inflammation,  and  es})ecially  pain,  are  combated  by  means  of  an  ice-bay; 
placed  on  the  abdomen  just  above  the  symphysis.  To  avoid  local  free/iiii;- 
four  layers  of  muslin  should  be  laid  between  the  bag  ami  the  skin.  Instead 
of  the  ice-bag  there  may  be  used  a  rubber  coil  through  which  ice-water  is 
made  to  circulate.  The  ice-bag  or  the  coil  is  to  be  kept  on  continually  day 
and  night. 

Cold  is  j)referable  to  heat,  as  it  is  more  soothing,  abridges  the  course  of 
the  disease,  and  perhaps  even  has  some  direct  antiseptic  value,  certain  microbes 
being  restrained  from  developing,'^"  while  a  moist  warm  application  offers  the 
very  best  chances  for  the  development  of  all  lower  life.  If,  however,  cold  is 
contra-indicated,  as  in  diarrhea,  low  vitality,  puerperal  diphtheria,  etc.,  warm 
flaxseed-meal  poultices  should  be  placed  on  the  abdomen. 

When  the  disease  enters  on  a  more  subacute  stage,  the  writer  uses  a  Priess- 
nitz  compress ;  that  is,  a  towel  wrimg  out  of  coid  water,  placed  on  the  abdomen, 
and  covered  with  some  waterproof  material.  The  pad  becomes  warm  in 
a  quarter  of  an  hour,  and  is  renewed  four  times  a  day.  This  transition  from 
cold  to  heat  is  a  very  powerful  absorbent,  and  it  is  well  liked  by  patients. 
Internally  there  arc  given  5  grains  of  quinin  four  or  six  times  a  dav, 
small  doses  of  an  opiate  pro  re  nata,  and  a  moderate  amount  of  stimulants. 

If  inspection  of  the  cervix  shows  diphtheritic  patches,  the  treatment  is 
much  more  energetic  ;  then  the  whole  cervix  up  to  the  os  internum  is  cauter- 
ized with  the  above-mentioned  solution  of  ehlorid  of  zinc,  the  uterus  is  washed 
out  with  antiseptic  Huid,  and  there  is  left  in  it  an  iodoform  siq)posit()rv. 
These  injections  are  repeated  once  in  twenty-foiu"  hours,  and  a  new  supposi- 
tory is  introduced.  This  treatment  is  continued  until  all  sloughs  are  thrown 
off  and  fever  has  ceased.  A  warm  jxjidtice  is  applied  over  the  abdonicn. 
liarge  and  fre([tient  doses  of  strong  stimulants  should  be  given — at  least  IimH' 
an  ounce  of  whiskey  or  of  brandy  every  two  hours. 

Digitalis  may  be  needed  as  a  heart  tonic,  preferably  in  the  form  of  tlir 
officinal  infusion  (.^ss,  four  times  a  day) ;  but  if  the  patient  cannot  swallow  or 
vomits  the  medicine,  the  tincture  may  be  injected  hypodermatically  in  doses 
of  from  5  to  10  minims,  r(>peate(l  according  to  circumstances.  Tincittire  of 
strophanthus  in  do.ses  of  5  or  6  minims  is  also  an  excellent  heart  tonic,  <^li- 
nin  is  given  in  moderate  doses,  not  with  a  view  of  reducing  the  temperature, 
but  as  a  tonic  and  antiphlogistic,  one  of  the  ])roperties  of  this  drug  beinii  to 
prevent  the  migration  of  the  leucocytes  from  the  blood-vessels.''' 


m 


PATHOLOGY   OF    THE   PVEllPEItlUM. 


725 


t  diivs.  WluMi 
riis.'  The  lol- 
■otto,  tanipoiu'd 
L-enta  with  the 
once,  since  the 

the  application 
;  at  the  tinulus. 

m. 

s  of  an  ice-hati 
1  local  freeziiii; 
3  skin.  Instead 
lioh  ice-water  is 
t'ontinually  day 

res  the  course  of 
certain  microlx's 

lication  otVers  the 
however,  cold  is 

Lheria,  etc.,  warm 

iter  uses  a  Priess- 
1  on  the  abdonuMi, 
jeconies  warm  in 

s  transition  tVoin 

iUeil  by  patients, 
six    times  a  day, 

nt  of  stimulants. 

the  treatment  is 

iternum  is  canter- 
uterus  is  waslicd 

form  suppository. 

\(\  a  new  supposi- 


louj^hs  are  thrown 

the  abdomen. 

— at  least  half 


,-er 
ren 


the  form  of  the 
•annot  swallow  or 
naticallv  in  dosi's 


Tinctur 


(■  III 
(Jni- 


Ices. 

lieart  tonic. 

the  temperatmv, 

this  druj;  beiivi  to 


In  dmccthif/  mctrititi  the  process  of  elimination  is  often  .so  protracted  tljat 
the  use  of  poisonous  anti.septics,  such  as  corrosive  sublimate  and  carbolic  acid, 
becomes  dangerous.  Under  such  circumstances  the  writer  has  foinid  a  satu- 
rated solution  of  boric  acid  suitable.  All  intra-uterine  injections  should  be 
warm,  as  a  cold  Huid  sometimes  causes  collapse. 

Piitri'ficcnce  of  (he  litems  is  a  condition  that  has  disappeared  from  all  well- 
(n-dered  lying-in  institutions  since  strict  a-scptic  or  antiseptic  treatment  has  been 
introduced.  If  a  case  shoidd  come  under  the  observation  of  the  writer,  he 
woidd  treat  it  with  creolin  injections,  iodoform  suppositories,  alcohol,  quinin, 
and  albuminoid  food.  If  possible,  dead  tissue  should  be  removed  with  the 
large  didl-wire  curette,  but  the  operation  is  dangerous,  and  it  should  be  per- 
iormed  with  the  utmost  care,  as  there  is  considerable  danger  of  perforating  the 
solt  uterine  wall,  and  infection  of  the  new  wounds  might  aggravate  the  patient's 
condition. 

Cellulitis  and  Adenitis  are  treatetl  with  the  ice-bag,  and  later  with  the 
I'riessnitz  compress.  If  the  resolution  is  unduly  slow,  the  abdominal  wall 
over  the  swelling  .should  be  painted  once  a  day  with  tinctiu'c  of  iodin.  After 
this  application  has  been  repeated  for  a  few  days,  and  the  e})idermis  has  become 
hard,  the  writer  covers  the  abdominal  wall  with  a  piece  of  lint  soaked  in  the 
following  wash : 


I^.  Acidi  carbolici, 
(ilycerini, 

A(pi!C, 


Si); 

M.  .siij. 


Bse 


This  preparation  softens  the  epitlerniis,  prevents  cracking,  and  promotes 
alisorption  of  the  iodin. 

When  the  tenderness  has  been  so  much  reduced  that  a  specidum  nuty  be 
used,  it  is  well  to  combine  the  external  painting  with  that  of  the  vaginal  vaidt, 
and  thus  bring  the  'odin  more  in  direct  contact  with  the  aifected  part.  This 
ii|)|)lication  is  repeated  every  three  days.  Care  shoidd  be  observed  to  take 
so  little  of  the  tincliu-e  on  the  brush  or  applicator  that  it  does  not  trickle  down 
to  the  vulva,  where  it  burns,  while  it  is  not  felt  at  all  on  the  i()rnix.  In 
and)nlant  ])atients  it  is  well  to  wii)e  off  the  redundant  tincture  with  ab.sorbent 
cotton  befori    ibey  rise  from  the  table. 

If  sup])uration  sets  in,  it  shotdd  be  hastened  by  means  of  warm  llaxseed- 
iiical  poultices ;  when  the  ab,sce,ss  is  formed  it  should  be  opened  vith  the 
knili'  through  the  skin  or  the  vagina,  or  both.  If  there  is  any  doid)t  as  to 
the  presence  of  ])us,  it  maybe  settled  by  using  a  hypodermic  syringe  or  an 
asjjiratiug  needle.  The  common  hypodermic  .syringe  is  too  short,  but  one  may 
lie  made  having  an  attachment  to  the  ca.se  and  the  pi.ston.*  If  there  is  pu.s, 
the  needle  may  be  u.sed  as  a  guide  for  the  knife.  Some  surgeons  u.se  a  trocar. 
Dr.  Hache  Enunet  con.structed  a  trocar  that  at  the  .same  time  carries  a  drainage- 
tniie.^-  Some  canulas  iiave  holes  through  which  they  may  be  fastened  to  the 
*  X  very  satisfactory  instrument  of  this  kind  has  been  made  for  the  writer. 


/ 


i; 


72G 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


I   ! 


vagina  with  silver  wire.  Both  in  puncturing  and  in  cutting,  the  wound  must 
be  made  behind  a  line  drawn  transversely  through  the  cervical  canal,  in  order 
to  keep  clear  of  the  ureter  and  of  the  uterine  artery.  The  surgeon  should 
likewise  feel  for  and  avoid  vaginal  arteries.  Often  one  or  more  drainage- 
tubes  are  inserted. 

These  operations  should  be  performed  with  full  antiseptic  precautions. 
The  best  way  of  disinfecting  the  vagina  is  to  rub  it  with  tinctura  saponis  viri- 
dis  carried  on  absorbent  cotton  or  on  gauze  held  in  a  long  forceps,  and  to  irri- 
gate with  corrosive-sublimate  solution  (1  :  2000). 

If  an  abscess  communicates  with  the  intestine  and  does  not  close,  a  countor- 
opening  should  be  made  in  the  abdominal  wall  or  in  the  vagina,  and  thorough 
drainage  be  established.  If  a  fistulous  tract  remains  leading  from  the  pelvis 
to  the  vagina  or  the  skin,  and  the  patient's  life  is  in  danger  from  exhaustion, 
a  cure  may  yet  be  ac(!omplislied  by  vaginal  hysterectomy,  with  or  without 
salpingo-oophorectomy,  but  the  operation  may  be  a  very  difficult  undertaking. 
The  internal  treatment  is  the  same  as  stated  before. 

Lymphangitis. — Lymphangitis  of  the  vulva  and  the  groin  is  treated  with 
compresses  soaked  in  a  lead-and-opium  wash  : 


I^.  Tincturae  opii, 

Li(pioris  plnmbi  subacetatis  diluti, 
Sig.  For  external  use. 


.5SS  ; 
q.  s.  ad  5viij. — M. 


r 


'i1! 


\i\ 


If  the  inflannnation  runs  into  suppuration,  the  treatment  is  the  same  as  tliat 
above  described  for  suppurative  cellulitis.  Lymphangitis  of  the  uterus  is  treated 
with  ice-bags,  opiates,  saline  aperi  nts,  quinin,  and  .dcohol. 

Peritonitis, — Opinions  are  much  divided  as  to  the  advisability  of  using 
antiseptic  intra-uterine  injections  in  peritonitis.  Personally,  the  writer  gives 
one  injection,  on  the  assumption  that  besides  the  microbes  which  already  have 
found  their  way  from  the  uterus  to  the  peritoneal  cavity,  and  which  are  beyond 
reach,  there  may  be  others  in  the  uterine  cavity  that  it  may  be  advantageons 
to  remove.  The  writer  has  never  seen  any  bad  effect  from  this  practice,  while 
sometimes  it  seemed  to  do  good. 

The  abdomen  is  covered  with  two  large  ice-bags,  whose  weight  is  dinun- 
ished  by  suspending  them  from  a  cradle.  Instead  of  the  ice-bags,  a  rubber  inil 
\,  ith  circulating  ice-water  may  be  employed.  It  is  only  when  the  above-named 
counter-indications  against  ice  are  present  that  a  warm  flaxseed-meal  poultice 
should  be  substituted. 

A  remedy  of  the  greatest  value  in  ])uerj)eral  peritonitis  is  opium,  given  in  ;is 
large  doses  as  the  patients  can  stand — and  they  can  stand  enormous  doses — tlie 
only  indication  to  stop  being  the  ecmdition  of  the  respiration.  It  is  perlcctiy 
safe  to  give  the  drug  in  doses  repeated  at  short  intervals  until  the  respiratdiy 
movement  sinks  to  14,  or  even  to  12,  per  minute.  The  best  opiate  for  this  pur- 
pose is  morphin.  To  relieve  pain  as  promptly  as  possible  it  is  well  to  txirin 
with  a  hypodermatic  injection  of  a  quarter  of  a  grain  of  the  drug.    Afterwiwd 


PATHOLOGY    OF    THE  PUERPERIUM. 


127 


'■'  it,;<s|: 


n  r        j;  ft    ^ 


n  is  treated  with 


the  same  as  tlint 
uterus  is  troatcd 


it  is  better  to  give  the  medicine  by  tlie  mouth,  because  too  many  injections 
would  be  needed  ;  because  they  ouglit  only  to  be  given  by  the  doctor;  because 
the  medicine  is  brought  directly  to  the  affected  i)art ;  and  because  hypodermatic 
injections,  if  not  given  with  the  greatest  care,  disinfecting  both  the  instrument 
ami  the  skin,  are  apt  to  can!-«  abscesses  which  may  prove  a  serions,  even  fatal, 
loinplication.  In  this  way  ^  to  J  grain  is  given  every  half  hour  until  the 
patient  is  fully  under  the  iiiHuence  of  the  drug — that  is  to  say,  is  free  from 
pain,  and  yet  not  in  a  deeper  narcosis  than  that  from  which  she  can  easily  bo 
aroused. 

Lawson  Talt  pointed  out  the  danger  of  using  opiates  after  laparotomies, 
and  the  advantages  of  moving  the  bowels.  This  treatment,  which  undoubtedly 
is  a  great  advance  in  gynecology,  should,  in  the  writer's  opinion,  not  be  applied 
to  puerperal  peritonitis.  In  the  writer's  younger  years  the  treatment  with 
aperients  was  in  vogue,  and  he  is  still  harassed  by  the  memory  of  the  poor 
tortured  women  who  were  plied  with  senna  and  were  given  insignificant  doses 
of  opium;  with  that  plan  the  mortality  was  much  greater.  With  the  "opiimi 
plan "  he  has  saved  one-half  of  the  cases  affected  with  general  jjcritonitis.'*^ 
Others  have,  however,  diametrically  opposite  views  on  this  sidyect.  Gott- 
sc'halk,  for  instance,  keeps  the  bowels  open  and  rarely  uses  opiates.^' 

If  morphin  has  too  depressing  an  effect,  especially  if  the  heart  is  weak, 
atropin  may  be  added  to  the  morphin.  By  adding  1  part  of  atropin  to  1000 
of  Magendie's  solution  the  latter  may  be  given  according  to  the  above  rule : 

1^.  Atropina;  sidphatis, 

Solutionis  morphina3  (Magendie), 
Sig.  Four  to  eight  minims  as  prescribed. 

Alcohol  should  likewise  be  given  in  very  largo  doses,  from  half  an  ounce  to 
one  oimce  every  two  hours  or  oftener.  The  writer  gives  ((iiinin  in  the  inod- 
(Mute  dose  of  5  grains  every  foin-  hours,  which  periods  of  administration  keep 
up  the  iuHuence  of  the  drug  continually. 

No  aperient  medicine  is  given.  An  evacuation  takes  place  from  time  to 
time  spontaneously,  and  if  it  does  not  an  enema  is  given.  Pure  glycerin 
(lij-li)  ""•.V  be  used.  The  hygroscopic  ])roperty  of  the  glycerin  attracts 
iiuich  fluid,  softens  scybala,  and  lubricates  the  passage.  Another  good  rectal 
injection  is  composed  of  a  (piart  of  fiaxseed-meal  tea  with  a  tablespoon  fid  of 
castor  oil  and  a  teaspoonful  of  oil  of  turpentine.  A  still  more  powerful  enema 
is  made  of  inspissated  ox-gall  (a  teaspoonful)  or  fresh  gall  (a  tablespoonful), 
glycerin  and  castor  oil  (a  tablespoonfid  of  each),  table  salt  (a  heaping  teaspoon- 
fnl),  and  flaxseed-meal  infusion  (a  tabl(>spoonful  to  a  (piart  of  water). 

Frank  has  seen  (>xcellent  residts  from  the  subcutaneous  injection  of  pure 
creasotc  .'{  grams  (45  minims)  pro  dh;  or  from  an  emulsion  of  creasote  and 
oleum  camphoratum,  Tm.  half  a  gram  (8  minims),  beginning  with  0.5 
^i'lam  morning  and  evening,  and  increasing  the  dose  gradually.  The 
injection  is  nuule  deeply  into  the  gluteal  region  or  into  the  muscles  of  the 
spiiie.'''' 


.^ij.-M. 


iM 


mm 

mm 


''  I 


!    •• 


^:\ 


728 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


Occasionally  digitalis  or  stropliantluis  may  be  used  as  a  heart  tonic,  and 
strychnin  is  employed  as  a  general  tonic,  especially  as  a  tonic  for  the  res- 
piratory organs.  When  used  as  a  respiratory  stimulant  the  hypodermatic 
method  is  preferable. 

For  vomiting  cocain  and  hydrocyanic  acid  are  the  best  remedies.  The 
hydrochlorate  of  cocain  may  be  given  by  the  mouth  or  hypodermatically  (gr. 
\,  repeated  every  two  hours).  The  hydrocyanic  acid  the  writer  gives  by  the 
mouth  in  the  following  mixture: 


I^.  Acidi  hydrocyanici  diluti, 
Acidi  citrici, 
Sodii  bicarbonatis, 
Syrupi  rubi  Idaei, 
Aquae  destillatse. 


3ss; 

aa.  gij; 
Iss; 
ad  5vj. — M. 


Sig.  A  tablespoonful  every  one,  two,  or  three  hours. 

An  ice-bag  placed  over  the  pit  of  the  stomach  is  also  useful  in  restraining 
vomiting. 

The  diet  consists  of  milk,  beef-tea,  and  oatmeal  gruel.  The  beef-tea  may 
be  made  of  fresh  mi'iced  meat,  which  is  put  into  a  bottle  with  just  water 
enough  to  touch  all  the  meat,  the  water  being  acidulated  by  adding  a  little 
dilute  hydrochloric^  acid.  The  bottle  is  corked  and  boiled  for  an  hour  in  a 
pot  of  water.  This  beef-tea  makes  a  very  strong,  nourishing,  and  stinuila- 
ting  food,  which  is  taken  with  a  teaspoon.  If  more  bulk  is  desired,  the  beef-toa 
is  prepared  by  taking  a  pound  of  minced  beef,  a  teaspoonful  of  dilute  hych'o- 
chloric  acid,  and  a  pint  of  cold  water.  This  mixture  is  left  for  an  hour  or 
more,  and  is  stirred  every  quarter  of  an  hour  ;  it  is  then  placed  over  the  fire,  and 
is  taken  off  as  soon  as  it  reaches  the  boiling-point.  It  is  strained  through  a 
cloth,  and  salt  is  added  to  taste.  The  beef-tea  may  also  be  made  witii  the 
different  j)repared  extracts,  such  as  those  of  Valentine,  Armour,  or  Moiis- 
(juera.  Liebig's  meat  extract  is  less  suited  for  this  purpose.  Max  Kuntfo 
and  his  followers  give  even  solid  food — eggs,  veal  cutlet,  and  ham.*** 

To  give  an  idea  of  the  amount  of  morphin,  alcohol,  and  food  that  may 
be  administered,  the  writer  may  mention  that  one  of  his  patients  who  recovered 
took  in  twenty-three  days  21(5  grains  of  morphin,  228  ounces  of  whiskey, 
1078  ounces  of  milk,  and  418  ounces  of  beef-tea,  making  an  average  of  'J 
grains  of  morphin,  9|  ounces  of  whiskey,  45  ounces  of  milk,  and  7^  ounces 
of  beef-tea  in  twenty-four  hours.  The  greatest  amount  of  morphin  given  in 
one  day  was  13f   grains. 

jNIany  obstetricians  make  extensive  use  of  antipyretic  remedies — large  doses 
of  quinin,  salicylate  of  sodium,  antipyrin,  antifebrin,  phenacetin  ;  others  arc 
strenuously  opposed  to  their  use,  and  the  writer  belongs  to  the  latter  ealegoiy. 
These  drugs  rather  mask  than  cure  the  disease.  Some  of  them — salicylate  of 
sodium  and  antipyrui — are  particularly  objectionable,  because  they  weaken 
the  patient.     The  best  is  phenacetin  (gr.  v  every  four  hours),  since  it  lowers 


art  tonic,  and 
3  for  the  res- 
hypodermatic 

medies.  Tlu^ 
-matically  {p: 
r  gives  by  tlic 


in  restraniiuff 

lie  beef-tea  may 
with  just  water 
adding  a  little 
jr  an  hour  in  a 
ig,  and  stimuhi- 
rcd,  the  beet-tea 
of  dilute  hydro- 
for  an  hour  or 
)ver  the  fire,  and 
■ained  througli  a 
made  with  tlie 
inour,  or  M«>iis- 
Max  Kuii^'o 
A  ham.*" 

food  that  niiiy 
;s  who  recovered 
ices  of  whiskey, 
m  average  of  1) 
,  and  Ih  ounees 
liorphiu  given  in 

lies— large  doses 
|etin  ;  others  are 
latter  categitry. 
L — salicylate  of 
Ise  they  weaken 
since  it  lowers 


PATHOLOGY   OF   THE  PUERPEItlUM. 


729 


the  temperature,  combats  pain,  and  does  not  to  the  same  degree  weaken  the 
heart.  In  this  class  may  be  reckoned  carbolic  acid,  which  the  writer  has  given 
with  good  effect  in  cases  of  offensive  diarrhea : 


I^.  Acidi  carbolici  purissimi, 
Liquoris  iodi  compositi, 
Mucilaginis  acaeite, 
Syrupi  aurantii, 
Aquffi  destillatae, 
Sig.  A  tablespoonful  every  hour. 


M.  TTlxvj; 

fl-5ij  ; 
.Sss; 
q.  8.  ad  Sviij. — M. 


The  best  way  of  reducing  the  high  temperature  is  the  external  application 
of  cold.  In  addition  to  the  ice-bags  on  the  abdomen  an  ice-cap  may  be  placed 
on  the  head,  for  which  purpose  some  are  made  in  the  shape  of  a  helmet.  It 
is  grateful  to  the  patient  to  be  washed  over  the  whole  body  with  equal  parts 
of  alcohol  and  cold  water,  but  this  has  a  more  refreshing  than  a  really  an- 
tipyretic effect.  The  latter  is  obtained  by  a  Kibbee  fever-cot,  the  cold  pack, 
or  the  cold  bath.  The  fever-cot  consists  of  a  wooden  frame  havino;  a  net- 
work  of  cord,  under  which  is  a  rubber  sheet  forming  an  inclined  plane 
toward  one  end  of  the  oot,  where  a  water-pail  is  placed.  A  folded  blanket 
is  laid  over  the  netting  to  protect  the  patient  against  being  cut  by  the  cords, 
and  a  rubber-covered  pillow  is  laid  at  the  head  of  the  cot.  A  folded  sheet  is 
laid  across  the  middle  two-thirds  of  the  cot,  the  patient  being  so  placed  that 
tliis  sheet  reaches  from  her  armpits  to  the  trochanters.  Her  clothes  are 
drawn  up,  and  her  legs  are  covered  with  woollen  stockings  and  a  blanket. 
Bottles  containing  hot  water  may  be  placed  against  the  soles  of  her  feet. 
The  sheet  is  folded  over  the  patient's  chest  and  abdomen,  and  water  is 
poured  gently  from  a  pitcher  over  the  sheet,  beginning  with  water  at  a  tem- 
jK'rature  of  from  85°  to  90°  F.,  and  gradually  diminishing  it  to  from  75°  to 
80°  F.  This  aj)plication  is  continued  for  a  quarter  of  an  hour,  when  the 
])atient  is  covered  up.  At  the  end  of  each  hour  the  procedure  is  repeated  if 
the  temperature  again  rises. 

Where  the  fever-cot  is  not  ojtainable  the  cold  pack  may  be  substituted  in 
the  following  way  :  Two  beds  are  each  covered  witii  a  rubber  or  an  oil-eloth 
sheet,  over  which  is  placed  a  blanket,  and  over  the  blanket  is  laid  a  nuislin 
slieet  wrung  out  of  cold  water.  The  patient  is  placed  on  the  wet  sheet,  which 
is  wrapped  around  her  except  at  the  feet.  If  the  circulation  is  bad,  hot-water 
bottles  or  hot-water  bags  may  be  i)laccd  against  the  soles,  one  or  two 
l)Iaiikets  being  laid  over  the  patient.  At  the  end  of  ten  minutes  she  is  re- 
moved to  the  second  bed,  where  the  same  procedtu-e  is  repeated.  Foiu"  )r  six 
siieh  packs  may  be  needed  to  reduce  the  temjM'rature  as  nnich  as  is  wanted, 
and  the  handling  of  the  patient  may  cause  her  pain  and  necessitates  the  help 
of  three  nurses. 

The  patient  is  less  disturbed  by  the  cold  batli,  which  is  a  powerful  refrig- 
erant, cU'id  which  should  be  given  in  the  following  manner :  A  bath-tub  is 


1 


■.^ 


i 


780 


AMERICAN  TEXT- BOOK  OF  OBSTETRICS. 


I 


filled  with  water  slightly  below  blood-teraperatiirc,  into  which  bath  the  patient 
is  gently  let  down,  carrying  her  on  the  sheet  of  the  bed  upon  which  she  has 
been  lying.  The  water  is  then  gradually  cooletl  by  withdrawing  warm  and  sul)- 
stituting  cold  water,  until  it  reaches  80°  F.  It  is  well  to  give  the  patient  a 
tablespoonful  of  brandy  before  the  bath,  and  she  must  be  watched  carefully 
by  the  physician  while  she  is  in  the  bath  ;  at  any  sign  of  collapse  she  should 
be  removed  from  the  bath ;  otherwise  she  may  remain  in  it  for  fifleen  or 
twenty  minutes. 

In  local  peritonitis  laparotomy  is  indicated  if  milder  remedies  have  not 
the  desired  effect;  and  since  it  is  often  difficult  to  decide  whether  the  peritoni- 
tis is  general  or  is  localized,  it  is  better  to  give  the  patient  the  benefit  of  the 
doubt.     Several  cures  under  such  circumstances  have  been  reportetl.'*' 

By  turning  out  the  large  curdled  masses  and  the  sero-fibrinous  or  the  puru- 
lent fluid,  washing  out  the  peritoneal  cavity  with  peroxid  of  hydrogen,  and 
leaving  a  glass  drainage-tid)e  for  further  escape  of  the  fluid  or  gas,  it  would 
seem  that  we  increase  the  chances  of  the  patient ;  but  if  we  want  to  operate  at 
all,  we  should  not  wait  until  her  whole  system  is  poisoned  and  death  is  inuni- 
nent.  The  condition  is  not  totally  different  from  cases  of  rupture  or  of  gunshot 
wounds  of  the  intestine  or  of  the  bladder,  in  which  early  operation  yields  very 
fair  results,  and  certainly  much  better  than  the  expectant  method.* 

Still,  as  some  patients  recover  by  medical  treatment,  and  since  in  fatal  cases 
the  operation  may  seem  to  have  caused  the  death  of  the  patient,  recourse  to 
laparotomy  has  so  far  been  rather  limited  during  the  acute  stage  of  the  disease. 
If  the  i)atient  gets  over  this  stage  and  there  are  left  encystetl  peritonic  exuda- 
tions, the  operation  ought  to  be  })erformed. 

Pleurisy. — If  the  infection  locates  in  the  ])leura,  producing  pleuritis,  there 
should  be  applied  to  the  chest  an  ice-bag,  which  is  not  only  very  effective*  in 
soothing  the  pleuritic  pain,  but  also  abbreviates  the  course  of  the  disease.  If, 
however,  the  affected  part  caiujot  be  reached,  warm  applications  should  be  pre- 
ferred, either  flaxseed-meal  poultices  or  spongiopiline — that  is,  a  piece  of  gutta- 
percha-covered  felt  which  only  needs  dipping  into  hot  water. 

In  the  exudative  form  of  j)leurisy  tincture  of  icnlin  may  be  painted  on  tlio 
skin.     Internally,  the  iodid  of  potassium  and  diuretics  are  given,  for  exami)lo: 


I^.  Tritici  repentis  radicis  decoctionis,  5ss-oviij  ; 

Potassii  acetatis, 
Potassii  bitartratis, 

Potassii  citratis,  da.  .^j. — M. 

Sig.  A  tablespoonful  from  four  to  six  times  a  day. 


The  amount  of  fluid  in  the  ))leural  cavity  is  rarely  large  enough  to  call  for 
thoracentesis  by  aspiration.  If  the  fluid  becomes  purulent,  the  empyema  should 
be  operated  on  by  resection  of  a  jiiece  of  a  rib. 

Pneumonia. — When  the  lungs  become  inflametl,  the  chest  should  be  mv- 
*  T.  H.  Rurchard  collected  39  eases  with  23  recoveries ;  that  is,  60  per  ccnt.^ 


PATHOrAHiV   OF    THE   PUERPERIUM. 


731 


ered  with  large  warm  flaxseed-mcal  poultices  well  protected  with  oiled  mus- 
lin, and  a  flannel  binder  with  sshoulder-straps  of  flannel.  These  poultices 
need  not  be  changed  more  than  four  or  six  times  in  twenty-four  hours.  Stim- 
ulants and  tonics  are  highly  indicated.  A  favorite  j)rescription  of  the  writer 
is  citrate  of  ammonia,  obtained  by  mixing  the  carbonate  with  citric  acid : 

I^.  Animonii  earbonatis,  gij. 

Div.  in  chart.  No.  xij. 
Sig.     No.  1,  one  powder  four  times  a  day. 

I^.  Acidi  eitrici, 

Sacchari,  aa.  gij. — M. 

Div.  in  chart.  No.  xij. 
Sig.    No.  2,  one  powder  four  times  a  day,  mixed  with  No.  1. 

Perhaps  this  preparation  serves  to  dissolve  the  fibrinous  exudation,  or  perhaps 
it  only  acts  as  a  stimulant.  Care  should  be  taken  to  change  the  position  of  the 
patient  to  prevent  stagnation  of  blood  by  gravitation.  If  edema  supervenes, 
dry  cupping  is  valuable. 

Endocarditis  and  Pericarditis. — If  the  pericardium  is  inflamed,  the  treat- 
iiiont  consists  in  the  same  external  apjilications  am  .liureties  as  those  recom- 
mended for  pleuritis.  The  inflannnation  of  the  endocardium  is  hardly  within 
roach  of  therapeutic  measures.  Ice-bags,  digitalis,  and  strophanthus  may,  how- 
ever, be  tried. 

Enteritis. — Offensive  diarrhea  is  best  combated  with  internal  antiseptics — a 
ininiin  of  carbolic  acid  in  a  mucilaginous  menstruum,  repeated  every  hour, 
(Hiinbiiu'd  or  not  with  the  same  amount  of  liquor  iodi  composita ;  naphthalin 
(n''-  '.)~^''.)  every  two  hours) ;  or  salol  (gr.  v  every  two  hours).  Enemas  with  a 
t('asj)oonfnl  of  starch  and  25  drops  of  laudamnn  give  great  relief  when  the 
patient  suffers  from  tenesmus.  A  heaping  teaspoonful  of  subnitrate  of  bis- 
muth may  be  added  to  advantage. 

Hepatitis. — Pain  in  the  right  hypoehondrium  may  be  relieved  with  an  iee- 
biig  or  with  a  Haxseed-meal  poultice.  If  the  bowels  are  constipated,  calomel 
(t;'r.  v-x)  is  preferred  as  an  aperient  on  account  of  its  cholagogue  properties. 

Nephritis. — A  warm  flaxseed-meal  poultice,  or  a  bag  with  digitalis  leaves 
(lipped  in  hot  water,  is  placed  under  the  loins.  Diuretics  are  given  (see 
I'lcnnxjl).  Small  doses  of  chloral  hydrate  (gr.  xv-xx  one  to  three  times  a 
(lay)  diminish  the  albumin  in  the  urine.  Chlorid  of  iron  may  be  given  in 
the  following  form: 

I^.  Tincturne  ferri  chloridi,  .^ss  ; 

Syrupi  simplieis,  .^j  ; 

Aqute,  <|.  s.  ad  .^viij. 

Sig.  One  tablespoonful  four  times  a  day. 

To  j)rotect  the  patient's  teeth  she  should  be  directed  to  gargle  with  a  solution 


Lh 


732 


AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 


>r  r-ii 


1:1    ' 


of  sodium   bicarbonate  (3ij-3viij)  after   taking  the  medicine.     Warm  baths 
are  useful. 

If  uremic  symptoms  appear,  elimination  through  the  skin  and  the  intestiiir 
must  be  attempted.  To  accomplish  elimination  through  the  skin  the  most 
powerful  means  is  a  hot-air  bath,  which  may  be  obtained  by  placing  an  alco- 
hol lamp  under  a  chair  beside  the  bed,  an  open  umbrella  over  the  abdomen 
of  the  patient,  and  then  covering  both  with  a  waterproof.  Perspiration,  how- 
ever, is  weakening,  and  it  ought  not  to  be  prolonged  over  two  hours. 

Free  evacuation  of  the  bowels  should  be  obtained  by  the  most  powerful 
drastic  purgatives,  such  as  croton  oil  (|  drop  every  half  hour)  administered  in 
pill  form  or  in  castor  oil  or  in  almond  oil,  or,  if  the  patient  cannot  swallow, 
mixed  with  butter  and  rubbed  on  the  tongue ;  common  elaterium  (gr.  \-\ 
every  hour) ;  Clutterbuck's  elaterium  (gr.  \),  elaterin  (gr.  tVtV)>  ^^'  gamboge 
(gr.  1  every  half  hour). 

The  diet  should  consist  exclusively  of  milk,  either  in  its  natural  state,  or 
peptonized,  or  as  koumiss,  or  as  matzoon.  These  preparations  of  milk  should 
be  given  only  in  small  quantities  (tablespoonful  or  even  teaspoonful  doses),  and 
if  even  they  cannot  be  retained  recourse  should  l)e  had  to  rectal  alimentation 
with  Leube-Roscnthal's  solution,  Rudisch's  becf-peptonoids,  or  an  egg  with 
half  an  ounce  of  brandy  and  3J  ounces  of  milk. 

Vomiting  is  combated  by  hydrocyanic  acid,  cocain  (see  Pe)'itonitis),  bismuth, 
strychnin,  tincture  of  iodin,  carbolic  acid,  croasote,  or  lumps  of  ice,  and  an  ice- 
bag  or  a  turpentine  stupe  applied  to  the  pit  of  the  stomach. 

Encephalitis  and  Meningitis. — If  localization  takes  place  in  the  brain 
or  its  envelopes,  little  is  to  be  expected  of  therapeutical  measures.  The  head 
should  be  covered  with  the  above-mentioned  ice-cap  or  an  ice-water  coil.  The 
bowels  should  be  kept  loose.  Ergot  and  liquor  barii  chloridi  (TTtv  q.  4  h.) 
may  be  given,  besides  quinin,  with  a  hope  of  causing  contraction  of  the 
cerebral  blood-vessels  and  checking  the  migration  of  white  blood-corpuscles. 

Delirium,  restlessness,  <tnd  insomnia  are  quieted  by  bromids,  chloral, 
cannabis  indica,  opiates,  sulphonal,  or  trional.  Abscesses  in  the  subcuta- 
neous or  subfascial  connective  tissue  are  opened  and  treated  according  to  tlio 
rules  of  antiseptic  surgery. 

Arthritis. — If  localization  takes  place  in  a  joint,  it  should  first  of  all  he 
immobilized  by  proper  splints  and  bandages,  but  in  such  a  way  as  not  to  in- 
terfere with  other  treatment.  In  the  beginning  an  ice-bag  applied  around  the 
inflamed  joint  has  often  an  excellent  effect.  Later,  tincture  of  iodin  or  lly- 
blisters  may  serve  as  counter-irritants.  If  the  effusion  becomes  purulent,  the 
joint  should  be  em])tied  with  the  aspirator-needle  and  be  injected  with  a  solu- 
tion of  carbolic  acid  (3  to  5  per  cent.),  creoliu  (2  per  cent.),  or  peroxid  ot' 
liydrogen.  If  this  treatment  does  not  suffice,  the  joint  should  be  laid  oj)en  i)y 
a  free  incision. 

Skin. — Puer])eral  cutaneous  eruptions  hardly  call  for  special  treatment.  If 
they  itch,  considerable  relief  may  be  obtained  from  bathing  the  skin  with  the 
following  solution  of  carbolic  acid : 


PATIIOIAJdV   OF    Till':    rCEIU'EllUM. 


733 


f  > 


Warm  baths 


I^.  Acidi  carbolici, 
Alooholis, 
(jilycerini, 
Aqiui', 


3.SS ; 

ful.  oSS ; 
q.  s.  ad  .5vj. 


Bed-Hores  should  be  treated  very  carefully.  A;  >(  as  the  skin  becomes 
rod  over  the  sacrum,  the  trochanters,  the  heels,  oi  uuier  places  exposed  to  pres- 
sure, the  |)atient  should  be  |Maced  on  suital)le  rubber  air-cushions,  and  so  far 
lis  possible  be  shifted  so  as  not  to  press  on  the  att'ectcd  spot.  Under  the  heels 
are  placed  rubber  rings  filled  with  air,  or  a  similar  contrivance  is  improvised 
hy  winding  a  strip  of  nuislin  in  a  spiral  line  along  a  wad  of  oakum,  thus 
lurming  an  elastic  ring  into  the  opening  of  which  the  heel  fits.  The  red  spot 
is  bathed  frequently  with  lead-water. 

If  there  is  an  excoriation,  it  should  be  dressed  with  glycerite  of  tannin  (sj 
to  5J)  or  with  the  following  ointment : 


I^.  lodoformi, 

Balsami  peruviani, 
Vaselini, 


5j. 


If  gangrene  has  developed,  the  dead  tissue  should  be  removed  with  knife  or 
with  scissors  as  soon  as  a  line  of  demarcation  has  formed,  and  the  sore  should 
he  dressed  with  lint  or  cotton  dipped  in  a  10  per  cent,  camphor  emulsion  or  a 
2  per  cent,  creolin  emulsion  : 

!^.  Camphorje,  .^ss  ; 

Mucilaginis  acaciie,  .^j  ; 

Aquae,  q.  s.  ad  5v. — M. 

Sig.  Shake  well.  For  external  use. 

When  once  the  hole  is  filled  by  granulation  the  above-mentioned  milder 
remedies  may  be  substituted. 

In  severe  cases  much  benefit  is  derived  ncm  plating  tlie  patient  on  a  water- 
iiiattress,  which  adapts  itself  very  evenly  to  the  whole  lower  surface,  and  facil- 
itates changes  in  position  by  the  ease  with  which  the  water  flows  from  one 
part  of  the  mattress  to  another. 

Phlebitis. — 1.  Phlcf/masia  Alba  Bolcns. — The  affected  limb  should  be 
l)aii)ted  once  a  day  with  tincture  of  iodin  along  the  swollen  veins,  and  be  sur- 
rounded by  cotton  batting, slightly  compressed  with  roller  bandages,  and  elevated 
oil  cushions,  so  as  to  favor  reflux  of  venous  blood  and  lymph  and  to  prevent 
stagnation  and  congestion.  In  protracted  eases  blue  ointment  may  be  substi- 
tuted for  the  tincture  of  iodin,  but  to  prevent  tearing  off  a  piece  of  a  throm- 
bus, which  would  form  an  embolus,  the  ointment  should  be  smeared  carefully 
on  the  skin,  avoiding  deej)  pressure.  As  there  is  great  tendency  to  relajtse,  the 
patient  should  be  kept  quietly  on  a  lounge  or  in  an  easy -chair  with  rai;«?d 
extremity  for  a  fortnight   after   the   swelling  has  subsided.     Circumscribed 


V  m 


7;i4 


AMEIilVAN   TEXT-BOOK   OF   OliSTKTliJVS. 


abscesses  must  be  opened  and  be  dressed  antiseptically,  and  in  eases  of  <liff'iisc 
snbf'aseial  phlegmon  several  long  ineisions  slioi.'d  be  made  at  an  early  date  to 
limit  tlie  destrnetion  in  the  deeper  |)arts. 

2.  Tujldinmafion  of  Vdricoxc  \Ynix. — It'  varicose  veins  become  inflamed, 
the  limb  is  immobilized,  and  covered  with  cloths  dipped  in  a  lead-i>nd- 
opinm  wash.  The  cloths  are  kept  cool  by  evaporation  and  addition  of  ."<"■.  iliiid 
or  by  changing  them.  If  the  cool  application  meets  with  objection,  flaxseed- 
nieal  jionltices  may  be  sid)stitnted.  After  the  acnte  stage  has  passed  the  limit 
is  slightly  compressed  with  a  roller  bandage,  and  when  the  patient  begins  to 
walk  abont  the  bandage  is  replactnl  by  an  clastic  stocking. 

3.  Utrrlm'  PIMuUh  calls  for  all  the  general  and  local  treatment  described 
in  the  preceding  Images,  esjiecially  quinin,  alcohol,  ice-bags  or  warm  ])onltices, 
and  hot  vaginal  donches. 

Acutest  Septicemia. — In  those  cases  in  which  the  infection  takes  snch  a 
rapid  course  that  no  local  inflammations  find  time  to  develop  there  is  scant 
hope  of  saving  the  patient's  life.  We  should,  however,  try  to  better  her 
chances  by  following  the  principles  laid  down  above.  High  temperature 
should  be  lowered  by  cold  baths  and  local  refrigerating  aj)])lications.  The 
patient's  strength  should  be  kei)t  up  by  the  administration  of  alcolutl,  quinin, 
strychnin,  atropin,  digitalis,  and  strophanthus.  Pain  and  restlessness  should 
be  subdued  with  hyi)odermatic  injecti(ms  of  small  doses  of  nior])hin,  Frank's 
injections  of  creasote  may  be  trie<I.  Thierry  of  Rouen  claims  to  have  obtained 
recovery  in  ten  cases  of  the  most  severe  septicemia  without  localization,  after 
having  failed  with  everything  else,  by  means  of  oil  of  turpentine  injected  sub- 
cutaneously  in  gram  doses.  It  forms  an  abscess,  and  in  one  case  he  produceil 
even  so  manv  as  three  abscesses."' 


!  'n 


t       11 


.>■ 


IB    >'  1 


2.    SinUNVOLUTlOX. 

By  subinvolution  is  meant  the  retardation  or  arrest  of  the  processes  by 
which  the  uterus  is  returned  to  its  normal  dimensions,  position,  and  anatomical 
structure  after  premature  termination  of  pregnancy  or  subsequent  to  delivery 
at  term.  This  anomaly  may  also  be  present  in  varying  degree  in  the  ligaments 
of  the  uterus,  the  vagina,  and  the  abdcjuiinal  walls.  Usually  in  from  six  to 
ten  weeks  the  ])hysiological  changes  known  as  lin-ohdion  have  been  complcteil. 

Et/ohf/j/, — Since  the  physiological  changes  in  the  uterus  after  delivery  uw 
brought  about  by  a  diminution  in  its  blood-supply,  resulting  from  contraction 
and  retraction  of  the  uterine  ujuscle-fibres,  it  is  obvious  that  the  causes  of 
failiu'o  in  involution  must  be  sought  for  in  any  factor  or  factors  modifying  tiio 
amount  of  blood  going  to  the  organ  or  interfering  with  its  firm  contraction. 
Several  conditions  may  obtain  in  an  individual  that  operate  in  either  the  mic 
or  the  other  manner;  indeed,  not  infrequently  the  one  condition  will  cini- 
tribute  to  retard  involution  both  by  increasing  the  amount  of  blood  in  the 
uterus  and   by   interfering  with   its  contraction. 

The  most  frequent  condition  interfering  with  normal  involution  by  dctci- 
mining  an  excess  of  blood  is  a  change  in  the  endometrium,  which  change  is 


!f    f 


fisos  of  (litViiso 
1  early  dato  to 

nine  inflaiucd, 
n  a  load-iMid- 
>n  of  ."<"■.  Ilniil 
c'tion,  flaxsocd- 
lassed  tlio  liinli 
ticiit  begins  to 

moiit  described 
k-arni  poultices, 

on  takes  such  a 
)  tiicre  is  scant 
'  to  better  her 
gli  temperature 
dicatious.  Tlic 
alcohol,  quiuiu. 
tlcssness  should 
rphin.  Fraid<'s 
:o  have  obtained 
Dcalization,  after 
ine  injected  sub- 
•ase  he  produced 


[he  ju'occsses  by 
and  anatomical 

iieut  to  delivery 

in  the  liganu'ut< 

in  from  six  to 

[been  complete  1. 

Ifter  delivery  :nv 
Vom  contract  ii  111 

lit  the  causes  of 
•s  modifyirir  the 
hrin  contractimi. 
in  either  the  one 
Idition  will  cmi- 
of  blood  in  the 

llution  by  dcti  r- 
Lvhich  chanp'  is 


PATHOLOGY  OF    THE  PlJEIiPEIUCM. 


735 


either  hypertrophy  occurring  in  the  latter  months  of  pregnancy,  or  an  inflam- 
ination  developing  after  delivery,  the  result  of  septic  infection.  Very  fre- 
i|uently  associated  with  infection  is  la(u>ration  of  the  cervix  or  of  the  ))erineinn 
with  uterine  displacement,  together  with  uterine  and  peri-uterine  inflammatory 
|)ro(lucts.  Other  causes,  miieh  less  frerpient,  are  polypoid  and  interstitial  or 
-nbnuicous  fd)roid  tnu'nr.'  and  cardiac  and  hepatic  diseases  producing  engorge- 
ment of  the  pelvic  viscera.  Later  in  the  process  of  involution  chronic  consti- 
|)ation,  assuming  the  erect  posture  and  engaging  in  exercise  or  laborious  work, 
and  the  resumptiim  of  sexual  intercourse  too  sunn  after  abortion  or  after  de- 
livery at  term,  are  causes  very  likely  not  only  to  retard,  but  even  to  arrest, 
involution. 

The  conditions  that  may  cause  subinvolution  by  interference  with  the  con- 
traction of  the  womb  arc  usually  operative  shortly  after  labor,  and  therefore 
(heir  early  recognition  is  important.  Of  these  conditions  the  most  important 
are  large  masses  of  hyi)ertrophied  de(;idua,  placental  polyps,  placent.'c  succen- 
tiiriatje,  large  blood-clots,  and  displacement  of  the  uterus.  The  latter,  when  it 
occurs  within  a  few  days  after  labor,  is  commonly  due  to  a  misplaced  compres.s 
and  an  injudiciously  firm  abdominal  binder,  to  an  over-distended  bladder,  or  to 
dragging  adhesions.  In  rare  cases  an  extra-uterine  tumor  may  be  discovered. 
Women  who  fnmi  necessity  or  desire  do  not  nurse  their  children  are  more 
likely  to  develop  subinvolution — a  fact  which  supports  the  belief  of  the  close 
nervous  connecti(m  between  the  uterus  and  the  mammary  glands. 

That  constitutional  disturbances,  independent  of  any  local  disorder,  may  in- 
fluence the  course  and  progress  of  involution  is  by  no  means  certain.  The  older 
writers  were  willingto  attribute  subinvolution  very  largely  to  defccti\  c  nutrition 
and  to  the  enervating  ett'ects  of  acute  and  chronic  diseases.  That  such  influence 
is  exceptional  the  writer  is  forced  to  believe.  At  the  present  writing  tlun-e  is 
under  his  care,  in  the  last  stages  of  phthisis,  a  jjatient  whose  physical  force  is 
at  a  minimum,  yet  involution  of  the  uterus  has  |)rogressed  in  a  ])erfeetly  unin- 
terrupted manner.  Analogous  cases  are  repeatedly  observed.  There  are  indi- 
viduals, however,  in  whoiu  there  seems  to  be  a  general  lack  of  tone :  their 
muscles  are  flabby  ;  they  are  indisposed  to  take  any  active  exercise,  and  are 
trcqiiently  of  gouty  or  of  rheumatic  antecedents.  Women  of  this  class  some- 
times have  subinvolution  assocnated  later  with  uterine  displacement  without  a 
distinct  local  cause.  Nevertheless,  it  is  certainly  wiser  for  the  obstetrician  to 
search  for  a  local  cause  in  every  case  than  to  be  content  with  attributing  a 
failing  involution  to  any  constitutional  disorder  that  may  complicate  the  puer- 
)i('ral  period. 

Diaguims. — As  subinvolution  is  the  starting-point  of  numerous  intrapelvic 
disorders,  it  is  important  that  the  obstetrician  should  recognize  its  presence,  and 
at  an  early  date  begin  measures  to  correct  the  abnormality,  since  deferred  treat- 
ment ])ermits  an  aggravation  oi"  the  local  changes  which  occur  in  the  early 
stages,  exposes  the  patient  not  infrequently  to  great  danger  of  infection,  and, 
it'  the  latter  is  safely  pass(>d,  renders  !ier  very  liable  to  subsequent  ill  health 
from  intrapelvic  disordei-s. 


n\ 


u 


.^r 


If'  IS;-,  I 


Svl 


" 


U 


r 


«■/■ 


I'  •<  i 


')  Nil 


736 


AMJ'JJiJCA.y    TKXT-IiOOK    OF   OJiSTETJtlCS. 


In  tlio  early  stiifjcs  of  the  proeess  of  involution  abdominal  palpation  prae- 
ti.sed  at  tlie  daily  visit  will  disclose  any  eessation  in  the  (;radnal  diminution  in 
the  size  and  height  of  the  womb.  For  practical  purposes  it  may  be  stated 
that  the  fundus  uteri  on  the  ihiy  Ibllowing  delivery  will  be  found  a  finger's 
breadth  above  the  lunbilieus  ;  on  the  third  and  fourth  days,  a  trifle  below  the 
und)ilicus ;  on  the  lifth  and  sixth  days,  two  tingers'  breadth  below  the  umbil- 
icus; on  the  seventh,  eighth,  and  ninth  days,  three  or  four  fingers'  l>rea(hli 
above  the  symphysis;  and  on  the  tenth,  eleventh,  and  twelfth  days  the  fundus 
is  usually  slightly  above,  on  a  level  with,  or  a  little  below,  the  symphysis.'" 
This  process  of  involution  continues  throughout  the  puerperal  period,  and 
earefid  intra-utcrine  measurements  taken  at  varying  intervals  up  to  the  tentli 
and  twelfth  weeks  show  a  steady  dimiiuition  up  to  a  point  when  the  dimen- 
sions of  the  involuting  wond)  are  really  less  than  those  of  the  unimpregnated 
uterus.  Later,  the  size  of  the  organ  by  subse(|uent  engorgement  of  the  uterine 
vessels  is  permanently  increased  to  a  slight  degree.  Associated  with  the  failure 
»)f  the  uterus  to  decrease  steadily  in  size  there  are  apt  to  bean  increase  in  and  a 
prolongation  of  the  bloody  lochia,  a  coated  tongue,  and  constipation.  It  is  thus 
not  a  dilHcidt  matter  to  make  an  early  diagnosis  of  sid>involution;  and  an  early 
recognition  of  the  condition  is  of  the  greatest  practical  importance. 

The  diagnosis  of  subinvolution  in  its  later  stage  is,  unfortunately,  too 
often  left  to  the  gynecologist.  At  this  time  the  uterus  is  larger  than  normal 
and  is  freijuently  displaced,  usually  backward,  the  os  is  more  patulous  than  it 
should  be,  •■\vs\  the  crvix  very  probably  is  lacerated.  The  walls  of  the  uterus 
an;  considerably  thickened,  its  vessels  and  lymphatics  are  enlarged,  and  its 
endometrium  has  undergone  interstitial  and  glandular  hypertrophy.  If  invo- 
lution is  permanently  arrested,  connective-tissue  development  in  the  muscle- 
walls  soon  follows,  the  changes  in  ilic  mucous  membrane  are  permanent,  and 
chronic  metritis  and  endciictritis  are  established,  to  be  followed  perhaps  hy 
periuterine  inflammatory  disease. 

Treatment. — From  the  foregoing  enumeration  of  the  most  imjiortant  causes 
of  subinvolution  it  is  aj)parent  that  the  i)roper  treatment  of  each  patient  will 
be  governed  by  the  cause  or  causes  that  may  be  present  retarding  normal  invo- 
lution. While  the  patient  is  in  bed  the  cause  will  usually  arise  from  retention 
within  i\\(\  wond)  of  decidual  or  jdacental  masses  and  blood-clots,  or  of  shnds 
of  the  membranes  which  may  or  may  not  be  undergoing  })utrefactive  change, 
but  which  are  always  a  source  of  danger  and  usually  require  removal.  Tlic 
blood-clots  accumulated  within  the  womb  can  often  be  removed  by  stimulating 
the  uterus  to  contract  by  gently  rubbing  the  fundus  of  the  uterus  several 
times  each  day  through  the  abdominal  wall,  followed  by  snug  application 
of  the  pad  and  binder.  When  this  maneuvre  is  not  followed  by  proiujit 
reduction  in  the  size  of  the  wond)  aiid  by  dinunution  of  the  loss  of  blood,  the 
cavity  of  the  uterus  nmst  be  explored  with  the  finger ;  then,  if  required, 
the  <;urette  and  placental  forcejis  should  be  used,  followed  by  irrigation  with 
creolin  or  biehlorid  solutions  and  with  boiled  water,  and  the  introduction  of 
a  strip  of  sterilized  iodoform  gauze,  which  should  be  removed  and  may  be  rc- 


.■;  I* 


fU"! 


PATHOLOGY    OF    Till':    I'lFJtl'KliirM. 


737 


•alpiition  pnic- 

dimimitutn  in 
may  l)*'  s^tiitctl 
omul  a  fiuj>;<'r's 
tvillf  below  tlic 
low  tlic  uml)il- 
(iii^crs'  broatltli 
lays  the  liindns 
\w  syinpliysis.'" 
i-al    pentxl,  and 

iij)  to  tlio  U'utli 
\\m\  tlie  (Vinicii- 

uniinpri'jjiiiatcd 
nt  of  tlic  uterine 

with  the  tailuie 
increase  in  and  a 
ition.  It  is  tluis 
ion ;  and  an  early 
imce. 

ntbrtnnately,  too 
i-jTor  than  normal 
;  patnlous  than  it 
,alls  of  the  ntenis 
jenlarged,  and  its 
[rophy.     If  h»vo- 

it  in  the  muscle- 
permanent,  and 

)wed  perhaps  !)>■ 


placed  at  the  end  of  forty-eight  hours.  When  putrefactive  chanj;e  has  hejjun 
to  take  place,  which  is  ann(»unced  by  fetid  discharfje,  rapid  pidsc,  and  fever,  the 
necessity  for  enrettaj^e  is  al)solute.  Kven  when  fetid  discharjic  is  aitsent  the 
pulse  and  temperature  may  be  such  as  to  re(piire  cnrrettagc.  The  temperature 
chart  (Fig.  42.'5)  illustrates  the  advantage  of  removing  hypcrtrophied  decidna.    In 


^^^ 

^^^ 

"^ 

1 

"~~" 

DIMM* 

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18 

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; 

106° 
106"" 

■i- 

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IfMft 

A 

10t° 
103° 

f 

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fj 

1<H« 
109^ 

i 

: 

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VOP 

100° 

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k' 

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s 

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07° 

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(5U. 

— 

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^ 

- 

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. 

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—  - 

T 

Sb 

^ 

xl 

— 

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s 

< 

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— 

-  - 

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980 
970 

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•A 

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11081 

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-■ 

Fiu.  1'23.— Uypcrtrophied  duciduu  removed  with  curette  and  placental  forceps  on  the  iiintli  ilay ;  lochia 

not  ollViisive. 

this  case  the  odor  of  the  discharges  was  not  offensive.  In  the  absence  of  signs 
of  decomposition  the  dangers  of  removing  foreign  material  from  the  interior  of 
tiic  womb  are  in  direct  proportion  to  the  obstetrician's  ignorance  of  antiseptic 
details.  It  should  be  remembered  that  curettage  employed  against  puerperal 
infection  accomplishes  the  most  good  when  it  is  resorted  to  early,  and  especially 
aftci-  abortion.  When  infection  has  spread  from  the  decomposing  d6bris  to  the 
uterine  wall  the  operation  is  less  effective,  and  sometimes  does  harm  by  destroy- 
ing the  barrier  of  exudate  which  nature  supplies  to  limit  septic  absorption. 

If  the  womb  is  displaced,  it  should  be  rej>laced,  and  attempts  should  be 
ina<le  to  keep  it  in  position  by  the  application  of  a  lateral  compress  if  the  dis- 
piac.'cnient  is  lateral,  which  is  not  very  rare ;  by  the  Sims  or  the  prone  jiosi- 
tioii  for  .several  hours  each  day  if  the  displacement  is  backward  ;  and  in  all 
cases  by  regular  evacuation  of  the  bladder  and  bowel. 

When  the  above  treatment  has  been  instituted,  or  even  when  there  has  been 
no  occasion  for  it,  the  duty  of  the  obstetrician  is  always  to  make  a  vaginal 
examination  before  ceasing  his  attendance,  noting  tlie  size  and  position  of  the 
uterus,  the  condition  of  the  adnexse,  and  determining  the  nature  and  degree  of 
injuries  of  the  cervix  and  vagina.  If  he  now  finds  the  uterus  displaced,  a 
j)ro|)erly  fitted  pessary  should  be  applied  and  carefully  watched,  smaller  sizes 
being  substituted  as  the  involution  of  the  genitalia  advances.  At  the  same 
time  it  is  desirable  to  deplete  the  i)elvi(^  viscera  by  copious  hot  injections, 
by  irlycerin  tampons,  and  by  free  catharsis.  Septic  processes  in  or  about 
47 


AMFJiJCAX    TEXT- HOOK    OF    OJi.ST/:T/iJC<S. 

the  uterus  should  receive'  ;ij)|>ni|)riate  ticatuieiit.  Advice  may  be  iieedeil  as 
to  tlie  subsequent  necessity  lor  reparative  oiteratioii.  The  rarer  causes  of  sub- 
iuvohitioii — canh'ac  or  hepatic  (hseases  produeini;-  venous  stasis  in  tlie  pdvic 
organs — sliouM  not  be  ovcrhioked.  Tlie  value  of  the  rc<::;ular  adniinistratioM 
of  ergot  as  a  means  for  promoting  more  rapid  involution  of  the  uterus  is 
doubtful.  The  writer  has  reserved  the  use  of  ergot  for  those  rare  cases  whid 
seem  to  be  (K'pendent  upon  either  a  general  lack  of  muscle-tonus  or  iqxtn  th 
presence  of  snuill  and  nuiltiph'  fil)roids,  in  \vhi<'li  eases  u  pill  composed  of 
ergotin  (gr.  J),  (piinin  (gr.  ij),  and  strychnia  (gr,  ^'o),  administered  thrice 
daily  in  conjunction  with  the  application  of  the  faradic  current,  has  seemed 
beneficial.  Should,  however,  the  use  of  ergot  impair  to  any  extent  the  diges- 
tion or  the  milk-secreting  functions  of  the  indivitlual,  it  is  best  to  discon- 
tinue its  use.  IVpletion  of  the  pelvic  viscera  by  the  employment  of  copious 
hot  injections,  of  glycerin  tampons,  and  of  free  catharsis  is  also  usefid  in  this 
class  of  cases.  Fibroid  and  polypt)id  tumors  should  bo  treated  as  directed 
in  the  discussion  of  Puerperal  J[>  iiorrli<t(/cs  (p.  ()04). 

When  the  treatment  of  subinvolution  is  first  instituted,  several  weeks  after 
the  patient  has  left  her  bed,  and  if  she  complains  of  innpient  bleeding,  leucor- 
rheal  discharges,  dragging  sensations,  a  feeling  of  weight  antl  distress  in  the 
back  and  loins,  and,  finally,  is  overtaken  by  the  digestive,  (fireulatory,  and 
reflex  nervous  disturbances  of  subacute  and  chronic  inflanunatory  changes  in 
and  about  the  uterus,  the  case  demands  most  careful  gynecological  examination 
and  treatment,  involving  the  repair,  perhaps,  of  a  lacerated  cervix  and  peri- 
neum, the  correction  of  a  backward  displacement,  or  treatment  directed  to  the 
endometrium  or  to  the  periuterine  structures. 

3.  llKM()ui:nA(!i;s  in  thk  Pi'kiu'EIUI'm. 

Excessive  bleeding  from  the  uterus  within  twenty-four  hours  after  delivery 
is  called  "  post-]>artum  "  hemorrhage.  Its  causes  and  treatment  have  been  (li>- 
cusswl  under  Dt/xtocia  (p.  600).  Hemorrhage  occurring  later  than  twenty-four 
hours  after  tleliverv  is  called  "  puerperal  "  or  "  secondary  "  hemorrhage.  I" he 
(juantity  of  blood  lost  during  the  first  eight  days  of  the  puerperium  has  been 
stated  (p.  654)  to  be  three  and  a  cpuirter  pounds.  Any  excess  of  this  amount 
should  be  looked  upon  as  abnormal.  The  bleeding  nuiy  vary  from  a  sliglilly 
excessive  discharge,  which  is  the  more  common,  to  a  sudden  and  alarming  hem- 
orrhage, which  can  as  (piiekly  be  fatal  or  alarming  in  its  atter-efl'ects  as  tin 
hemorrhage  that  sometimes  occurs  immediately  after  labor.  The  bloody  lochia 
continuing  furnishes  a  favorable  soil  for  the  development  and  mtdtiplicalioii 
of  micro-organisms,  and  thus  is  an  additional  risk  to  the  puerpera. 

When  it  is  noted  that  the  bloody  lochia  are  excessive  and  jjro'onged  beyniul 
the  third  day,  or  when,  having  ceased  at  the  usual  time,  there  is  a  return,* 
investigation  should  be  instituted  at  once  to  determine  the  cause,  since  the 
proper  treatment  of  the  case  usually  depends  altogether  upon  accurate  deter- 

*  A  rettini  of  the  liioody  loeliiii  for  ii  day  or  two  wlion  tlie  iiiitient  first  rises  from  her  I"  il  is 
of  common  oecurreiu'i'  iii\il  of  no  jintholoKieal  signiticancu. 


l'ATII()Lf)(jy    OF    THE    I'V ERPEniVM. 


7;5<> 


bc!  nei'cU'tl  as 
{•iiusos  ol"  sul)- 
i  ill  the  pi'lvic 
luliuinistration 
r  tlu'  ulonis  is 
iri'  cases  whii'li 
IS  or  »ip"»  til"' 
1  composi'd  ol 
inistcml   thricf 
.'lit,  lias  siviiu'tl 
xteiit  the  (Hti;os- 

bcst  to  cVisc'oii- 
iiont  of  copious 
^,)  useful  in  this 
at 0(1  as  clirc'tctl 

^roral  weeks  alter 
\)leecling,  leiicor- 
nl  distress  in  the 

(•irculatory,  and 
natory  changes  in 
gical  examination 

cervix  and  peri- 
!nt  directed  to  the 


)urri  after  delivei  y 
ent  have  been  di>- 

than  twenty-four 
icmorrhage.     'fhc 

rperium  has  hcc" 
s  of  this  aninuut 
,'  from  a  sVn^htly 

nd  ahirming  luni- 

atU-r-etVects  as  the 
rhe  Woody  hichiii 
nd  nudtipliciiti"" 

lerpej'a. 

prolonged  lioycMi.l 
lero  is  li  return,* 
lie  eanse,  since  tho 
ion  accurate  det'i- 
it  rises  from  lier  I" '1  '* 


niiiiation  of  the  cause.     A  careful  inquiry  will  necessitate  an  exaiuiiiation  of 
tiie  uterus,  its  contents,  its  position,  and  of  the  adjacent  structures. 

Tlie  causes  of  puerperal  secondary  heinorrbage,  arranged  as  nearly  as  may 
he  in  tho  order  of  their  fre(pioney,  are  : 

1.  Retained  sociindiiies  and  bhiod-ch)ts; 

2.  Displaceiuent  of  the  uterus; 

.'5.    Displaceuienl  of  tiiroiul»i  in  the  uterine  sinuses ; 

4.  Relaxation  of  tho  uterus  ; 

").    Fibroid  or  polyjioid  tumors; 

(>.   Ilomatoniata ; 

7.    Pelvic  engorgement  ; 

5.  Secondary  bh'cding; 
i).  Malignant  disease. 

In  a  series  of  ."JOOO  deliveries  seven  eases  of  severe  puerperal  heniorrliago 
were  observed.  Tlie  cause  in  two  cases  was  over-distentioii  of  the  bladder, 
protlucing  uterine  displacement;  in  one,  retained  portions  of  placenta;  in  two, 
the  kidney  of  pregnancy  ;  and  in  two  eases  no  cause  could  be  found. 

Retained  Secundines. — Tho  most  l"ro((U(>nt  cause  of  hemorrhage  in  the 
piierporiuin  is  retention  of  a  portion  of  the  secundines,  coinnionlv  fragments 


Fi<:.  r.'l.-  Ki'tiiiiioil  liypiTtrcipliiLd  dccidu;!'. 

of  placenta,  more  rarely  portions  of  the  membranes.  Cases  of  profuse  bleeding 
IVoni  retained  secundines  an^  far  more  freiitiently  observed  after  aliorlioii  or 
miscarriage  than  after  labor  at  term,  'i'lie  writer  recently  rcmovcil  a  piece  of 
licaltliy  placenta  from  an  almost  moril)und  patient  who,  after  a  miscarriage,  had 
lii'i'U  [)lecdi!ig  contimiously  and  profiix'ly  tlir(.ughout  a  period  of  sixteen  weeks, 
flic  frccpiency  of  retained  j)ortioiis  of  placenta  causing  hemorrhage  after  deliv- 
ery at  term,  compared  with  retention  not  foljnwcd  by  excessive  bleeding,  indi- 
<';itt'<  that  not  infrequently  nature  succcsst'ully  disposes  of  the  remnant,  in  tho 


i 


'I     « 


III    < 


f  ! 


i. 


li 


740 


AMERICAN   TEXT- BOOK   OF   OBSTETRICS. 


nhst'iice  of  infection,  by  disintegration  and  drainage,  Martin*'  reiwrts  nine  cases 
of  retained  po''tions  of  placenta  in  2'JGO  births;  in  six  of  the  nine  cases  there  was 
not  even  an  excess  of  the  locliia,  and  in  but  two  was  the  hemorrhage  severe. 
The  frecjuency  of  retained  membranes  is  much  greater,  analysis  of  various 
statistics  giving  a  proportion  of  about  5  per  cent,  JJut  the  frequency  and 
probability  of  hemorrhage  produced  thereby  are  by  no  means  so  certain,  clin- 
ical testimony  on  this  point  being  at  variance.  It  is  reasonable  to  believe  that 
retention  of  considerable  portions  of  the  membranes  favors  the  accumulation  in 
the  uterus  of  blood-dots  which  may  be  of  sufficient  size  to  prevent  firm  con- 
traction, and  thus  indirectly  the  retained  memljranes  may  be  responsible  for 
bleeding,  which,  however,  is  seldom  profuse  enough  to  endanger  life. 

When  considerable  portions  of  the  decidua  are  retained,  whether  hyjiortro- 
phied  during  pregnancy  or  after  labor,  and  when  to  these  are  added,  as  is  verv 
common,  clot-formations  of  fibrin  and  blood,  an  excessive  and  prolonged  locliial 
discharge  is  almost  certain  to  result  (Fig.  424).  Syphilitic  endometritis,  occur- 
ring either  during  pregnancy  or  after  labor,  is  a  frequent  cause  of  liypertrophiod 
decidua.*^ 

Should  a  large  blood-clot  be  retained  in  the  iiterus,  the  bloody  flow  may 
almost  cease,  and  be  replaced  by  a  watery  discharge  ;  within  a  few  days  tlieic 
may  be  a  sudden  discharge  of  disintegrated,  followed  by  bright,  blood  in  such 
large  quantity  as  to  cause  the  patient's  death  within  an  hour,  A  case  of  this 
kind  has  been  reported  by  Parvin. 

The  so-called  "placental  and  decidual  polypoid  tumors,"  having  their 
origin  in  the  puerperium  and  causing  hemorrhage,  are  really  layers  of  clotted 
blood  or  fibrin  deposited  upon  fragments  of  the  secundines  or  upon  a  rough- 
ened placental  site,  ThesQ  til)rin-formations*^  may  in  very  rai*e  cases  become 
malignant,  as  will  be  pointed,  out  later,  Remy ''Mias  recorded  an  interesting 
case  of  inversion  of  the  uterus  in,the  third  week  due  to  the  eflbrts  of  the  uterus 
to  expel  retained  fragments  of  the'placcnta, 

Dkifinos'iH  (ind  Treatment. — Carefid  management  of  the  third  stage  of  labor 
always  includes  an  insp,ectiou  of  the  placenta  and  of  the  membranes,  to  deter- 
mine whether  any  portions  of  either  have  been  retained  in  the  uterus,  AVh(  ii 
there  has  been  an  accessory  placental  growth — either  succenturiata,  which  h;is 
blood-vessel  communications  with  the  main  placental  growth  and  is  therei'dre 
functionally  active,  or  sj)uria,  which  has  no  such  cimncction — the  diagnosis  \<, 
of  course,  very  difficult,  and  in  the  latter  case  is  practically  impossible.  The 
succenturiate  ])Iacenta  can  l)e  diagnosticated  by  examining  the  membranes  with 
transmitted  light,  and  observing  large  vessels  passing  from  tiie  circund'creiiee 
of  the  main  placenta  through  the  membranes  and  terminating  in  torn  extrem- 
ities where  they  have  been  (l(>tached  from  the  accessory  growth. 

So  connnouly  is  puerperal  hemorrhage  due  to  retained  secundines  that  it  is 
visually  justiliable  at  once  to  explore  the  uterine  cavity  when  tiie  bleediiii;  is 
jirofuse ;  vaginal  and  abdominal  examination  will  disclose  a  failure  in  tlie  imr- 
inal  diminution  in  size  of  the  uterine  body.  If  the  cervix  is  retracted,  which 
is  umisual  when  the  uterus  contains  material  that  should  have  been  thrown  oil'. 


PATHOLOGY    OF    THE   PUlJIiPlJliirM. 


741 


i-ts  nine  cases 
scs  there  was 
•hage  severe, 
is  of  various 
•cquency  and 
certain,  elin- 
o  believe  that 
cunuiUition  in 
ent  firm  con- 
esponsible  tor 

life. 

ther  hypertro- 
aed,  as  is  very 
[)longed  lochial 
metritis,  oocur- 
:'  hypertrophic*! 

lootly  flow  may 

,  few  days  there 

t,  blood  in  su(l\ 

A  case  of  this 

,"  having   their 
layers  of  clotted 
upon  a  rough- 
re  cases  beeoiuc 
I'd  an  interesting 
rts  of  the  uterus 

Id  stage  of  lai»tv 
Ibranes,  to  detcr- 
uterus.     ^V1"" 
Iriata,  whieh  has 
and  is  therefnro 
[the  diagnosis  w, 
Inpossible.     'fli'' 
Ineuibranes  with 
Le  circumfereiuc 
liu  torn  exlniu- 

ludines  that  it  is 

Ithe  bleeding  is 

llure  in  the  uoi- 

Iretracted,  whi'li 

])een  thrown  "11, 


Hegar's  or  branched  dilators  may  be  employed  to  open  it  sufficiently  for  the 
introduction  of  the  finger,  and  by  biiiianual  examination  the  interior  of  the 
uterus  should  be  explored.  Fragments  of  retained  secundines  may  thus  be 
removed,  followed  by  thorough  curettage,  removal  of  dislodged  particles  by 
placental  forceps,  and  an  intra-uterine  douche  of  sublimate  solution  (1  :  4000), 
followed  by  boiled  water,  or  of  creolin  (2  per  cent,  solution).  When  treatment 
is  undertaken  after  involution  has  advanced,  and  the  size  of  the  uterus  renders 
the  introduction  of  the  finger  difficult,  the  curette  and  forceps  cautiously  but 
thoroughly  used  will   suffice. 

Uterine  Displaceraents. — The  puerperal  uterus  may  become  displaced 
backward,  forward,  upward,  downward,  laterally,  or  more  rarely  it  may  bo 
inverted.  From  a  clinical  standpoint  it  is  desirable  to  consider  abnormalities 
in  the  position  of  the  uterus  according  as  the  symptoms  occur  early  or  late  in 
the  puerperium. 

The  normal  position  of  the  uterus  immediately  after  labor  is  marked  ante- 
vorsion  with  prolapse,  especially  of  its  lower  segment.  During  the  first 
twenty-four  hours  its  retraction  elevates  the  body  of  the  womb  to  its  natural 
position  of  anteversion,  and  the  fundus,  from  the  large  size  of  the  organ,  moves 
freely  about  from  side  to  side,  rendering  a  displacement  likely  of  occurrence 
if  tlie  woman  is  kept  lying  in  one  position,  or  when  the  bowel  or  the  bladder 
is  permitted  to  become  over-distended,  or  when  a  compress  and  binder  have 
improperly  been  applied.  The  result  of  such  displacement  is  occlusion  of  the 
uterine  canal  by  angulation-stenosis,  with  consequent  retention  of  the  lochial 
discharge  and  the  accumulation  of  blood-dots,  which,  if  they  do  not  undergo 
putrefactive  changes  and  expose  the  patient  to  tl  e  dangers  of  infection,  lead  to 
snhinvolution  of  the  womb  by  mechanically  preventing  contraction  and  pro- 
moting a  passive  congestion  of  the  organ.  The  lochial  flow,  which  at  first  may 
have  been  diminished  and  very  watery,  finally,  after  a  few  days,  reappears,  at 
first  very  dark,  then  bright  red,  and  usually  profuse,  and  in  I'are  instances  there 
may  be  alarming  hemorrhage. 

Tile  angulation  produced  by  a  flexion  of  the  womb  either  forward,  back- 
ward, or  lateral  while  the  patient  is  yet  in  bod  diminishes  the  lochial  How 
until  it  may  almost  wholly  cease,  the  blood  being  retained  in  the  uterine 
cavity.  Very  commonly  under  these  circumstances  there  occur  putrefactive 
clianges  accompanied  by  elevated  temperature;,  rapid  pulse,  and  other  signs  of 
putrid  absorption.  Such  cases  are  rejieatedly  observed,  and  when,  as  should 
always  be  done,  an  intra-uterine  douche  is  given,  the  first  introduction  of  the 
syringe-nozzle  corrects  the  angulation,  and  is  at  once  followed  by  a  sudden 
i;nsii  of  ortensive  fluiv'  containing  shreds  of  necrotic  decidna  and  blood -clots. 
The  displacement  inten'"res  also  with  inv(4ution,  as  previously  stated,  and 
favors  the  retention  and  hypertrophy  of  deci<lua  ;  lience  tlie  irrigation  should 
nlwiiys  be  followed  by  curettage.  Cases  which  escape  infection,  but  ultinuitely 
lend  to  engorgement  of  i\\G  pelvic  and  uterine  vessels,  are  f()IU)wed  by  bleed- 
iiig  more  or  less  profuse.  Usually  the  How  is  moderate  but  persistent,  and 
after  a  time  the  patient  is  rcihiced  in  strengtii.     Occasionally  a  snddeu  and 


/"     ■( 


.:v~: 


t  I' 


ri 


742 


AM  Eli  IVAN   TEXT-BOOK  OF   OBSTETRICS. 


alarming  loss  of  blood  will  occur.  In  addition  to  exploration  of  the  uterine 
cavity,  the  condition  of  the  bowel  and  the  bladder  should  receive  attention, 
and  by  the  careful  adjustment  of  a  properly-placed  pad  and  binder  the  dis- 
placement can  often  be  corrected.  The  displacement  caused  by  an  over- 
distended  bladder  is  almost  invariably  upward  and  to  the  right.  The  nurse 
should  receive  minute  instructions  as  to  the  manner  of  adjusting  the  pad,  and 
when  the  displacement  is  lateral  she  should  be  taught  to  press  the  uterus 
toward  the  median  line  and  to  reapply  the  pad  several  times  each  day. 

Inversion  of  the  puerperal  uterus  usually  occurs  immediately  or  soon  after 
labor,  but  it  may  occur  during  the  puerperium,  even  so  late  as  the  third  week, 
as  happened  in  the  case  reported  by  Il6my.®* 

The  cause  of  this  rare  accident  may  be  severe  straining  at  stool,  or  efforts 
of  the  womb  to  expel  a  foreign  body,  such  as  a  polypoid  tumor  or  a  largo 
piece  of  placenta.  The  diagnosis  and  treatment  of  inversion  of  the  uterus  have 
been  discussed  (pp.  619-623).  It  remains  only  to  be  stated  hero  that  when  this 
accident  first  occurs  several  days  after  delivery,  it  should  be  borne  in  mind 
that  the  inverted  uterus  is  especially  likely  to  be  mistaken  for  a  polypoid 
tumor,  from  which  it  is  readily  diagnosticated  by  bimanual  and  rectal  exam- 
ination and  by  an  attempt  to  pass  a  uterine  sound.  Other  conditions  to  he 
remembered,  which  under  some  circumstances  sinuilate  an  inverted  uterus,  aro 
hematoma  of  the  vulva,  of  the  vagina,  or  of  the  cervix,  prolapse  of  the  uterus, 
and  possibly  vaginal  enterocele. 

Displacement  of  the  uterus  at  a  later  period  of  the  puerperium  is  usually 
retroflexion  or  retroversion  (PI.  43),  with  varying  degrees  of  prolapse. 

The  cause  of  the  displacement  is  almost  invariably  subinvolution,  not  only 
of  the  titerus,  but  also  of  its  ligaments  and  of  the  vagina.  The  injury  of  tlic 
vagina  which  contributes  to  the  displacement  is  a  neglected  laceration  of  tlio 
])elvic  fascia  and  the  levatores  ani  muscles.  In  very  rare  cases,  when  those 
injuries  have  been  very  severe  and  the  entire  attachment  of  the  vagina  liiis 
boon  severed,  premature  getting  up  and  prolonged  straining  at  stool  or  the 
lifting  of  heavy  weights  have  caused  w.'iplete  y)ro/a/;sc  of  the  puerperal  uterus. 
The  treatment  of  such  displacements  belongs  to  gynecology  and  comprisos 
curetting  and  packing  the  uterus  with  gauze,  followed  by  plastic  operations  on 
tlio  vagina,  or  one  of  the  operations  devised  for  suspending  or  fixing  tlio 
uterus  in  its  normal  position. 

Separation  or  Disintegration  of  Thrombi  in  the  Sinuses  at  the  Pla- 
cental Site. — Ah'riiiiMir  hemorrha<»:('  tnav  follow  cither  of  these  accidents  ovcii 
so  kite  as  two  or  three  weeks  after  delivery.  .S>paration  may  occur  when  the 
])atient  is  permitted  to  assume  an  upright  posture  or  is  allowed  to  get  out  of 
bed  soon  after  labf)r.  After  the  third  day  this  danger  would  appear  vcrv 
slight,  since  in  several  thousand  cases  at  the  Preston  Petreat,  Piiilack  Iplii.i, 
where  it  has  born  customary  for  the  nurse  to  lielp  the  patient  to  the  cotiiinndc 
rolled  to  the  bedside,  no  ''\A\  acci.Ii'Ut  has  Ix'oii  reconled. 

Disintegration  of  clots  leading  to  <laiig<M'ous  hemorrha|,'e  sometimes  ac<  iiii- 
panics  puerperal  infection  which  has  produced  necrotic  changes  in  the  thnirnlii. 


PATHOLOGY   OF    THE   PUERPEItlL'M. 


743 


'  the  uterine 
;e  attention, 
der  the  dis- 
by  an  over- 
The  nurse 

the  pad,  and 
ss  the  uterus 

each  day. 
or  soon  after 
le  third  week, 

itool,  or  efforts 
lor  or  a  largo 
he  uterus  have 
that  when  this 
borne  in  niiiul 
for  a  polypoid 
d  rectal  exam- 
onditions  to  bo 
n-ted  uterus,  are 
se  of  the  uterus, 

crium  is  usually 
['  prolapse. 
)lution,  not  only 
le  injury  of  tl>o 
aceration  of  the 
ases,  when  these 
'  the  vagina  has 
at  stool  or  the 
uerperal  uterus. 
and  comprises 
tic  operations  i>ii 
or  fixing  the 

ises  at  the  Pla- 

Le  accidents  even 

L  occur  when  the 

jved  to  get  out  of 

\\\A   appear  very 

[it,  riiihuhlphin, 

to  the  coniuiotlc 

Lmetimes  aeeoiii- 
Is  in  the  thronii'i. 


Hemorrhage  may  occur  spontaneously  in  these  cases,  and  it  has  been  observed 
in  the  course  of  treatment  when  the  cavity  of  the  womb  is  curetted.  When 
alarming  bleeding  occurs  soon  after  delivery  and  the  uterus  is  found  empty, 
dislodgement  of  thrombi  should  be  susjKicted,  and  the  bleeding  should  be  con- 
trolled by  an  intra-uterine  tampon  of  iodoform  gauze.  The  same  treatment  is 
applicable  to  hemorrhage  from  disintegration  of  thrombi. 

Relaxation  of  the  Uterus. — Hemorrhage  from  this  cause,  and  of  severe 
tvpe,  may  rarely  occur  within  the  first  three  days  after  labor.  It  may  be  a 
sudden  outpouring  of  blood,  or,  the  cervix  being  obstructed  by  a  clot,  the  blood 
may  accumulate  in  the  uterus,  in  which  case  the  patient's  condition  of  faintness 
!uid  the  pain  caused  by  the  over-distention  of  the  uterus  may  be  the  only  signs 
of  the  accident  until  the  size  of  the  uterus  is  ascertained  by  pali)ation.  Bleed- 
lug  so  sudden  and  alarming  as  this  is  invariably  due  to  relaxation  of  the  uterus. 
'I'his  accident,  which  is  of  rare  occurrence,  is  usually  found  in  women  of 
lowered  vitality  and  muscular  weakness.  One  case  of  the  writer's,  occurring 
forty-eight  hours  after  labor,  was  doubtless  due  to  the  exhaustion  and  relaxa- 
tiou  following  vigorous  purgation  and  the  free  use  of  chloral  and  vcratriun  in 
the  treatment  of  violent  eclamptic  attacks  chiring  labor.  In  two  other  cases 
the  hemorrhage  occurred  ten  and  twelve  hours  respectively  after  the  delivery 
of  twins.  Sudden  and  profound  emotion  lias  been  followed  by  profuse  hemor- 
rhage, probably  the  result  of  relaxation,  although  alteration  in  blood-pressure 
has  been  claimed  to  produce  it.  Hemorrhage  due  to  relaxation  of  the  womb 
sliould  be  treated  promptly  by  emptying  the  womb  by  expression  or  by  the 
introduction  of  the  hand,  followed  by  the  usual  means  of  controlling  bleeding 
inunediately  after  labor,  resorting,  if  need  be,  to  the  employment  of  an  intra- 
uterine iodoform-gauze  tampon. 

Fibroids. — Tiie  dangers  of  uterine  fibroid  tumors  complicating  the  puer- 
perium  are  twofohl.  The  greater  danger  is  the  possibility  of  the  tumor  under- 
goiug  necrotic  change  and  sojitic  absorption  from  the  sudden  diminution  of  its 
blood-supply  during  the  proces,ses  of  involution  of  the  uterus.  Tiie  lesser 
ilauixor,  yet  one  of  great  importance,  is  the  hemorrhage  it  may  occasion,  rarely 
profuse,  but  usually  sufficiently  prolonged  to  impair  seriously  the  patient's 
streugtli  and  health.  Hemorrhage  is  very  prone  to  occur  when  the  tumor 
is  suhnuicous  or  podunculated.  Interstitial  and  subperitoneal  tumors  may  not 
he  productive  of  hemorrluigo,  but  they  may  undergo  the  sloughing  change 
ju-t  referred  to,  and,  besides,  may  so  thin  the  uterine  wall  as  to  add  the  risk 
of  perforation  when  the  uterine  cavity  is  being  explored  by  the  curette  or 
other  instrument. 

Till'  <li(i(/nosif<  of  fibroid  tumors  in  the  puerperal  uterus  can  he  made  by 
iutra-utorine  and  Ititnainial  (>xamin!ition.  If,  when  a  tumor  is  discovenHl,  Ikmu- 
orrliage  is  the  only  complication  present,  it  may  be  coiitroned  temporarily,  if 
iint  profuse,  by  the  daily  use  of  ergot,  strychnia,  hydrastis,  and  the  faradic 
eurreut.  Sluaild  tiio  tumor  be  polypoid,  it  is  l)est  to  remove  it  l>y  the  wire 
ecia-cur  and  scissors.  If  slougiiing  has  ocetirred,  wliieh  is  annouueed  by  a  foul 
ilischarge,  this  troatment,  or  removal  of  the  tumor  by  the  blunt  curette,  care 


WIMi 


.:.^ 


744 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


beinjij  tak((ii  not  to  porforatc  the  uterine  wall,  or  hysterectomy,  is  imperative. 
Should  interstitial  or  subperitoneal  tumors  become  necrotic  and  threaten  sepsis, 
liysterectomy  is  indicated. 

Hematoma. — I  fcmatonia  in  the  puerperium  has  been  discussed  on  page  680. 

Pelvic  Congestion. — Pelvic  congestion  from  any  cause  may  occasion 
hemorrhage  of  varying  severity  in  the  puerperium.  The  increased  blood- 
supply  to  the  pelvic  organs  and  the  return  for  a  few  days  of  the  blocnly  lochia 
when  the  puerperal  woman  first  rises  from  her  bed  constitute  a  frequent  and 
physiological  example  of  the  occurrence  of  pelvic  congestion.  When  the 
bleeding  is  prolonged  beyond  a  few  days,  a  j>athological  i'ondition  should  he 
looked  for  in  subinvolution  with  uterine  displacement,  in  periuterine  inflam- 
mation, or  in  a  too  early  resumption  of,  or  desire  for,  sexual  intercourse. 
Occasionally  other  causes  may  be  discovered,  such  as  an  accumulation  of  fecal 
masses  in  the  rectum,  an  intrapelvic  tumor,  or  disease  of  the  liver,  kidneys, 
or  heart. 

Secondary  Bleeding. — Rare  cases  have  been  recorded  of  rupture  of  an 
artery  or  a  vein  by  erosion,  and  of  hematomata  and  secondary  hemorrhage 
following  lacerations,  in  which  cases  the  bleeding  was  controlled  teniporarilv 
by  the  pressure  of  the  child's  head  during  labor.  In  such  cases  the  bleed- 
ing vessel  should,  if  possible,  be  found  and  ligated  ;  otherwise  a  firm  antiscj)- 
tic  tampon  is  the  t)nly  recourse. 

Hemorrhage  from  malignant  disease  is  of  rare  occurrence,  since  malig- 
nant diseases  of  the  uterus,  cither  carcinoma  or  sarcoma,  usually  prevent  con- 
ception. Digital  examination  will  at  once  make  the  diagnosis  of  malignant 
disease  of  the  cervix,  and  the  hemorrhage  may  be  controlled  by  a  vaginal 
tampon  frecpiently  renewed  until  the  advisability  of  hysterectomy  has  been 
considered. 

Cancer  within  the  body  of  the  womb  complicating  the  puerperium  is  also 
rare.  Whether  in  most  cases  the  disease  exists  prior  to  impregnation,  as  insisted 
npon  by  Veit,  or  whether  it  develops  after  labor,  either  at  the  placental  site 
or  in  the  decidua,  is  not  by  any  means  certain.  In  either  case  death  ensues 
within  a  few  weeks  or  months.  IVriiller  "*  found,  in  an  analysis  of  577  cases  of 
carcinoma  of  the  uterus  treated  in  Gusserow's  clinic,  that  in  8.14  per  cent,  tiie 
disease  developed  during  pregnancy  or  the  puerperium.  Cases  of  malignant 
disease  develojied  at  the  ])lacental  site  have  been  reported  by  Chiari,®'  Kuchcr,''^ 
and  others.  Von  Kahlden®'  described  n  case  of  malignant  degeneration  of  a 
placental  polyp  in  which  case  death  occurred  eleven  weeks  after  •.elivery. 

Ciottschalk^"  reviews  10  cases  of  malignant  deciduoma,  of  which  eight  had 
j^reviously  been  reported,  and  he  records  a  case  (a  vi-para  set.  forty-two)  in 
which,  the  recurring  heniorrhages  not  being  relieved  by  repeated  curettage,  he 
dilated  the  cervix  and  examined  microscopically  the  scrapings  from  tlie 
j)lacental  site.  Sarcomatous  new  growths  of  the  fiml)ria3  of  the  placenta  were 
found.  Although  the  patient's  g(>neral  condition  was  bad  and  her  temperatnre 
was  104^  F.,  tin  uterus  and  ovaries  were  rem')ved  eight  weeks  after  delivcrv, 
and  recovery  folio  ved.     Paeon  ^'  described  in  detail  a  case  of  deciduoma  malig- 


i  imperative, 
vcateii  sepsis, 

I  on  page  680. 
may    occasion 
rcased  blootl- 
bloody  locliiii 
frequent  aiul 
,.     When    the 
ion  shonUl  ho 
itcrine  inflani- 
lal  intercourse. 
Illation  of  fecal 
liver,  kidneys, 

'  rupture  of  an 
ary  heniorrliaso 
led  temporarily 
tiases  the  blccd- 
e  a  firm  antiscp- 

nce,  since  mali,u;- 
dly  prevent  coli- 
tis of  malignant 
,1  by  a  va};inal 
ectomy  has  been 


PATIIOLOUY   OF    THE   PUERPERIUM. 


^/^. 


745 


luun,  and  gives  a  table  of  all  the  cases  reported,  fifteen  in  number,  of  tumors 
composed  of  elements  derived  from  decidual  cells,  and  five  cases  of  tumors  com- 
posed of  elements  derived  from  chorionic  villi.  He  points  out  the  important 
clinical  fact  that  half  of  the  cases  followed  molar  pregnancy,  and  in  support 
of  the  notion  that  the  tumors  began  during  pregnancy  he  states  that  in  twelve 
out  of  18  cases  the  hemorrhage  was  known  to  have  ap])eared  almost  innue- 
(liately  after  labor  or  abortion.  As  to  prognosis,  he  says,  "  All  cases  have  ter- 
minated fatally  except  two  which  have  l)cen  reported  this  year.  In  one  of 
tiiese  cases,  that  of  Novd-Josscrand,  the  uterus  has  been  removed.  In  three 
previous  cases  this  operation  was  done;  in  vain.  The  other  non-tiital  case  was 
Menge's  patient,  who  received  a  simple  curettement  of  the  uterus.  The  fur- 
tlier  report  of  this  case  will  be  of  special  interest." 

When  continued  hemorrhages  are  not  relieved  by  the  curette  and  are  not 
tiai'cable  to  constitutional  disturbances  or  to  other  evident  local  causes,  the 
possibility  of  malignant  disease  shoidd  be  thought  of,  and  the  scrapings  should 
Itc  subjected  to  critical  microscopical  analysis.  The  result  of  malignant  disease 
ol"  the  puerperal  uterus  in  the  reported  cases  has,  with  one  exception,  been  a 
rapidly  fatal  termination,  except  when  the  uterus  was  wholly  removed.  This 
fact  pt)ints  to  extirpation  as  being  the  only  rational  treatment  when  a  positive 
diagnosis  of  malignancy  has  been  made  sufficiently  early.  Should  the  hemor- 
rliage  meanwluiu  be  profuse  and  alarming,  the  intra-uterine  gauze-tampon  may 
he  employed, 

^Vmong  other  condiii<nis  very  rarely  causing  puerperal  hemorrhage  should 
1)('  included  profound  emotion,  syphilis,  chlorosis,  scurvy,  nephritis,  and 
malaria.  Hemorrhage  due  to  either  of  the  blood-dyscrasije  is  probably  the 
result  of  changes  in  the  blood  preventing  the  formation  of  obliterating  coagula 
(( 'azeaux). 

There  is  yet  some  difference  of  opinion  as  to  malaria  being  a  factor  in 
puerperal  bleeding.  Billon  in  his  inaugural  thesis  (Paris,  1883)  denic's  any 
such  influence  after  carefully  analyzing  90  cases.  Lifegeois,  however,"  de- 
scribes such  a  case,  and  the  writer  recently  observed  a  case  of  free  bleeding 
a|)})arently  due  to  this  cause.  It  has  been  pointed  out  by  Winckel"  that  free 
i)l('e(ling  often  fi)llows  the  determination  of  blood  to  the  internal  organs  by  a 
clilll,  which  fact  may  explain  the  hemorrhage  observed  in  some  cases  of 
iiwilaria. 

4.  Anomalies  of  tiik  Nipples  and  the  Breasts. 

The  anomalies  of  the  nipples  are  of  clinical  importance  by  reason  of  their 
relation  to  inflammation  of  the  breast  during  lactation.  In  ninety-seven  cases 
(if  puerperal  mastitis  Birket''*  found  imperfect  development  of  the  nipples  in 
fiirty-eiglit, 

Athelia,  or  absence  of  the  nipple,  is  sometimes  congenital ;  it  may  In;  the 
result  of  traumatism  or  of  suppuration  of  the  breast  in  the  nc  w-born  infant. 

Microthelia  is  the  name  given  to  .small,  ill-developed,  or  sunken  nipples. 
Mlrnithelia  is  by  no  means  unconmion  ;  it  may  be  the  result  of  a  congenital 


WM 


.u.  . 


^1 


746 


AMEIilCAN    TKXT-nOOK    OF    OBSTKTllWS. 


defect,  or  the  condition  may  he  acquired  fVotu  the  wearinj;  of  faulty  clothing  or 
of  corsets  compressing  tiic  breasts  and  flattening  or  even  invaginating  tlu.' 
nipples.     The  accompanying  illustration  (Fig.  425)  shows  diagrammatically 


Flo.  4t!r>.— Faulty  development  of  the  nii>i)le. 

several  varieties  of  l)adly-slia])ed  and  ill-dcveloju'd  nip])lcs  which  interfere  witii 
suckling.  The  sunken  or  invaginatcd  nipple  cannot  readily  he  grasjwd  by  the 
infant's  mouth,  and  the  insufficient  flow  of  milk  aggravates  the  child  and  loads 
to  vigorous  biting  and  tugging,  which  are  soon  followed  by  erosion  or  fissures 
of  the  nipple.  When  the  infant  takes  the  mushroom-shaped  nipple  into  its 
mouth  the  narrow  base  of  the  attachment  of  the  nipple  tf)  the  breast  is  further 
occluded  and  thus  a  free  flow  of  milk  is  prevented,  and  traumatism  of  the 
nipple  follows  the  increased  efforts  of  the  child.  The  treatment  of  microtlielia 
will  be  referred  to  later. 

Polythelia. — In  polythelia — supernumerary  nipples — the  multiple  nipples 
are  usually  found  in  a  line  running  downward  and  inward  or  upward  and  out- 
ward, analogous  to  the  situatio^i  of  the  nipples  in  the  lower  animals.  Bruce"' 
found  supenuimerary  nipples  relatively  frequent  among  women — 4.8  per  cent. 
in  104  women. 

Amazia,  or  congenital  ab.sence  of  one  or  of  both  breasts,  is  an  extreiiicly 
rare  anomaly.  According  to  Delbert,  the  absence  of  otie  breast  has  been 
observed  only  in  women,  and  the  absence  of  both  breasts  occurs  only  in  mon- 
sters having  usually  other  deformities  incompatible  with  life. 

Mioromazia,  or  small  breast,  which  is  a  defect  very  much  more  irequent 
than  amazia,  is  sometimes  associated  with  an  infantile  uterus. 

Polymazia,  or  supernumerary  mammary  glands,  is  an  anomaly  more  fre- 
quent than  ama/ia.  The  multiple  breasts  may  vary  from  a  small  nodule  ol' 
glandular  tissue  to  a  fully-developed  breast  capable  of  nouri.shing  an  iiilaiit. 
Although  sometimes  situated  in  the  axilla,  on  the  back,  or  on  the  thigli,  l!ie 
glands  are  commonly  seated  upon  the  anterior  wall  of  the  chest. 


DISKASKS   OF   TIIK    r.liKAST. 


I'l.ATi:   17. 


nmltiplo  nippl'"' 
upward  ami  oiit- 
nimals.  Bnicr"'' 
en — 4.8  per  n'lit. 

is  an  pxtiTincly 
breast  has  Ix-'H 
urs  only  in  nmii- 


'^■,i.'. 


'h  more  iVeqin'iit 


W 
til 


lionialv  more 


u 


l.ll.^l.A-l.^  nl  nil    Niii'i  I  :   lji.-i..iMi|  ihr  iiii'i'lf    liMiii  a  I'huU^raiili; 


.1 


..       V. 


I 


m 


:-ii 


PATHOLOGY   OF    THE    PVERPElilUM. 


747 


|l 


5.    DiSKASE   OF   TIIK   NlPPLES. 

Sore  Nipples. — Under  the  term  "sore  nipples"  is  usually  described  u 
afroiij)  of  inflammatory  conditions  of  the  nipple  varyinf]^  in  severity  from  a 
simple  yet  painful  erythema  to  erosions,  ulcers,  and  fissures  that  may  occasion 
so  great  distress  as  absolutely  to  contra-indicate  nursing.  Clinically,  sore  nip- 
ples are  of  the  greatest  importance  on  account  of  their  close  relation  to  mastitis 
and  mammary  abscess.  When  the  irritation  of  the  nipple  passes  beyond  simple 
erythema,  the  epithelium  is  denuded  at  one  or  more  points,  leaving  the  under- 
lying papillie  unprotected.  Within  a  few  hours  there  is  likely  to  appear  an 
erosion  (PI.  47)  situated  most  often  upon  the  apex  of  the  nipple,  next  in  frc- 
(juency  upon  the  sides,  and  least  frequently  at  the  base  of  the  nipple.  If  at 
this  time  proper  curative  treatment  is  neglected,  the  erosions  are  often  con- 
verted into  fissures. 

When  the  natural  divisions  between  the  papilhe  at  the  summit  of  the  nipple 
are  deeper,  broader,  and  larger  than  normal,  the  removal  of  the  overlying 
e|)ithelium  by  the  lips  and  tongue  of  the  child  in  the  act  of  sucking  leaves  deep 
fissures  which  are  very  troublesome,  cause  intense  pain,  and  often  bleed  at  each 
nursing.  Fissures  situated  at  the  base  of  the  nipjile,  at  the  junction  of  the 
nipple  and  the  areola,  are  usually  semilunar  in  shape;  tlioy  are  often  the  most 
dillicult  to  heal,  because  the  act  of  sucking  almost  always  separates  their  edges, 
and  thus  at  each  repeated  nursing  they  grow  deeper  and  extend  more  and  more 
around  the  nipple,  sometimes  even  penetrating  a  milk-duct  and  leaving  a  milk- 
fistula.     Rarely  the  nipple  is  thus  partially,  or  even  wholly,  amputated. 

The  frequency  of  fissures  of  the  nipple  is  estimated  by  Kehrer  as  44  per 
(•out.  in  primiparre,  in  whom  sore  nipples  are  certainly  (uore  frequent  than  in 
inultipane.  Hiibner  states  that  51  per  cent,  of  ntn-sing  mothers  between  the 
tiiird  and  the  fifth  day  will  have  fissured  nipples.  Winckel  found  seventy-two 
among  150  nurses.  Dluski^*  found  one  hundred  and  eighty-one  cases,  ninetv- 
nine  being  slight,  in  433  recently-confined  women  in  Baudelneque's  clinic. 
Women  with  delicate  skin,  particularly  blondes,  are  more  liable  to  have  sore 
nipples.  The  frequency,  certainly  of  severe  cases,  is  doubtless  in  some  measure 
(l('])ondent  upon  the  degree  of  cleanliness  and  care  of  the  nipples  in  the  early 
(lays  of  lactation. 

Ktiolnrii). — The  anatomical  structure  of  the  nipple,  jvirticularly  wlieti  there 
are  dovelopmental  defects,  predisposes  the  organ  to  inflammation,  on  account 
of  the  injury  it  is  likely  to  ret^eive  during  the  act  of  sucking.  The  delicate 
ppitiiolir'  covering  of  the  nipple,  being  softened  and  macerated  in  the  child's 
mouth.  •;  then  readily  removed  at  various  points,  leaving  the  ])a])illie  unpro- 
tected and  bathed  with  milk  and  often  with  blood,  both  of  which  are  excellent 
iiH^dia  for  the  growth  and  development  of  micro-organisms.  When  the  nipples 
are  misshapen,  short,  or  inverted  (Fig.  425),  the  infant  is  unable  readily 
to  gnis])  the  nipjde  with  its  mouth,  and  efllbrts  at  sucking  are  consequently 
more  violent  and  the  traumatisms  to  the  nipple  are  thereby  correspondingly 
iiKToased.     While   some   authors   consider   the   traumatism   of  sucking   the 


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AMERICAN    TEXT-BOOK   OF   OBSTETllICS. 


most  important,  elpmont  in  tiie  etiology  of  sore  nipples,  others  lay  most  stress 
upon  hat'terial  invasion  from  tlie  nurse's  or  the  mother's  fingers,  from  soiled 
eloths,  and  olten  from  the  child's  mouth.  The  truth  doubtless  lies,  as  is  so 
oflen  the  wise,  in  the  middle  ground.  The  trauma  lessens  the  resistance  ol" 
the  nipple-structures  to  invasion  by  micro-organisms,  and  when  scrupulous 
cleanliness  of  Ixith  the  nipple  and  the  infant's  mouth  is  neglettol  a  slight  irri- 
tation becomes  un  infected  wound.  Bumm"  fre(|uently  found  in  fissured  niii- 
})les  bacilli  and  cocci,  and  even  the  staphylococcus  aureus  and  albus,  when  there 
was  no  adjacent  inflammation. 

Symplotm. — From  the  third  to  the  fifth  day  of  the  puerperium  the  ulceration 
at  some  point  of  the  nipple  usually  aj)pears,  accompanied  by  very  severe  pain, 
and  in  nervous  individuals  easily  responding  to  reflex  irritation,  or  when  tiio 
sore  is  infectwl,  the  temperature  may  rise  as  high  as  104°  F.  or  higher,  and 
may  even  be  accompanied  by  convulsive  movements.  The  nervous  irritation 
and  the  api)rehension  of  the  excruciating  pain  occasioned  by  nursing  some- 
times prevents  sleep  and  seriously  interferes  with  the  appetite  and  digestion. 

Treutmeut. — The  prophylaxis  should  begin  in  the  latter  months  of  prejj- 
nancy.  Pressure  upon  the  nipples  by  corsets  and  by  clothing  must  be  avoided. 
The  nipples  should  be  washed  morning  and  evening  with  a  bland  soap  and 
water,  followe<l  by  inunction  with  cacao-butter,  lanolin,  or  sweet  oil,  and  onee 
each  day  they  should  be  treated  with  a  saturated  solution  of  alum  or  with  a  aO 
per  cent,  solution  of  glycerol  of  taimin.  When  the  latter  is  used  the  patient's 
underclothing  slu)uld  be  protecttnl  from  being  soiled  by  the  tamiin.  If  tiie 
7iipplc  is  invaginateil,  attempts  may  be  made  to  draw  it  out  with  the  fingers, 
or,  what  is  more  effective,  by  bu<!cal  suction  or  by  the  application  over  the 
nipple  of  the  mouth  of  a  bottle  just  emptied  of  hot  water.  These  mani|)nla- 
tions  are  to  be  employed  only  in  the  last  months  of  pregnancy,  since  they  can 
cause  premature  termination  of  pregnancy.  Layers  of  adhesive  plaster  around 
the  nipple,  4  centimeters  (l^  inches)  in  width  and  13  millimeters  (|  inch)  thick, 
may  be  worn  some  months  before  labor.  When  these  measures  fail,  if  the  in;il- 
formation  and  shortness  of  the  nipple  are  not  too  great,  and  if  it  is  espeeiaily 
urgent  that  the  mother  should  nurse  her  child,  the  operation  of  mammillaplasty, 
first  suggesteil  by  Kehrer,  will  improve  the  defect.  Williams"  thus  deserihes 
the  ojH'ratiou  :  "A  circular  strip  of  skin,  together  with  the  subjacent  fibro-f'atty 
tissue,  is  excised  from  the  prominent  cutaneous  fold  surrounding  the  depressed 
nipple;  or,  instead  of  a  circular  strip,  two  crescentic  pieces  may  be  removed 
(Kehrer).  Care  should  be  taken  to  avoid  injuring  the  subjacent  ducts ;  this 
will  be  retidercil  almost  impossible  by  keeping  the  incisions  external  to  the 
areola.  On  suturing  together  the  opposite  cut  edges  of  the  manimillary  ;md 
mammary  skin  the  nipple  will  be  pulled  into  its  proper  position.  In  a  ea<e 
reported  by  Herman^'  the  operation  residted  in  a  permanent  cure.  Of  course, 
not  much  good  can  be  expectetl  from  this  proceeding  when  the  nipph'  is 
congenitally  stuntetl  and  malformed." 

From  the  earliest  periotl  of  lactation  close  attention  to  cleanliness  of  tiic 
nipple  and  of  the  child's  mouth  is  of  the  greatest  importance.     At  least  onee  a 


lay  most  stro.-s 
rs,  from  soik'd 
«  lies,  as  is  so 
B  I'esistancfi  of 
leii  scriipuloiis 
il  a  sliglit  irri- 
n  fissured  nip- 
)us,  when  tin  ih- 

I  the  ulccratiun 
ry  severe  pain, 
in,  or  when  tlio 
or  higher,  and 
rvous  irritatiiiii 
nursing  somc- 
nd  digestion, 
iionths  of  preg- 
uist  be  avoided. 
Idand  soap  and 
!et  oil,  and  once 
mi  or  with  a  AO 
ied  the  patient's 
tannin.     If  the 
vith  the  fingers, 
eation  over  llic 
iiesc  manipula- 
since  they  can 
plaster  aronnd 
|s  (J  inch)  thick, 
fail,if  thenii.l- 
it  is  espeeiaily 
[lammillaplasty, 
I'  thus  descrilies 
,eent  fihro-fatty 
g  the  depressed 
ay  be  removed 
lent  ducts ;  tliis 
external  to  tlio 
ammillary  and 
on.     Ill  a  c:i<c 
Ire.     Of  eunrsc, 
the  nipple  is 

lanliness  of  tlio 
At  least  once  a 


PATIIOLOaV   OF    TirE  PUERPKRIUM. 


(49 


day,  preferably  oftener,  the  child's  mouth  should  be  washetl  with  a  saturated 
solution  of  boric  acid  or  of  borax.  Before  and  after  each  nursing,  which  shoidd 
be  at  regular  intervals,  the  nipples  are  to  be  washed  gently  but  thoroughly  with 
absorbent  cotton  and  the  boric-acid  solution  and  carefully  dried.  If  the  epi- 
thelium is  at  all  inflamed,  the  nipples,  after  nursing,  should  be  covcretl  with 
a  protective  ointment.  For  this  purpose  either  of  the  following  ointments, 
spread  upon  a  clean  piece  of  lint  or  waxed  paper,  will  be  useful : 

^.  Acidi  borici,  gr.  xx  ; 

Olei  ricini, 
Bismuth!  subnitratis,  aa  5ij. 


Or, 


'S^.  Tincturae  benzoini  compositse, 
Olei  olivse. 
Lanolin, 


3u; 

3vj 


80 


Or  the  nipple  may  be  covered  with  lint  wet  with  dilute  lead-water — a  plan 
having  the  disadvantage  of  necessitating  thorough  washing  from  the  nipple 
of  every  trace  of  the  lead  lotion  before  the  child  nurses.  The  distilled  extract 
of  witch-hazel  diluted  with  three  or  four  parts  of  water  the  writer  has  found 
especially  useful,  alternating  this  lotion  with  the  bisnuith  paste. 

When  the  epithelium  is  eroded  at  several  points  or  in  one  large  area,  fol- 
lowing the  same  precautionary  cleansing  before  and  after  nursing,  the  oint- 
ments above  referred  to,  or  either  of  the  following,  may  be  used :  Iodoform, 
gr.  x;  oxide-of-zinc  ointment,  5ss;  or,  Ichthyol,  .^j  ;  lancdin  and  glycerin, 
aa  siss ;  olive  oil,  siiss.  The  compound  tincture  of  benzoin,  or  a  lO-grain 
solution  of  silver  nitrate,  painted  on  with  a  brush,  will  sometimes  be  useful. 
Powdered  tannic  acid  dusted  over  the  raw  surface,  and  kept  in  place  by  a  small 
circular  piece  of  lint  smeared  with  eosmolin,  is  highly  ])ralsed  by  Garrigucs."' 

For  a  distinct  and  deep  fissure,  whether  situated  at  the  apex  or  the  base  of 
the  nipple,  the  solid  stick  of  nitrate  of  silver,  applied  carefully  and  only  to  the 
fissure,  is  perhaps  the  most  efficient  treatment.  This  application  may  often 
with  advantage  be  followed  a  day  later  by  careful  coaptation  of  the  surfaces 
of  tiie  fissure  by  pressure  with  the  fingers,  the  coaptation  being  thus  main- 
tained until  the  fissure  is  permanently  held  together  by  a  few  drops  of  col- 
lodion and  a  thin  film  of  absorbent  cotton. 

While  one  or  more  of  these  local  applications  are  being  carried  out  it  is  always 
desirable  to  resort  to  a  mammary  binder  (see  Fig.  429,  j).  75."})  and  to  relieve 
somewhat  the  mother's  pain  and  prevent  further  injury  to  the  nipple  by  using 
a  nipple-shield.  Of  the  numerous  varieties  of  shields,  that  figured  in  the  illus- 
tration (Fig.  427) — a  glass  bell  with  a  soft-rubber  nipple — is  most  useful.  The 
siiicld  should  always  be  taken  apart  after  nursiiifr,  be  ''leansed  thoroughly,  and 
bo  kept  immersed  in  a  tumbler  containing  boric-acid  solution.  It  is  desirable 
also  occasionally  to  wash  the  shield  in  a  5  per  cent,  carlxjlic  solution  or  to  boil 
tii<'  glass  bell  for  twenty  minutes.  Persistence  on  the  part  of  both  mirsc  and 
mother  will  often  overcome  the  child's  aversion  to  a  shield,  particularly  if  the 


1  •'; 


.-if  . 


760 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


glass  bell  of  the  shield  is  tightly  applied  to  the  areola  and  partially  filled  witli 
milk  by  stroking  the  breast  before  the  rubber  nipple  is  placed  in  the  child's 


Fui.  42t;.— The  Y-bandage  (Bostdii  I.jinn-in  IloKpitiil). 

mouth.  If  the  shield  can  be  used,  much  has  been  gained  toward  the  preven- 
tion of  more  serious  trouble  in  the  breasts  by  thus  avoiding  congestion  and 
engorgement  of  the  glands — an  accident  not  uidikely  to  occur  if  the  extreme 
pain  of  suckling  makes  it  necessary  to  give  up  nursing,  and  if  at  the  same 

time  the  nurse  is  not  skilled  in  preventing  mammary 
engorgement  by  massage  (PI.  48),  a  measure,  when  the 
manipulations  are  skilfully  performed,  vastly  superior  to 
the  breast-pump.  The  nipple-shield,  however,  should 
not  be  used  in  case  the  fissure  is  so  situated  that  the 
action  of  the  shield  is  observed  to  aggravate  the  condi- 
tion by  pulling  open  the  fissure,  thus  failing  to  relieve 
the  mother's  pain  each  time  the  child  sucks.  Fissures 
located  at  the  base  of  the  nipple  will  sometimes  be  aggra- 
vated by  the  shield.  The  shield  should  be  given  up  at 
the  earliest  possible  moment  after  the  nipple  has  healed. 
Sometimes  it  will  be  necessary  for  a  few  days  to  remove  the  child  wholly 
from  the  nursing  breast.  Usually  twenty-four  hours  will  be  sufficient  to  allow 
the  fissures  to  heal  under  appropriate  treatment,  but  in  severe  cases,  when 
mammary  inflammation  is  threatened,  three  or  four  days  may  be  requiretl. 
Meanwhile  massage  and  other  means  to  prevent  mastitis  are  to  be  employed. 
In  very  exceptional  cases  nothing  short  of  artificial  feeding  and  drying  up  of 
the  breasts  will  give  permanent  relief — a  defeat  not  to  be  permitted  except  in 
the  presence  of  an  imminent  mammary  abscess  or  when  the  epithelium  oi'  tlic 
patient's  mammary  glands  and  the  nipples  have  proved,  on  the  one  hand,  un- 
equal to  a  sufficient  supply  of  milk,  and  thereby,  on  the  other  hand,  incajiaMe 
of  tolerating  the  more  active  biting  and  tugging  of  the  infant  at  the  nijiplc, 
which  effi)rts  continue  to  destroy  its  epithelial  covering. 


Fio.  427.-Nipplc-shIel(J. 


■(■!■■ 


PATHOLOGY   OF   THE   PUERPERIUM. 


751 


Uy  filled  witli 
in  the  child's 


vard  the  prcvcii- 
r  congestion  and 
r  if  the  extreme 
I  if  at  the  same 
enting  mammary 
easnre,  when  the 
astly  superior  to 
[however,  should 
situated  that  the 
•avate  the  condi- 
failing  to  relieve 
sucks.     Fissures 
Lctimes  be  afrjira- 
d  1)6  given  up  at 
ipple  has  healed, 
the  child  wholly 
lufficient  to  allow 
ere  cases,  when 
lay  be  recpiircd. 
to  be  employed. 
nd  drying  up  itf 
■mitted  except  in 
pitheliura  of  tlic 
Ihe  one  hand,  un- 
hand, ineap:d)le 
mt  at  the  nippK', 


Abscess  of  the  Nipple. — Tiiere  has  been  described  ^^  a  deep  inflammation 
of  the  nipples  that  undergoes  resolution  or,  more  often,  results  in  the  forma- 
tion of  a  small  abscess  either  in  the  lactiferous  ducts  or  in  the  connective  tissue 
of  tiiO  nipple.  This  affection  is  a  very  rare  («nc.  If  pus  forms  in  the  ducts, 
it  is  evacuated  spontaneously  through  the  apertures  of  the  duets ;  if  the  abscess 
is  confined  to  the  connective  tissue,  the  nipple  enlarges,  and  becomes  very  red 
and  tender,  which  changes  are  often  soon  followed  by  a  spontaneous  opening ; 
when  the  opening  is  delayed  an  incision  should  be  made  on  the  circumference 
of  the  nipple,  after  which  there  is  rapid  healing.  Lactation  should  be  inter- 
rupted for  a  few  days  until  there  is  no  longer  a  trace  of  pus. 

Eczema. — Eczeinatous  affections  of  the  nipple  and  the  areola  sometimes 
spread  to  the  adjaccut  integument  of  the  breast ;  these  affections  arc  often  dif- 
ficult to  cure,  weaning  being  necessary  in  some  stubborn  cases.  Stumpf,**  who 
has  thrown  the  light  of  bacteriology  upon  the  clinical  fact  that  eczema  of  the 
nipple  sometimes  leads  to  mammary  abscess,  demonstrated  the  presence  in 
eczema  of  the  breast  and  nipple  of  a  staphylococcus,  probably  pyogenes  aureus ; 
he  found  the  same  micro-organism  in  the  milk  of  those  affected,  and  he 
believes  that  the  reinfection  thus  occurring  explains  the  stubborn  character  of 
the  disease. 

Treatment. — Protective  ointments  containing  zinc,  salicylic  acid,  or  carbolic 
acid  are  useful  in  some  cases ;  in  other  cases  more  active  remeilies,  such  as 
resorcin,  nitrate  of  silver,  or  corrosive  sublimate,  should  be  employed,  care 
being  taken  always  to  wash  the  nipple  thoroughly  before  nursing. 

The  breast  is  sometimes  affected  with  scabies,  and  occasionally  with  herpes 
zoster.  Syphilitic  ulcers  should  be  recognized  promptly,  and  should  receive 
local  and  constitutional  specific  treatment.  When  the  child  presents  no  evi- 
dence of  syphilis  weaning  is  imperative. 

6.  Diseases  op  the  Breasts. 

Conerestion  and  Engorgement  of  the  Mammary  Olands. — At  the  first 
appearance  of  the  flow  of  milk,  and  thereafter  throughout  the  lactation  period, 
especially  during  the  first  two  weeks,  it  is  not  uncommon  suddenly  to  find  the 


Flii.  128.— Kreast-piimp. 


'^j 


51 


.'if'  . 


breaf?ts  engorged  with  milk,  accompanied  sometimes  by  pain  and  tenderness 
and  a  .slight  rise  in  temperature ;  or  the  reaction  may  be  so  slight  as  to  occasion 


7r>'j 


AMi:itlVAy    TKXT-IKHiK    Or'    iHiSTETHICH. 


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only  <li.strcss  aiul  a  sense  <»('  fulness  of  the  niatnniary  jjlamls.  Ilypersorretion 
olinilk  and  ex|t(>snn'  to  cold  are  eomnionly  the  eanses  of  lliis  (condition,  wlileli 
is  |trorn|itly  i'eliev«'d  hy  reniovintr  the  ex«'essive  atnonnt  of  milk  iti  tln^  hrea^t 
and  hy  |)reventin<;  fnrther  enjrorj^enient.  The  over-distent  ion  f)f  tlu'  jflanrl  i~ 
relieved  l)y  more  fre(|nent  application  of  the  infant  to  tlu;  breast,  hy  massa^i 
or  hy  the  hreast-piimp.  Of  the  vjirions  hreast-pnmps  offered  in  the  shop- 
that  called  the  "  Kti},dish  "  (V\<r.  428)  is  the  mt.st.  desirable  and  enieieni, 
l"'nrther  enjrorj^einent  will  he  picvented  by  th((  administration  of  one  or  twu 
fidl  doses  of  a  saline  pnrjje  to  obtain  free  catharsis,  and  by  comjjrcHsion  of  iii< 
l>r<'asts  with  a  mammary  binder. 

Siijtport  anil  ('<»n/nr.'ixiini.  off/ic  /Irraufs. — Various  means  have  l)ren  devixil 
for  obtainitif^  compression  of  the  breasts.  Strappinji;  with  strips  of  adhe.-ivc 
plaster,  th(!  roller  bandaj^e,  paintinj^  the  breasts  with  contractile  collodion,  ami 
the  various  types  of  mammary  bin<lers  an;  means  each  of  which  has  its  chain- 
pions.  As  a  matter  of  fact,  with  the  ex(!eption  of  adhesive;  plaster,  with  which 
it  is  not  easy  to  obtain  persistent  uniform  <'ompression,  and  which  is  tronlijc- 
sonie  on  account  of  the  painful  excoriiitions  of  the  skin  produced,  each  n!' 
these  m(!ans  is  sjiecially  useful  under  c«'rtain  circumstanc(;s,  and  each,  fhcref'ori', 
lias  its  s|»ecial  indications.  It  is  the;  writer's  custom  in  both  hospital  and  pri- 
vate practice  to  apply  a  mammary  binder  to  every  puerperal  patient  when  th.' 
milk-flow  is  bejrinninj;  to  be  established.  At  this  time  support,  not  coniprc— 
.-ion,  of  the  breasts  is  desired.  I'\»r  this  purpose  the  Murphy  binder  (see  Kiu. 
\1'2,  and  description,  pajrc  fii\'2)  is  ordinarily  nscfl,  bccausf;  of  its  simplicitv, 
elliciency,  an<l  ready  i  •.anufactiire.  When,  however,  the  nipples  an;  stunted  or 
olhi'rwis(!  ill-developcfl,  the  Murphy  l)inder  has  the  disadvantajfe  of  a^ro^n;- 
vatin^  the  def<!(;t  l)y  firndy  compressing!;  the  nipple  af^ainst  the  breast,  and  liv 
increasintr  the  heat  and  moisture  of  the  nipples,  both  of  which  elf(!cts  remlcr 
sore  nipph's  more  liable  of  occurrence.  To  escape  these  disadvantajfcs  the  wrilcr 
has  some  of  tlies<'  banda<res  made  with  an  opeiiiufr  about  the  size  of  a  silver  liiiH- 
ilollar  ov('r  each  nipple  f  l''ij;.  I2!>j.  TIk;  marj^ins  of  the  openinjrs  are  luilinii- 
hole  stitched.  This  modified  bandage  is  used  when  the  nipples  an;  stunted  or  arc 
inverted  or  when  it  is  necessary  to  make  a|)plii'ations  to  er(»ded  nipples — >iicli, 
for  example,  as  the  bi.-muth  paste  <»r  the  witch-ha/el  lotion.  The  nipple,  afl(r 
bcin<;  clcinscd,  is  smeared  with  the  paste,  an<l  a  disk  of  chnin  waxf-d  paper  with 
a  film  of  the  paste  at  its  centre  is  placed  over  the  nipple,  after  which  the  baml- 
nj;(!  is  applied.  TIk;  infant  may  now  be  nursed,  or  repeated  ap|)lications  ul'  a 
loti«)n  may  be  made,  without  Ioos(!nin^  the  banda<>;e.  Should  the  nipple  ami 
the  areola  show  any  eviclences  of  «'dcnia,  which  will  sonjetimes  happen  win n 
the  bandajfc  is  too  tightly  applied,  the  swellinjf  will  be  relieved  by  looscmiiLr 
the  bandajfc  and,  if  necessary,  by  pinning  over  each  openin;.j  a  strip  of  iiiii-liii 
only  sli^rhtly  compressing;  the  nipple. 

When  it  is  desired  to  compress  the;  breasts  flnnly,  as  in  threatened  ina-titis 
and  alter  massajre,  a  strai<;ht  strip  of  uid)lcached  muslin  tii^htly  «'ncinliiiLf 
th(!  chest  over  the  breasts,  or  the  Y-banda^'^e  (F'oston  Lyinfr-in  Hospital/,  i- 
|)refcrr(»l    (Kij^.   42<»).     The    latter    is    applied    as    indi(;ate<l    in   Fijfiire    l.'JO. 


I'ATinnjKiY  <u'  Tin:  ri'iiurEiuiM. 


I  •)■> 


■■**'»  ii'i    ' 


mm\'^ 


vixsrsorrctii)!! 
(lition,  wIikIi 

ill  tilt'  l)r(!i-t 
i"  the  j^laiiil  i- 
t,  by  massiitrc, 

ill  the  slioii- 

iiiid  «'iVKiiiii. 
f»f  OIK!  <»r  IW" 
lircHsion  ol"  iIm' 

,•(>  hcc'H  »l('vi-'  il 
ips  of  iidlioivc 
.  collodion,  aii'l 
•h  lias  its  cliniii- 
st(!r,  willi  wlii<  li 
liicli  is  trouhli- 
)(liic('<l,  cadi  m!" 
I  (wli,  tli«  n'tori', 
Hospital  and  Jtri- 
piiticiit  when  lli" 
irt,  not  coinprf" 
l»indcr  (s,«'<'  Fi'J. 
of  its  siinplidly. 
Ics  are  stnntcd  or 
iitajro  of  -.v^ixri- 
hrcust,  and  l)V 
1  (ittcM'ts  rcmli  T 
inta}f('s  tin-  writiT 
ol"  a  silver  liall- 
linj^s  arc  l)iitt"n- 
[irc  stunted  or  mv 
■.1  nipples— >ii<li, 
The  nipple,  iil't'T 
,vax(!d  paper  Willi 
which  the  Iminl- 
applieatioiis  »\'  ;i 
Id  the  nippl*'  and 
^les  happen  wlien 
Ivcd   hy  looseiiiiiil 
a  strip  oi"  nni^lin 

Ireatened  niii-titi« 
lijrhtly  cneinliiiL' 
t-iii   Hospital). 


I'll.,  l.li.-  Moililiiil  Miir|iliy  Nrcii.st  IiIikIit.  Klii.  i:]ll.—T\if  Y-l)lilii|ii(.'r'  (lii.slnij  I.yiiii;  in  llLspitiilj 


I 

I: 


i 


,  (<^ 


in 


Ki^nn 


:{(). 


I'm.   I  ;1  — Kipllcr  liiiiicliii.'i'  iipplii'il  In  liotli  Ijrrii'-ls 
IK 


Kl'..  i:U.-  I!iilli-r  liiiiiiliiL'i-  M|i|ilii'il  Id  diic'  lircM^l. 


■v-(' 


I  ( .1 


754 


AMKlilCAA    TKXT-JiOOK   OF   OliSTE'riiW^. 


After  (Instill};  the  siirliu-c  of  tlic  hrcast  with  powdonnl  starch  or  other  hhinii 
(luHtiiijf-powdor,  the  Imsc  of  the  Y  is  <h'awii  iM'iieath  tlic  patient's  haek  nntil 
the  apex  of  the  fork  is  external  t(t  the  outer  edj^e  of  the  breast.  The  paticni 
now  lifts  upward  and  toward  each  otiier  the  two  breasts,  un*l  the  h>wer  arin 
of  the  fork  is  sinngly  (h'awn  across  the  chest  l>eneath  tlie  breasts,  the  inferior 
border  of  this  arm  extendin*;  at  h'ast  an  inch  behtw  the  niar^fin  of  tiif 
glanihilar  tissue.  The  free  end  of  the  ann  is  now  pinned  to  tlie  free  end  nl 
the  strip  that  has  passe<l  beneath  the  back,  and  the  inferior  border  is  pn . 
vented  from  slipping  upward  bv  two  safety-pins  attaching  it  to  the  abdoniiii;il 
binder.  The  npj)er  arm  of  the  fork  is  then  drawn  across  the  chest  above  the 
breasts,  the  up|K'r  border  of  this  arm  extending  an  inch  iH-yond  the  glandnl.ir 
tissue  of  the  breast,  and  the  free  end  of  the  arm  is  pinned  to  the  en«l  of  tlic 
strip  passing  behind  the  back.  The  upi)er  border  of  this  arm  is  prevenl((l 
from  slipping  by  pinning  it  to  the  shoulder-straps.  To  secure  smoothness  nf 
the  bandage  and  unit<)rm  jurssure  of  the  breasts,  safety-pins  are  now  applied 
where  the  two  arms  of  the  bandage  join  each  other  uiwh'r  the  axilhe;  the 
pinning  slioidd  be  from  the  axilla  toward  the  areola  in  order  to  decrease  the 
j)ressnre  of  the  bandage  gradually  as  the  nipple  is  approached.  A  foldtd 
towel  covered  with  a  layer  of  absorbent  cotton  is  now  placed  between  the 
breasts  to  exert  ])ressure  upon  their  inner  surfaces,  and  the  two  arn>s  of  tlii' 
bandage  are  brought  together  and  iijstened  between  the  breasts  by  means  nl'  ;i 
safety-pin.  This  bandage,  when  properly  applied,  slptuld  exert  so  niiuli 
C()mj)ression  of  the  breasts  that  milk  soon  begins  to  How  from  the  ni|i|ili. 
The  bandage  will  therefore  occasion  considerable  pain,  making  it  necessai\  tn 
loosen  it  after  a  few  hours.  It  should  be  worn  for  several  days,  with  a  degree 
of  compression  oidy  short  of  producing  pain.  After  all  signs  of  iuHanuniitiun 
have  subsided  the  Murphy  binder  may  be  substituted. 

Ordinarily  the  two  bandages  just  described  will  serve  the  pin-pose  ot'  sup- 
port or  of  couipression  of  the  breasts.  When,  however,  it  is  desired  permaneiitiv 
to  discontinue  lactation,  and  to  dry  up  the  breasts  when  abscess  is  tlireafeiKd, 
the  degree  of  compression  needed  is  best  obtained  by  a  tight  roller  baiidairc 
(Figs.  431,  4;}2)  or,  what  is  even  more  eflicieiit,  though  very  paiiifiii.  hy 
a  dressing  of  c()ntractile  collodion.  A  circidar  piece  of  material  sold  id  the 
shops  inuler  the  nanu'  of  "silk  illusion  "  is  appli(><l  to  the  breast,  and  sliniild 
extend  2  or  3  inches  beyond  its  periphery,  with  a  central  openini:  t''i' 
the  nipple  and  areola.  To  prevent  puckering  and  to  secure  close  adiiptnlinii 
to  the  contour  of  the  breast,  the  material  is  cut  at  intervals  of  an  inch  or  hhmc 
from  the  periphery  toward  and  halfway  to  the  c(>ntral  opening.  The  liiiM-t 
is  smoothly  covered  with  the  circular  |)iece  of  illusion  thus  ])repareil.  ;iiid  ;i 
thin  layer  of  coll(»dion  is  applied  and  allowed  to  dry.  Successive  lavci-  nf 
collodion  will  give  any  amount  of  compression  desired.  Xotwithstaiidiiisr 
every  precaution  a  circle  of  blisters  around  the  j)eriphery  of  the  dressing'  i< 
likely  to  occur.  This  disadvantage,  a»'d  the  possible  necessity  of  releasiii;:  iIk' 
breast  temporarily  for  practising  massage  when  compression  fails  tn  drain 
the  breast,  make  the  collodion  dressing  of  doubtful  utility.     A  very  ImimK' 


'■    I 


t"P 


f. 


IHSKASKS  OK  TIIK   liKKAST. 


I'l.ATK     IS. 


or  other  Ulaii'i 
iitV  back  uiitii 
t.     Tli«!  patitiit 

tho  lower  arm 
ists,  the  iiil'eri'i 

nlal'^;ill  ••*    <'"' 
the  tree  eml  "i 
:  border  is  jtn - 
(»  the  abdoiniiiiil 

chest  above  tlic 
11(1  the  f;lanthil:ir 
lo  the  end  of  the 
»nn  is  prevent!  (1 
e  smoothness  fl' 
i  are  now  a|»|»lii<l 
•  the  axilUe;  tlir 
•r  to  decrease  tlic 
lehed.     A  lol.l.'d 
iced  l>etwci>n  tlic 
two  arms  of  tlic 
its  by  means  of  a 
,1   exert    so    niiitli 

tVoni   the   nij'i'l'. 

n^  it  neeessarv  tn 
ays,  with  a  dci-nc 

s  of  iiiHannnatiiiii 


•iired  jM'rnKUiciitlv 

cess  is  tlireatcin'il. 

[ht  roller  biiiulaL'i' 

verv  painful,  liy 

iterial  sol.l  in  tin' 

Ibreast,  and  ^li'.uM 

ntral    oi)eniiiu  ''"' 

)•(•  close  adaptati"!! 

,f  an  inch  or  in<nv 


Nutwith>taii.r:iiir 
)f  the  dressiiiL'  i'' 
tv  of  reloasiii','  tl»' 


in 


Miissii^i'  (iT  llic  limi>t  irniin  plmioLTnplisl. 


i! 


I 


n 


t 

■ 

t  ,■: 

1|H 

!» 

■" 

(■' 

[ 

9 

^1 

ra^ff' 

t- 

1 

If 

im 

PATHOLOaV   OF   TIIK   PrERPKlUVM, 


755 


iipplitnl  Y-baiulafjo  or  the  rolli>r  bandaj^o  is  almost  as  offioieiit  and  cortainly 
is  loss  ti'oiiblosoinc  aiul  less  paintiil. 

MuHsage  of  the  Jhv(i»t». — To  achifve  the  best  results  IVoni  nianipulatioii  of 
tiio  breasts  it  is  nei'essary  to  know  its  liruitatioiis  as  well  as  its  iiulicatiotis,  and 
more  important  tlian  all  is  an  intimate  knowledge  of  its  teeliniqne.  The 
pliysieian  shoidd  give  the  matter  his  personal  attention  when  there  is  not  at 
hand  a  nnrse  upon  whom  he  ean  rely  for  its  projx^r  i)erformaiu'c.  The  im- 
portant eontra-indication  to  breast-massage  is  interstitial  inflammation  of  the 
l>reasts.  It  is  n  method  of  treatment  of  great  value  for  the  relief  of  pain  and 
t(<nsion  in  the  breasts,  due  to  engorgement  with  milk  when  the  infant  iails  to 
<iiipty  the  breast  properly,  esjHscially  when  the  nipple  is  sore,  lireast-massage 
is  also  useful  in  mastitis  to  empty  the  gland-aeini  of  their  contents,  and  even 
ol'pus  in  the  early  stage  of  parenchymatous  abscess;  thus  it  has  otlen  saved 
the  anxiety,  pain,  and  sequelte  of  lancing  such  an  abscess. 

Technique  of  BreaHt-moHHuge. — After  cleansing  the  breast  the  entire  skin- 
surface  of  the  breast  is  anointed  with  a  lubricant,  preferably  with  camphorated 
or  carbolized  oil.  It  is  the  writer's  practice  either  himself  to  perform  or  to 
teach  his  nurse  four  distinct  manipulations.  The  first  manipulation  is  one 
of  gentle  and  quick ly-rei>eated  strokes  of  the  finger-tips  (PI.  48,  Fig.  1). 
Til''  breast  can  conveniently  be  supjun'tetl  during  the  manipulation  by  the 
patient  placing  her  forearm  under  the  breast,  drawing  the  breast  uj)ward,  and 
supporting  it.  Starting  s.t  the  periphery  of  the  gland,  the  fingers  are  separate<l, 
and  are  brought  together  as  the  tips  of  the  fingers  terminate  the  stroke  at  the 
ni|)ple.  Each  segment  of  the  gland  should  thus  be  rapidly  stroked  in  succes- 
sion, paying  particular  attention  to  the  region  of  the  nipple,  and,  short  of 
producing  much  pain,  the  pressure  of  the  finger-tips  shoidd  gradually  be 
increased. 

After  this  manipulation  has  been  practisetl  for  about  five  minutes  and  pain  is 
no  longer  experienced,  the  ojierator  supports  the  breast  in  the  palm  of  one  hand 
placed  tmder  the  indurated  spot,  and  with  the  fingers  of  the  other  hand  this 
spot  is  again  stroked  toward  the  nipple,  using  deeper  and  firmer  pressure 
(PI.  48,  Fig.  2),     Each  nodule  of  induration  is  thus  treate<l  in  succession. 

The  palm  of  the  hand  is  next  placed  flat  u])on  the  inflamed  j)ortion  of  the 
breast  (PI.  48,  Fig.  3),  and  is  then  slightly  inclined  toward  the  periphery  of 
the  breast ;  steady  and  gentle  pressure  is  now  made  downward  against  the  chest- 
wall,  the  pressure  being  greater  under  the  outer  margin  of  the  hand — that 
is,  at  the  periphery  of  the  gland.  After  a  few  moments  of  steady  pressure 
irentle  rotary  movements  of  the  hand  are  practised  over  the  lump.  Pressure 
and  rotation  of  the  hand  are  thus  alternated  for  a  few  minutes  or  until  the 
])ationt  complains  of  pain,  when  the  stroking  movements  (PI.  48,  Fig.  1)  are 
renewed  for  a  short  time. 

Finally,  the  breast  is  grasped  firmly  with  both  hands  in  such  a  manner  as 
to  encircle  the  breast  com]>letely  (PI.  48,  Fig.  4) ;  the  whole  gland  is  gently 
raised  from  the  chest  and  compressed,  especially  over  and  at  the  base  of  the  in- 
durated nodule,  and  at  the  same  time  the  two  index  fingers  are  quickly  stroked 


:i| 


:^'-  . 


'.:.  '^ 


756 


AMERICAN    Ti:XT-liOOK   OF   OliSTKTRICS. 


toward  the  iiipplo,  wlioii  milk  is  usually  hccii  to  flow  iVotu  the  duds  tliut  empty 
tliat  portion  of  the  ^laud.  The  pressure  is  not  relaxeil,  so  long  as  the  milk  flows, 
until  the  patient  complains  of  the  pain  it  eommonly  oeeasions  in  u  few  minute^. 
After  a  few  moments  of  rest  and  reassurance  to  th"  patient  the  manipulations 
are  re|>eated  in  the  order  above  described  until  the  whole  gland  is  soil  and 
flaccid,  when  a  |)ressu re-bandage,  preferably  the  Y-banilage,  is  snugly  applied. 

Mastitis. — Frcquem'if. — It  has  been  estimated  that  about  one-fourth  of  all 
fertile  marrie<l  women  have  snfl'ered  from  inflammation  of  the  breast  at  muimc 
peritnl  of  their  reproductive  activity,  and  in  1000  (tonsecutive  deliveries 
Win(!kel**  obscrvwl  mastitis  in  6  per  cent,  of  the  patients.  This  iwrcentap.' 
undoubtedly  cxece<ls  the  number  of  eases  observetl  under  the  more  rigid  att«'ii- 
tion  in  recent  years  to  antisepsis  of  the  nipples  and  breasts.  Dciss**  records  a 
frerpiency  of  JJ.G  iM'r  cent,  in  1600  consecutive  confinements.  The  disease  is 
more  frequent  in  primiparie.  It  is  said  to  be  observed  oftenest  in  blondes  ami 
in  lymphatic  subjects.  It  is  rare  after  the  fourth  pregr.ancy  (Delber^j.  Tlicn- 
are  four  periods  of  the  puerperium  in  which  mastitis  is  mo«t  likely  t<»  occur. 
These  peri(Rls  are :  {a)  the  flrst  month  of  the  puerperium  ^^^•s|H•^•ially  the  first 
two  weeks),  while  both  the  mother's  nipples  and  breasts  and  the  infant  are 
adapting  themselves  to  the  mammary  function  ;  (/>)  when  suckling  is  suddenly 
given  up,  thus  favoring  stasis  and  its  ill  cfteets ;  (c)  the  jieriod  of  appearanri- 
of  the  fii-st  teeth,  at  which  time  the  nii)ple  is  again  exposed  to  injury  ;  {d)  and 
the  time  of  weaning,  when  cither  engorgement  of  the  gland  is  likely  to  (ncur 
because  the  regular  emptying  v>f  the  breast  is  not  attended  to,  or,  as  happens 
especially  in  hyperlactation,  the  child,  not  being  satisfietl  with  the  quality  and 
quantity  of  milk  secreted,  shows  its  dissatisfaction  by  biting  and  tugging  at 
the  nipple. 

Varieties. — It  is  customary  to  describe  three  varieties  of  mastitis,  according  to 
the  location  of  the  inflamed  area.  The  first  and  most  frequent  variety  is  the puren- 
chi/mafous  or  r/landiilar,  in  which  the  acini  of  the  gland  or  the  adjacent  con- 
nective tissue  is  primarily  attacl-"«l  by  inflammation  (Fig.  433).  In  either  case 
the  destructive  inflammation,  as  it  progresses,  may  end  by  involvement  of  both  the 
acini  and  the  connective  tissue.  A  second  variety  is  the  mbcutaneoris,  in  which 
the  connective  tissue  lying  immediately  beneath  the  skin  is  attacked.  The  third 
variety  is  the  rare  and  insidious  inflammation  of  the  post-mammary  or  xith- 
glandular  connective  tissue  between  the  gland  and  the  chest-wall.  This  divi>i()n 
of  mastitis  should  not  obscure  the  fact  that  clinically  two  or  all  three  varieties 
may  be  combined,  especially  in  cases  which  do  not  receive  prompt  treatment  in 
the  beginning,  since  either  variety  may  end  in  a  combination  of  all  three. 
Mastitis  commonly  begins  as  the  parenchymatous  variety  and  approaches  the 
skin-surface  of  the  gland. 

Etiology  and  Patholoyy. — The  etiology  of  puerperal  inflanmiations  of  the 
breast  has  actively  been  discussed  in  recent  years,  and,  although  the  investi<ra- 
ticnis  of  bacteriologists  have  wrought  a  change  in  our  notions  of  the  patliolotry 
of  mastitis,  the  subject  is  not  wholly  free  from  uncertainty.  Formerly  it  was 
believed  that  engorgement  (»f  the  gland  with  stasis  of  the  milk  was  invariably 


PATUOLOaV   (tF   THE    IHEIil^KltllM. 


767 


!trt  that  empty 

the  milk  Hows, 

a  few  minutes. 

iuuiiil>»l"tiuii> 

ml  irt  «*»1^  ""'1 
mngly  appru^l. 
u!-tburth  of  all 
!  breast  at  soiiic 
utivc  dt'livorics 
This  iKjrceiitam' 
lore  rigiJ  attcn- 
Oeiss**  rcfonlsii 
The  disease  is 
t  in  l)h>ndes  ati<l 
DeUwn J.    'ri»it' 
,t  likely  to  otnir. 
.»Hrially  tlie  liisl 
ul  the  infant  are 
kling  is  smUlenly 
iml  of  appearaiicf 
o  injury  ;  ((?) :""! 
,  is  iikoly  to  occur 
to,  or,  as  hapitciis 
th  tlie  quality  ami 
g  and  tuggiuj?  at 

istitis,  accordiiitr  to 
ariety  is  the p((/«  li- 
the adjacent  coii- 
;3).  In  either  c^-^ 
iveraent  of  both  tlie 

xdmu'oxm,  in  wliicli 
stacked.  Thethinl 
.mamviary  or  «"''- 
[vail.  This  division 

all  three  varieties 
rompt  treatment  in 

ition  of  all  tl.reo. 

ind  approaehes  tlie 

lammations  of  the 
^ugh  the  investitra- 
is  of  the  patholo^n- 
Formerly  it  was 
Ulk  was  invariably 


tlie  cause  uf  all  inamniury  intlannnation  ;  but  tliis  idea  lias  disappeared  largely, 
"iiKHj  most  pathologists  consider  iiiHaiumatioii,  wherever  found,  of  niiembic 
origin.  Kecent  exi)eriinents  have  shown  tiiat  stJisis  of  the  milk  will  not  pro- 
duce mastitis  except  when  the  milk  contains  bacteria.  Ligation  or  stoppage 
ol'  the  milk-ducts  l)y  colltnlion  (Kehrer)  fiiilcd  lo  produce  iiitlamiiiation  of  the 
lireast  in  animals.  The  CMrcme  rarity  of  mastitis  in  supernumerarv  breasts, 
and  the  fact  that  tiie  frccpiency  of  the  disease  lias  been  lessened  so  greativ  since 
antisepsis  has  l)een  extendeil  to  the  care 
ol'  the  breasts,  have  also  been  advanced 
as  arguments  in  favor  of  the  unimport- 
ance of  stagnation  of  the  milk.  There  • 
is,  however,  a  clinical  side  to  this  qiics- 


the  belief  that  milk- 


ri(i.  4;tS.— Miiiiiiimry   kI'iihI  :   1,  liictriil  ducts; 
gluniluliir  ui'inus  (I'luyl'air). 


tion,  wluch  lorccs  the  l)eiiet  mat  mil 
stasis  continues  at  least  a  predisposing 
I'aetor  in  mastitis,  es|)ecially  in  the  very 
important  parenchymatous  variety.  Sta- 
sis cert4tinly  is  a  frequrat  precursor  .p^ 
mastitis,  whether  the  accumulation  of 
.iiilk  in  the  gland  rei'dts  from  hy- 
persecretion, from  failure  lo  nurse  at 
pro])er  intervals,  or  from  insnfhcient 
emptying  of  the  gland  when  there  is 
anatomical  defect  in  the  shape  of  the 
nipples  or  narrowing  of  their  milk-ducts, 
— all  of  which  conditions  are  known  to 
bear  an  intimate  relation  to  breast-in- 
flammation. Honigman**  disproved 
the  statement  that  human  milk  has  bactericidal  properties  as  regards  the  micro- 
organisms commonly  found  in  mastitis ;  further,  it  is  believed  that  a  pent- 
up  milk-secretion  not  only  lessens  the  resistance  of  the  breast-tissues  against 
luicrobc  activity,  but  that  it  also  otl'ers  a  very  favorable  medium  for  the  rapid 
miiitiplicatiim  of  bacteria.  The  experiments  of  Colin  and  Xeumann,  before 
rct'erred  to,*^  demonstrate  the  fact  that  the  micro-organisms  ordinarily  found  in 
the  milk  are  more  numerous  the  longer  the  time  since  the  removal  of  the  milk. 
Although  we  must  admit  that  stasis  of  the  milk  predisposes  to  mastitis,  the 
eviiU'iiee  is  overwhelming  that  the  'inportant  element  in  etiology  is  inlt'ction. 

Siiiee  the  invostiiiations  in  1884  of  liumm,'**  bacteriological  studies  of  mas- 
titis  and  mammary  abscess  have  proved  that  these  diseases  are  the  result  of  the 
irritant  action  of  micro-organi;  ins,  and  that  the  infection  is  usually  due  to  fttdjilii/- 
/ococc/, eiti.  "  mtreus  ov  (ilbxs ;  someti mes. s//ry;^ococci  arc  found;  and  Moiinier^' 
liiis  shown  that  in  some  cases  staph t/lococci  are  associat(>d  with  other  miero- 
oi'iraiiisnis,  such  as  micrococcus  tctntffeus,  stirptococcus,  or  micrncoccHN  sii/jfldrus. 
Tims  it  will  be  seen  that  the  disease,  like  infection  of  the  parturient  tract,  may 
oritrinate  from  several  different  pathogenic  organisms.  The  nipples,  especially 
when  erodeil  or  fissured,  are  commonly  the  point  of  entrance  of  the  infecting 


.u 


i    i 


,  I 


i"1:;r 


'•   ;-  .i' 


758 


AMERICAN    TEXT- BOOK   OF   OBSTETRICS. 


agent,  anil  the  soiiiros  of"  inl'cction  are  either  the  chiUl's  month,  which  is  know  n 
to  be  the  habitat  of  several  micro-organisms  some  of  whi(rh  are  pathogenic,  or 
the  patient's  or  nnrse's  fingers,  or  unclean  appliances  used  about  the  nipple  and 
breast,  such  as  soiled  cloths  or  an  unclean  nipple-shield  or  breast-pump.  Tiic 
exact  manner  of  entrauce  into  the  breast  of  the  infecting  agent  in  all  cases  is 
notdefinitely  settled,  and  the  question  is  one  about  which  there  has  been,  and  is, 
considerable  controversy.  It  seems  certain  that  the  poison  may,  under  varyiiiir 
circumstances,  enter  the  gland  either  from  the  cutaneous  surface  through  tiie 
milk-ducts,  which  path  many  pathologists  believe  to  be  most  frequent,  or  through 
the  lymphatics ;  or,  circulating  in  the  blood,  the  infecting  poison  may  be  ex- 
creted by  the  nulk.  The  frequency  of  involvement  of  the  lower  segment  of 
the  gland,  and  the  fact  that  in  the  early  stage  of  mammary  abscess  pus  and 
milk  are  so  often  coincidently  expressed  tiirough  the  nipple  by  massage,  are 
thoughi  to  be  evidences  of  the  more  frequent  early  involvement  of  the  milk- 
ducts  (Delbert).  When  cracks  or  fissures  of  the  nipple  are  present,  Pingat 
believes  the  poison  is  likely  to  enter  the  lymph-channels ;  and  when  the  epi- 
thelium of  the  nipples  is  intact,  the  microbes  may  follow  the  milk-ducts  to  the 
acini,  there  multiply,  and  find  their  way  into  tiie  cellular  tissue.  Orth  thinks 
it  probable  that  atreptovocci  enter  the  lyn)ph-channels  and  that  staphylomcd 
enter  the  milk-ducts.  Williams  remarks  :**  "As  to  the  respective  parts  played 
by  the  lymphatics  and  ducts  it  is  not  easy  to  decide.  It  seems  certain,  however, 
that  each  has  its  rule.  In  superficial  inflammations  of  the  breast,  especially 
those  of  erysipelatous  origin,  most  pathologists  are  agreed  that  the  lymphatics 
are  chiefly  concerned  in  the  spread  of  the  disease.  In  other  cases  it  sceius 
probable  that  infection  takes  place  chiefly  by  the  ducts."  The  relative  import- 
ance of  the  ducts  and  the  lymphatics  as  pathways  for  the  entrance  of  infection 
at  first  thought  would  seem  to  be  a  problem  more  of  scientific  interest  than  of 
practical  value,  since  it  is  enough  for  prophylaxis  to  know  that  infection  almost 
always  occurs  through  the  nipple,  usually  when  the  integument  is  broken,  hut 
possibly  when  the  latter  is  intact.  It  will,  however,  be  pointed  out  later,  when 
the  treatment  of  mastitis  is  considered,  that  for  one  means  of  treatment — 
namely,  massage — it  is  of  importance  to  learn,  if  possible,  through  wliicli 
channel  the  infection  has  occurral. 

The  rarest  and  perhaps  the  least  important  channel  of  infection  of  the  breast 
is  by  micro-organisms  circulating  in  the  mother's  blood-current.  It  has  been 
shown  by  Escherich"  that  micro-organisms  in  the  blood-current  are  often 
eliminated  by  the  secretions,  notably  in  the  milk  as  well  as  in  the  urine.  It 
is  possible  also  that  secondary  to  puerperal  phlebitic  infection  of  the  genitalia 
a  metastatic  abscess  of  the  breast  can  occur.  Beyond  these  two  facts  little  is 
known  of  mastitis  and  mammary  abscess  originating  from  infection  of  the 
mother's  blood. 

The  actual  pathological  changes  resulting  from  infection  in  and  about  the 
parenchyma  of  the  gland  are  such  as  would  be  expected  from  micro-organisms 
rapidly  nndtiplying  and  finding  their  way  into  the  adjacent  tissues.  Aceonlinir 
to  Bumm,*^  the  milk  is  fermented,  its  sugar  converted  into  lactic  and  biit\  ric 


i 


PATHOLOGY    OF    THE   rVEIiPETiU'M. 


759 


acids,  and  coagula  of  casein  are  fbrruetl  containing  innumerable  bacteria.  The 
epithelium  lining  the  gland  becomes  swollen,  desquamates,  and  disappears. 
At  the  same  time  leucocytes  and  micro-organisms  infiltrate  the  periglandular 
tissues.  Small  tbci  of  suppuration  soon  become  numerous,  coalesce,  and  form 
larger  purulent  collections.  The  cavities  thus  forme<l  are  traversed  by  shreds 
of  partially  destroyed  tissues,  and  are  surrounded  by  a  protecting  wall  of  leuco- 
cytes to  prevent  the  further  progress  of  microbe  invasion  and  suppuration, 

JSymptoms. — All  varieties  of  mastitis  are  accompanied  by  the  signs  of  inflam- 
mation. The  patient  complains  of  chilly  sensations  or  has  a  distinct  rigor, 
followed  by  elevation  of  the  temperature  and  by  pain  and  tenderness  in  the 
afiected  breast.  Each  variety,  however,  has  a  train  of  symptoms  more  or  less 
distinct.  It  will  therefore  be  of  clinical  value  to  describe  first  the  parench.ym- 
atous  variety,  which  is  the  most  frequent.  Subcutaneous  and  subglandular 
mastitis  are  so  commonly  followed  by  suppuration  that  their  description  seems 
more  appropriate  in  the  section  upon  Mammary  Abscess. 

When  the  inflammation  begins  in  the  glandular  structures  of  the  breast 
there  will  be  found  one  or  more  hard,  localized,  tender  nodides  due  to  stasis  of 
the  milk  in  these  portions  of  the  gland.  Tiie  overlying  skin  is  either  not  red- 
dened or  there  may  be  only  a  faint  tinge  of  redness.  The  })ain  ])roduced  by 
liandling  the  breast  is  not  severe.  The  temperature  promptly  rises  to  a  great 
jieight — often  to  104°  F.  or  higher.  The  infection  which  has  taken  place 
through  the  lactiferous  ducts  is  at  this  time  producing  those  changes  in  the 
milk  and  the  epithelium  of  the  acini  that  have  been  described,  and  when 
prompt  abortive  treatment  is  not  employed  the  more  extensive  inflammatory 
changes  extending  into  the  comiective  tissue  are  likely  to  occur. 

Should  the  connective  tissue  surrounding  the  acini  of  the  gland  fii-st  become 
inflamed,  an  enlarged  nodule  is  at  this  time  not  so  apparent.  The  patient  com- 
plains of  an  ill-defined  painful  s|)ot,  the  temperature  rises  more  gradually,  and 
chilly  sensations  are  complained  of  oftener  than  a  rigor.  The  nipple  has  either 
recently  been  sore  or  will  be  found  eroded  or  fissured,  or  upon  close  inspec- 
tion a  crack  or  an  abrasion  is  observed  at  some  portion  of  the  areola.  There  is 
early  ralness  of  the  skin  that  is  soon  loUowed  by  edema.  It  will  frequently 
bo  noted  that  the  location  of  the  inflammation  corresponds  with  the  situation  of 
tlio  fissure  of  the  nipple.  Notwithstanding  early  treatment,  this  variety  is  more 
likely  to  resist  resolution,  the  inflammation  slowly  progressing  to  abscess- 
formation,  a  termination  especially  liable  to  follow  when  the  nipj)le  is  angrily 
inflamed  and  resists  treatment. 

The  clinical  signs  above  described  are  often  clearly  distinguishable.  There 
arc  cases,  however,  in  which  both  the  acini  and  the  surrounding  connective 
tissue  are  apparently  almost  coincidently  aftected,  and  the  difrerentiating  symp- 
toms are  correspondingly  obscure.  When  there  is  doubt  as  to  the  exact  vari- 
ety of  inflammation,  it  is  a  safe  clinical  rule  to  institute  the  treatment  to  be 
described  for  infection  of  the  gland-acini. 

Treatment:  I*roph}//a.riH. — The  prophylactic  treatment  of  mastitis  shoidd 
begin  in  the  last  months  of  pregnancy.     rro{)er  attention  to  the  nipples,  as 


r%:^ 

•i-.:!!. 

,.f  :'fr 

760 


AMERICAN    TEXT- HOOK   OF   OBSTETRICS. 


\ 


previously  describal,  to  get  tlicni  in  the  best  possible  condition  for  suckling, 
will  ilo  much  to  prevent  inHuniniation  of  the  broasts.  From  the  first  appli(;a- 
tion  of  the  child  to  the  breast  three  important  means  of  jirophylaxis  arc 
always  to  be  borne  in  mind,  and  are  to  be  impressed  upon  the  mother  or  the 
nurse;  they  arc:  (1)  The  strictest  cleanliness  of  the  l)reasts  and  nipples  througli- 
out  the  entire  period  of  lactation;  (2)  limitation  of  injury  to  the  nipples  by 
prompt  measures  to  maintain  their  epithelium  intact ;  (3)  prevention  of  stasis 
of  the  nailk  secreted. 

Curative  Treatinent. — When,  notwithstanding  all  these  precautions,  inflam- 
mation of  the  gland  actually  exists,  the  indications  are  to  put  the  gland 
absolutely  at  rest,  to  relieve  it  from  tension  and  from  the  accumulated  products 
of  inflammation,  to  prevent  further  engorgement  with  milk  and,  finally,  to 
lessen  its  blood-supply. 

The  first  and  always  essential  step  in  treatment,  especially  when  the  nipple 
is  sore,  is  the  immediate  removal  of  the  infant  from  the  breast,  to  secure  rest 
from  j)ain  and  from  functional  activity  of  the  gland,  to  promote  healing  of  the 
ni])plc  when  eroded  by  avoiding  traumatism  and  fresh  infection,  and,  further, 
to  avoid  the  danger  to  the  child,  slight  though  it  may  sometimes  be,  of  absorb- 
ing milk  changed  in  quality  by  the  products  of  inflammation  or  even  containing 
pus.  This  l)eing  effected,  much  has  been  done  to  prevent  abscess-formation  ; 
the  oidy  advantage  of  suckling — removal  of  the  milk — can  be  accomplished 
more  safely  and  less  violently  by  other  means.  The  next  step  in  the  treatment 
will  be  to  decide  whether  or  not  the  inflammation  is  situated  in  the  gland- 
acini,  and  whether  the  inflammation  has  so  far  advanced  that  efforts  to  prevent 
suppuration  will  likely  fail.  If  these  two  problems  could  readily  be  solved, 
the  seU'Ction  of  treatment  to  be  followed  in  individual  cases  would  not  be 
difficult. 

As  has  been  stated  above,  the  manner  of  onset,  the  condition  of  the  nipple, 
the  temperature,  the  character  of  the  pain,  the  appearance  and  feel  of  the  breast, 
an«l  the  relative  frequency  of  ])arenchymato»is  and  interstitial  inflammatiuii 
will  often  help  a  decision.  When  there  is  doubt,  it  is  best  to  consider  the 
case,  at  least  temporarily,  as  one  of  parenchymatous  inflammation.  It  is  per- 
haps more  ditticult  to  determine  whether  or  not  the  inflammation  has  advanced 
bevouil  the  usefulness  of  abortive  measures — in  other  words,  whether  or  not 
pus-formation  has  occnrRnl.  When  early  improvement  does  not  follow  prouipt 
and  vigorous  treatujent,  but,  on  the  contrary,  the  case  gets  steadily  worse  ami 
presents  some  of  the  signs  to  be  described  as  evidences  of  abscess-formatinii. 
curative   treatment  short  of  surgical   measures  is  not  to  be  employed. 

Having  decided  that  the  inflammation  is  largely  parcnchynnitous,  accoiii- 
panitnl  and  aggravated  by  inspissation  of  milk,  evacuaticm  of  the  milk  is  to 
be  obtained  by  skilfully  a|)plie<l  massage,  assisted  by  the  proper  use  of  tin' 
breast-pump,  bearing  in  mind  the  fact  that  as  the  breast-pump  only  withdiaws 
the  milk  from  the  large  ducts  near  the  nipple,  too  vigorous  ap})lieation  of  (lie 
pump  should  not  be  employed.  Short  of  jM'oducing  |)ain,  the  breast-pnni|i  i« 
a  valuable  adjunct  to  massage,  and  the  two,  skilfully  combined,  will  often  nmic 


11  for  sucklinji, 
\e  first  applii-i- 
)roi)hylaxis  »'*' 
e  inotlior  or  tlio 
ipples  throiij^h- 
tlio  nipplfs  l)y 
.•oution  of  stasis 

•autions,  inflain- 
put  the   gland 

iiulated  products 
and,  finally,  to 

when  the  nipple 
st,  to  socnre  rost 
)to  healing  of  the 
ion,  and,  further, 
nes  he,  of  absorh- 
ir  even  containiiit;; 
bsecss-forniation ; 

be  aeeoniplislu'd 
p  in  the  treatment 
ted  in  the  glanil- 
.  efforts  to  prevent 
readily  be  solvi'd, 
ses  would  not  he 

tion  of  the  nipple, 
feel  of  the  breast, 

itial  inflanunatiiiii 
-t  to  eonsider  tlie 

liation.     It  is  per- 

Ition  has  advanced 
s,  whether  or  not 

]not  follow  prompt 
steadily  worse  aii'l 
labscess-forinatinii. 

eniployeil. 
I'liymatous,  accoiu- 
lof  the  milk  is  i" 
[proper  use  of  the 
lip  only  withdraw- 
lapplieation  of  il"' 
Ihe  breast-pumi'  '- 
Id,  will  often  more 


I'ATIIOLOaV   OF    THE   PVKRPEItnM. 


761 


readily  empty  the  bieast  than  will  massage  alone.  Evacuation  of  the  milk  and 
relief  of  the  tension  in  the  breasts  liaving  been  aecomplished,  further  aecumu- 
lation  shoidd  be  prevented  by  firm  eorui)ression  of  the  breasts.  The  lessening 
of  blood-supply  to  the  gland  and  the  prevention  of  hypersecretion  are  also 
indicated,  aiul  are  obtained  by  the  derivative  action  of  saline  cathartics,  which, 
to  accomplish  most  good,  should  Ik?  given  freely  in  the  earliest  stage.  After 
this  time  their  value  in  large  doses  progressively  diminishes  in  cases  seriously 
threatened,  since  an  advantage  is  lost  if  the  flow  of  milk  is  thereby  almost 
wholly  stopped,  for  the  outflow  of  milk  at  the  same  time  relieves  the  gland  of 
the  products  of  microbe  activity. 

After  the  employment  of  massage  and  compression  of  tlie  breast  the  applica- 
tion of  an  ice-bag^  to  the  binder  over  the  painfid  lobe  of  the  gland  will  further 
lessen  the  blood-supply  and  relieve  the  pain,  and  will  have  the  well-known 
beneficial  effect  of  cold  upon  the  inflamed  area,  whether  or  not  this  effect  is 
gained,  as  has  been  asserted,  through  its  inhibitory  power  over  the  activities 
of  micro-organisms.  The  ice-bag  may  be  kept  in  place  continuously  for  from 
twelve  to  twenty-four  hours,  the  time  being  determined  by  the  disappearance 
(if  pain  and  a  fall  in  temperature.  Thereafter  it  may  be  used  intermittently 
(Uu'ing  from  three  to  six  hours,  until  all  tenderness  of  the  breast  disappears 
and  the  normal  milk-flow  is  re-established. 

In  addition  to  employing  the  ice-bag,  or  when,  as  rarely  happens,  it  is  dis- 
agreeable to  and  not  well  borne  by  the  patient,  the  ap{)lication  under  the  binder 
of  compresses  wet  with  lead-water  and  laudaninn  and  covered  with  waxed 
jKiper  is  a  most  valuable  means  of  allaying  inflammation  and  relieving  pain. 

When  the  inflammation  of  the  breast  is  thought  to  have  had  its  origin  in 
tlie  connective  tissues  about  the  acini  of  the  gland,  the  plan  of  treatment  to  be 
fctllowed  is  somewhat  different  from  the  preceding  treatment.  In  the  first  place, 
moderate  support  of  the  breasts,  best  obtained  by  the  Murphy  binder,  should  be 
employed,  and  not  the  firm  compression  of  the  breasts  so  useful  in  parenchym- 
atous inflammation.  Again,  massage  of  the  breasts  can  only  be  jiroductive  of 
Iiiinu  in  the  interstitial  inflammation,  since  the  relief  of  milk-stasis  is  not  so 
urgent  and  the  tissues  are  further  damaged  by  tlie  manipulation.  It  is  the 
I'ailnre  to  recognize  this  class  of  cases,  in  which  expression  is  contraindicatcd, 
that  has  helped  to  make  some  authors  condemn  massage  of  the  breasts.  Wiien 
the  operator  is  in  doubt  as  to  the  variety  of  inflammation  present,  or  when  the 
ease  presents  evidence  of  both  varieties  of  mastitis,  as  sometimes  liappens.  and, 
it  is  to  be  confessed,  makes  a  differential  diagnosis  difficult,  it  is  best  to  resort 
to  inassage  tentatively,  giving  it  up  and  deciding  that  interstitial  mastitis  is 
present  wiien  by  its  use  pain  is  not  diminished  and  the  temperature  fails  to  fall, 
Aliaiidoning  firm  (iompression  and  all  efforts  at  expression,  attempts  may  be 
made  to  conduit  the  inflammation  by  the  use  of  saline  cathartics  and  I)y  apply- 
iiitr  under  the  binder  lead-water  and  lau<laiuim  or,  which  is  of  doubtful  utility, 
I'elladonna,  either  the  extract  or  the  plaster.  Should  belladonna  be  used,  its 
lihysiojogical  action  upon  the  pupils,  the  skin,  and  the  throat  must  always  be 
looked  for,  and  the  drug  must  be  tliscontinued  l)cfore  a  poisonous  amoiuit  is 


Pi 


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m 


absorbed.  The  erosion  or  fissure  of  the  nipple  should  promptly  be  treated,  and 
be  cured  as  speedily  as  possible.  Notwithstanding  active  treainient,  suppuration 
of  the  breast  is  very  likely  to  be  the  outcome  of  interstitial  mastitis. 

Mammary  Abscesses. — Following  the  classification  of  mastitis,  abscesses 
in  the  mammary  gland  may  be  located  superficially  under  the  skin  or  deeply 
under  the  gland ;  or  most  frequently  the  abscess  follows  mastitis,  involvinjr 
primarily,  as  has  been  pointed  out,  either  the  secreting  structures  of  the  gUuul 
or  the  connective  tissue  adjacent  to  the  acini,  and  gradually  approaches  the 
skin.  Two  or  even  all  three  varieties  may  be  associated.  The  parenchym- 
atous variety,  approaching  and  finally  involving  areas  of  the  subcutaneous 
connective  tissue,  where  pointing  occurs,  is  most  frequently  seen.  Deep-seated 
abscesses  not  vigorously  treated  by  early  and  thorough  opening  may  burrow  in 
all  directions  and  destroy  the  gland,  or  several  portions  of  the  breast  may  suc- 
cessively be  attacked  when  incision  and  drainage  have  not  been  efficient. 

Parenchymatous  Abscess. — When  the  inflammation,  aggravated  by  inspis- 
sation  of  the  milk,  originates  in  and  is  limited  to  the  acini  of  the  gland,  active 
and  persistent  treatment  by  massage  and  compression  will  usually  be  followed 
by  resolution ;  or  sometimes  the  pain,  induration,  and  fever  will  disappear, 
and  after  three  or  four  days  caseous  milk  and  a  small  amount  of  pus  will  be 
expressed  with  the  milk.  The  appearance  of  the  latter  is  evidence  that  the 
inflammation  has  not  wholly  been  aborted.  If,  on  the  contrary,  the  signs  of 
inflammation  do  not  disappear  notwithstanding  active  treatment,  it  may  ho 
concluded  that  the  interstitial  tissues  of  the  breast  are  either  primarily  or 
secondarily  involved,  and  that  we  have  to  deal  with  the  most  frequent  type 
of  mammary  abscess  and  one  of  the  most  painful  and  distressing  compli- 
cations of  the  puerperium.  At  the  earliest  possible  moment  the  formation 
of  pus  should  be  discovered. 

Symptoms. — There  are,  unfortunately,  no  absolute  signs  of  suppuration 
short  of  fluctuation,  yet  in  deep-seated  or  in  slowly  progressing  cases  it  is 
dangerous  to  delay  treatment  until  fluctuation  is  apparent.  Left  to  itself,  the 
pus  will  require  about  two  weeks,  or  longer  Avhen  deeply  seated,  to  reach  tiie 
surface.  Frequently  the  abscesses  are  multiple  and  form  in  succession,  and  wiu  n 
neglected  may  recur  for  months.  Velpeau  observed  46  abscesses  in  one  breast 
within  a  period  of  two  or  three  months.  The  signs  suggestive  of  abscess-forma- 
tion are  recurrence  of  a  chill  or  a  chilly  sensation  ;  greater  rapidity  of  pulse; 
])ersistently  high  temperature ;  increasing  dull  pain  in  the  breast ;  pain  upon 
moving  the  arm,  sometimes  with  enlargement  and  tenderness  of  the  axillary 
glands ;  diminution  in  the  flow  of  milk  ;  bluish-red  discoloration,  with  boiijfi- 
ness,  adherence,  and  marked  edema  of  the  skin.  Of  these  signs,  rapid  piilso, 
bluish  discoloration  and  edema  of  the  skin,  and  marked  diminution  in  the  H<iw 
of  the  milk  are  most  important,  and  are  enough  to  warrant  an  exploratory 
incision.  It  should  be  remembered  that  some  fortunately  rare  cases  of  mam- 
mary abscess  develop  subacutely,  without  the  ordinary  signs  of  suppuratimi, 
or  even  of  inflammation.  The  use  of  an  aspirator-needle  has  been  rocdin- 
mcnde<l  for  the  detection  of  pus,  although  it  is  often  of  doubtful  utility.    Since, 


PATHOLOGY   OF    THE   PLERPERILM. 


7G3 


be  treated,  and 
nt,  suppuration 
ititis. 

stitis,  abscesses 
skin  or  deeply 
ititis,  involving!; 
js  of  the  gland 
approaches  tlu; 
"he  parenchyni- 
le  sulxjutaneoiis 
11.     Deep-seated 
;  may  burrow  in 
breast  may  suo- 
n  efficient. 
avate<l  by  inspis- 
the  gland,  active 
lally  be  followed 
'  will  disappour, 
it  of  pus  will  be 
vidcnce  that  the 
ary,  the  signs  of 
ment,  it  may  he 
her  primarily  or 
)st  frequent  type 
stressing  com  ph- 
ut the  formation 

of  suppuration 
ussing  cases  it  is 
,eft  to  itself,  the 
ited,  to  reach  the 
[cession,  and  when 
[sses  in  one  breast 
of  abscess-fonna- 
•apidity  of  pul'^i' ; 
reast;  pain  upon 
iS  of  the  axillary 
ition,  with  boji-iri- 
ligns,  rapid  ptdsc, 
[lution  in  the  How 
it  an  exploratory 
ire  cases  of  niani- 
of  suppuration, 
has  been  recom- 
[ul  utility.    Since, 


to  be  effective,  the  needle  always  requires  the  preliminary  use  of  au  anesthetic, 
and  since  it  may  not  find  pus-collections  which  can  be  found  by  the  finger 
through  an  incision,  tiie  aspirator-needle  shouKl  be  discardcH.1  for  the  more 
intelligent  and  less  uncertain  exploration  with  the  finger. 

Treabnent. — The  patient  shoidd  always  be  anesthetized  to  open  and  treat 
a  mammary  abscess  properly,  except  wiien  the  abscess  is  superficial  or  is  about 
to  point,  in  which  cases  a  chlorid-of-ethyl  spray  or  freezing  with  an  ice-and- 
salt  mixture  will  usually  be  sufficient.  After  rendering  the  skin  thoroughly 
aseptic  the  breast  is  grasped,  and  by  careful  palpation  the  collection  of  pus 
.should,  if  possible,  be  localized,  and  at  its  most  dependent  portion  there  is 
made,  in  a  direction  radiating  from  the  nipple  to  avoid  the  milk-ducts,  an 
incision  sufficiently  large  to  admit  the  finger  and  deep  enough  to  incise  only 
the  skin  and  the  subcutaneous  tissues  (about  J  to  $  of  an  inch).  Through 
this  opening  a  grooved  director  is  gently  passed  in  all  directions  until  the 
abscess-cavity  is  found,  when  a  dressing-forceps  is  introduced,  by  which  the 
tissues  are  sufficiently  dilated  to  admit  the  index  finger  into  the  abscess-cavity. 
With  the  finger  all  communicating  and  adjacent  cavities  are  searched  for  and 
are  freely  opened  and  all  friable  tissue  is  broken  down.  The  dressing-forceps 
or  a  probe  is  introduced,  is  pushed  through  the  cavity  to  the  skin-surface 
and  is  cut  down  upon  to  make  additional  openings  in  order  to  secure  free 
drainage.  Several  such  openings  should  be  made  in  the  skin  at  the  different 
portions  of  the  gland  where  pus  or  induration  has  been  detected  by  the  finger. 

After  thoroughly  dilating  all  entrances  to  the  pus-cavities,  thorough  irriga- 
tion is  made  with  an  antiseptic  solution.  Peroxid  of  hydrogen,  full  strength,  fol- 
lowed by  a  2  per  cent,  solution  of  creolin,  will  be  found  efficacious.  Weak  solu- 
tions of  carbolic  acid  or  of  bichlorid  of  mercury  may  be  used.  The  subsequent 
treatment  may  be  one  of  the  following  :  The  cavities  and  all  openings  may  be 
packed  firmly  with  sterilized  gauze  moistened  by  an  antiseptic  solution  (1  per 
cent,  carbolic  or  2  per  cent,  creolin),  followed  by  an  antiseptic  dressing  vinder  a 
firm  bandage.  After  from  twenty-four  to  thirty-six  hours  the  gauze  packing  is 
gently  removed,  the  cavities  are  irrigated  with  the  peroxid  of  hydrogen  diluted 
with  three  volumes  of  boiled  water,  followed  by  creolin  (1  per  cent,  solution) ; 
strips  of  gauze  are  lightly  placed  in  the  drainage-tracts,  and  a  compression 
hinder  is  comfi)rtably  applied.  The  next  day,  if  the  discharge  has  almost  dis- 
a|)peared,  an  antiseptic  dressing  is  applied,  and  firm  compression  is  secured 
hy  carefully-adjusted  compresses  placed  under  the  bandage.  A  large  aseptic 
hatli-s])onge,®*  slightly  hollowed  to  fit  the  breast  and  wrung  out  in  a  bichlorid 
or  creolin  solution,  will  provide  firm  and  equable  pressure  under  a  very  tight 
roller  bandage ;  or  the  Y-binder  may  be  employed,  supplemented  by  a  strip  of 
nuislin  drawn  tightly  across  both  breasts  to  compress  the  summits  of  the  breasts. 
Care  should  be  taken  to  lift  the  breasts  slightly  toward  the  clavicles  when  the 
hinder  is  applied.  The  antiseptic  solution  is  poin-ed  under  the  edge  of  the 
hinder  often  enough  to  keep  the  sponge  moist.  The  sponge  dressing  is  re- 
moved each  day  thereafter  and  the  breast  externally  is  gently  washed.  On  the 
eighth  or  the  tenth  dav  the  cavities  and  the  tracts  leading  to  them  will  usually 


f  R  h 

ill 

H 


■;i  r 


hir 


r.^.: ! 


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he  closcil,  when  the  sponge  conijiressioii  may  be  discoiitiniicd.  If  the  opeiiinjis 
have  not  united,  their  edges  may  be  brought  together  witli  adhesive  strips  or 
with  collodion. 

If  drainage  is  desired  by  means  of  drainage-tubes,  jierforated  rubber  tubes 
at  least  one-fourth  of  an  inch  in  diameter  should  be  drawn  through  the  open- 
ings after  irrigation,  and  a  i.jm  binder  should  be  applied  over  an  antiseptic 
dressing.  The  next  day  the  dressings  should  be  renewed  after  irrigating  the 
cavities,  and  the  dressing  may  now  be  left  undisturbed  for  four  days ;  then  tiic 
tubes  should  Im;  shortened  one-half  their  length,  the  cavities  be  irrigated,  and 
the  dressing  be  reapplied.  So  long  as  the  pus  is  thick  and  tenacious  the  tubes 
will  afford  better  drainage  than  strips  of  gauze,  but  if  the  i)rogress  of  the  case 
will  jwrmit,  gauze  should  be  substituted,  otherwise  the  tubes  should  gradually 
be  shortened,  and  they  may  be  removed  entirely  i)y  the  end  of  at  least  ten  days 
or  two  weeks.  The  disadvantage  of  the  drainage-tubes  is  the  tendency  on 
the  part  of  the  physician  to  allow  them  to  remain  in  the  breast  too  long,  and 
thus  to  cause  fistula?.  The  amount  and  character  of  the  discharge  and  the  dis- 
appearance of  the  cavities  in  the  breast  will  indicate  how  soon  the  tubes  may 
safely  be  removed. 

The  diild,  of  course,  must  not  be  nursed  from  the  diseased  breast,  but  may 
be  aj)plie(^l  to  the  sound  breast  in  order  to  keep  up  the  milk  secretion,  provided 
the  mother's  general  health  docs  not  indicate  the  desirability  of  weaning. 

Convalescence  is  promoted  by  the  administration  internally  of  tonics,  par- 
ticularly quinin,  strychnia,  and  iron. 

Subcutaneous  Abscess. — Subcutaneous  inflammationofthe  breast  is  usually 
followed  by  the  formation  of  an  abscess,  and  it  always  results  from  infection 
through  the  superficial  lymphatics,  the  septic  material  finding  entrance  into 
the  lymphatics  through  erosions  of  the  nipple  or  through  a  breach  in  the  con- 
tinuity of  the  areola  or  the  adjacent  skin.  Usually  the  inflame<l  area  is  cir- 
cumscribe<l ;  the  overlying  skin  raj)idly  becomes  very  red,  the  temperature  is 
elevated,  and  within  a  few  days  fluctuation  is  discovered,  announcing  the 
prompt  occurrence  of  suppuration.  The  prevention  of  this  form  of  inflamma- 
tion is  obtained  by  cleanliness  of  the  breasts  and  nipples.  In  the  beginniiiir 
of  the  inflammation  the  administration  of  a  saline  cathartic  and  the  application 
of  compresses  saturated  with  lead-water  and  laudanum,  with  or  without  nn 
ice-bag,  and  held  in  place  by  a  mammary  binder  without  compression,  will 
affoi'd  relief.  At  the  first  appearance  of  suppuration  an  incision  should  lie 
made,  either  wholly  within  or  outside  the  jiigmented  areola,  to  avoid  ;iii 
unsightly  scar;  the  abscess-cavity  sliould  be  irrigated  with  hydrogen  peroxid, 
full  strength  or  one-half  diluted,  followed  by  a  creolin  or  a  bichlorid  solu- 
tion, and  after  introducing  a  gauze  drain  a  firm  binder  should   be  applied. 

A  diffuse  inflammation  of  the  subcutaneous  connective  tissue  sometimes 
occurs,  which  conditi'^n  is  much  more  ferious,  but  fortiuiately,  is  now  very 
rare.  It  is  usu  .dy,  but  not  always,  ])receded  by  erysipelatous  inflammation  of 
the  overlying  skin,  and  is  aceompanie<l  by  chills,  high  fever,  and  severe  bnrii- 
ing  pain.     The  axillary  glands  are  often  tender  and  swollen.     The  subcutaiie- 


PATHOLOGY  OF   THE   PUERPERIUM. 


765 


f  the  openings 
esive  strips  or 

1  rnbber  tubes 
nigh  the  opon- 
r  an  antiseptio 
•  irrigating  the 
days ;  then  the 
L'  irrigated,  and 
icious  the  tubes 
;ress  of  the  case 
lould  gradually 
it  least  ten  days 
:he  tendency  on 
st  too  long,  and 
rsre  and  the  dis- 
I  the  tubes  may 

breast,  but  may 
jretion,  provided 
if  weaning, 
y  of  tonics,  par- 


ous connective  tissue  quickly  suppurates,  and  when  not  promptly  treated  by 
incision,  drainage,  and  thorough  antisepsis,  extensive  sloughing  occurs,  which 
may  be  followed  by  general  pyemia  and  death.  In  the  earliest  stage  the  appli- 
cation of  compresses  wet  with  creolin  solution  (10  per  cent.)  or  with  lead- 
water  and  laudanum  will  be  useful,  but  these  compresses  must  not  interfere 
with  early  recognition  and  evacuation  of  subcutaneous  collections  of  pus. 

Submammary  Abscess. — In  rare  instances  empyema  or  suppuration  result- 
ing from  disease  of  the  ribs  may  perforate  the  tissue  under  the  mammary  gland 
and  produce  an  abscess  situated  beneath  the  mammary  gland  ;  but  in  the  puerpe- 
rium  submammary  abscesses  practically  always  result  from  burrowing  toward 
the  chest-wall  of  a  parenchymatous  abscess.  Several  pockets  of  pus  may  thus 
be  formed  beneath  the  gland  and  at  its  periphery  ;  the  pus-cavities  con>municate 
after  a  few  days,  and  the  breast  is  lifted  from  the  chest,  the  gland  feeling  as  if 
it  rested  upon  a  fluid  base,  its  overlying  skin  becoming  tense,  but  usually  not 
red.  This  variety  of  mammary  abscess,  the  rarest,  is  of  very  great  importance, 
because  if  overlooked  most  serious  consequences  may  follow  before  spontaneous 
evacuation  of  the  pus  occurs.  The  inflammation  of  the  connective  tissue,  which 
almost  never  undergoes  resolution,  may  spread  to  the  abdomen,  to  the  other 
breast,  and  to  the  axilla,  and  pus  may  burrow  in  all  directions,  sometimes  even 
attacking  the  ribs  and  perforating  into  the  pleural  cavity.  The  symptoms  are 
not  characteristic,  since  the  deep-seated  pain,  the  high  fever,  the  edema  of  the 
overlying  and  adjacent  skin,  the  restricted  motion  of  the  arm  on  account  of  the 
pain,  and  the  involvement  of  the  lymphatics  in  the  axilla  may  be  present  in 
parenchymatous  abscess,  although  these  symptoms  are  usually  less  marked  in 
the  latter  variety.  The  absence  of  marked  redness  of  the  skin  and  the  pecu- 
liar sensation  imparted  to  the  gland  by  the  underlying  fluid  collection  are  the 
most  characteristic  signs. 

Treatment. — When  this  variety  of  abscess  is  suspected,  the  location  of  the 
pus-collections  may  be  searched  for  with  a  sterilized  aspirator-needle.  After 
thoroughly  disinfecting  the  skin,  the  patient  ovdinarily  being  etherized,  the 
breast  should  be  pushed  toward  the  clavicle  and  the  needle  held  parallel  with  the 
chest-wall,  and,  entering  the  skin  on  a  level  with  the  lower  margin  of  the  pectoral 
muscle  in  the  infra-axillary  region,  should  be  thrust  deeply  beneath  the  gland. 
When  the  pus  is  located  there  is  passed  into  the  cavity  a  grooved  director, 
which  will  serve  to  guide  a  pair  of  scissors  or  dressing-forceps,  the  blades  of 
which,  after  being  introduced,  are  separated  and  forcibly  withdrawn.  The 
cavity  is  then  explored  with  the  finger  and  adjacent  pockets  of  pus  are  opened, 
especial  care  being  taken  to  find  and  enlarge  the  opening  or  openings  between 
the  submammary  and  parenchymatous  abscesses.  Irrigation,  drainage,  and 
antiseptic  dressings  should  then  be  employed  as  in  other  varieties  of  mammary 
abscess. 

Abscesses  in  the  Areola. — The  glands  of  Montgomery  and  the  connective 
tissue  beneath  the  areola  sometimes  become  infected,  and  the  result  is  the  forma- 
t  ion  of  small  and  usually  superficial  abscesses.  The  abscesses  are  most  frequently 
observed  when  the  nipple  is  inverted  or  stunted,  thus  compelling  the  infant  to 


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l-  > 


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take  into  its  nioiith  a  portion  of  the  areola  in  order  to  got  a  b(>tter  grasp  of  the 
nipple.  The  skin  at  first  reddens  ;  the  ghinds  ba'oine  hard  and  more  prominent, 
and,  pointing  at  yellow  spots  in  tiieir  centres,  finally  jwrforate  the  skin  at  one 
or  more  places,  leaving  excavated  nieers  snrronnded  by  an  indurate<l  wall  of 
lymph.  These  no<lnles  may  remain  for  several  weeks,  or,  receiving  fresh  in- 
fection, they  may  break  down,  the  ulceration  being  followed  by  an  ngly  scar. 

Treatment. — Care  of  the  nip|)les  will  usually  prevent  infection  of  the 
glands.  Each  gland  when  infiamed  shoidd  be  incised  and  touched  with  a 
strong  bichlorid  solution,  after  which  the  edges  of  the  incision  are  approx- 
imated, covered  with  a  narrow  strip  of  gauze,  and  held  together  by  a  collodion 
dressing.     Nursing  need  not  be  discontimied. 

Prognosis  and  SEQUEi.iE  of  Mammary  iNFiiAMMATioN. — Mammary  ab- 
scess is  rarely  directly  dangerous  to  life.  Fatal  termination  has  been  recorded 
from  hemorrhage  due  to  erosion  of  blood-vessels  (Jacobus)  and  from  septi- 
cemia (Gross).  General  sepsis,  short  of  a  fatal  termination,  may  occur,  se- 
riously impairing  the  patient's  health.  In  an  interesting  case  of  the  writer's 
infection  of  the  breast  occurred  when  the  patient  washed  her  nipples  with  the 
same  oloth  and  water  used  for  cleansing  the  child's  buttocks  after  a  bowel 
evacuation  ;  systemic  infection  followed,  during  the  course  of  which  there 
developed  a  serious  albuminuria  pei*sisting  for  several  months.  When  treat- 
ment by  early  removal  of  the  pus  and  thorough  antisepsis  is  neglected,  a 
large  portion  of  the  gland,  sometimes  the  entire  gland,  is  destroyed.  Even 
when  the  suppuration  has  not  been  very  extensive,  the  firm  cicatrices  loft 
behind  frequently  interfere  with  proper  emptying  of  the  breast  in  subsequent 
lactations,  and  thus  jiredispose  to  tlie  recurrence  of  mastitis.  Milk-nodes  and 
fistulous  tracts  may  also  remain,  occasioning  distress  and  inconvenience. 

Milk-nodes. — Sometimes  the  exudate  about  the  abscess-cavity  is  not  wholly 
absorbed,  and  connective  tissue  thus  formed  may  constrict  one  or  more  lacteal 
canals,  giving  rise  to  indurated  nodular  masses  which  contain  the  remains  of 
inspissated  milk  and  which  n>ay  remain  for  an  indefinite  period.  Effort  should 
be  made  to  promote  the  absorption  of  these  masses  by  rubbing  them  with 
resolvent  ointments,  such  as  the  ointment  of  merciny  or  of  potassium  iodid, 
and  by  th*^  use  of  the  galvanic  current. 

Cold  or  Chronic  Abscess. — Very  rarely  the  symptoms  of  acute  inflamniii- 
tion  of  the  breast  subside,  and  after  a  long  period  severe  inflammatory  symp- 
toms may  occur.  The  purulent  collection  is  often  found  under  the  gland, 
and  it  requires  thorough  evacuation,  antisepsis,  and  compression. 

FistulsB  of  the  Breasts. — A  sinuous  tract  leading  to  the  abscess-cavity  may 
refuse  to  close  and  may  discharge  indefinitely  a  small  amount  of  pus.  A  more 
important  variety  of  fistula  is  that  due  to  injury  of  a  lactiferous  duct,  eitlicr 
wounded  by  the  knife  when  the  breast  has  not  been  lanced  careftdly  or  wlicn 
perforated  by  extension  of  an  absceas.  Such  a  fistula  may  for  months  or  lor 
years  discharge  either  milk  alone  or  a  mixture  of  milk  and  pus,  which  dischaiLre 
may  be  a  serious  drain  upon  the  woman's  health.  As  a  rule,  little  can  be  accom- 
plished in  the  treatment  of  these  fistulse  until  the  lacteal  secretion  has  been 


.1  I- 


PATHOLOGY  OF   THE  PUERPERIVM. 


767 


?r  grasp  of  the 
ore  pronilnont. 
he  skin  at  one 
u rated  wall  of 
'iving  fresh  in- 
aii  ngly  scar, 
ifeetion  of  th«' 
ouchetl  with  a 
)n  are  approx- 
•  by  a  colloilion 

-Mammary  ah- 
is  been  rcconlod 
md  from  septi- 

may  occur,  sc- 
>  of  the  writer's 
nipples  with  tiie 
s  after  a  bowel 

of  which  tlurc 
s.     When  treat - 

is  neglected,  a 
estroyed.  Even 
ni  cicatrices  left 
ist  in  subsequent 

MilU-nodes  an<l 
convenience. 

ity  is  not  wholly 

or  more  lacteiil 

the  remains  of 

,    Effort  should 

bing  them  with 

potassium  iodid, 

1  acute  inflaniina- 
immatory  syinp- 
Inder  the  gland, 

l)n. 

Iscess-cavity  may 
lof  pus.  A  more 
Vus  duct,  cither 
irefuUy  or  wlieii 
Ir  months  or  fur 
which  dischiuire 
tie  can  be  accoiii- 
3retion  has  l)e«ii 


arrested,  following  which  they  often  heal  spontaneously.  They  will  sometimes 
dose  under  persistent  compression  and  attempts  to  obtain  granulation  by 
injecting,  twice  weekly,  irritative  fluids,  such  as  tincture  of  iodin,  a  2  per  cent, 
solution  of  nitrate  of  silver,  or  chlorid  of  zinc  (gr.  xx-xl  to  f.^j).  Thorough 
curettement  and  gradually  shortened  drainage-tul)es  have  also  been  successfid. 
These  methods  of  treatment,  es|K?cially  in  intractable  cases,  have  been  dis- 
carded in  recent  years  for  excision  of  the  fistulous  tracts  and  immediate 
closure  by  deep  and  sui)erficial  sutures. 

Qalactocele. — Sometimes  one  of  the  lactiferous  du(!ts  happens  to  be 
occluded  permanently,  and  in  consequence  the  milk  accunudates  and  forms 
a  cystic  tumor  which  is  usually  of  no  pathological  or  clinical  importance  indess 
it  should,  as  rarely  happens,  attain  an  extreme  size,  when  it  may  be  tapped 
and  drained  and  cicatrization  of  the  cyst-wall  be  promoted. 

7.  AuuKST  OF  Lactation. 

There  are  in  practice  three  periods  during  which  it  may  be  desired  to  arrest 
the  secretion  of  milk  :  {n)  immediately  after  delivery  when  the  child  has  not 
survived  birth,  or  when  the  constitutional  condition  of  the  mother  is  such  as 
to  preclude  the  possibility  of  successful  lactation  ;  {!>)  at  any  stage  of  lactation 
when  weaning  has  been  determined  upon  in  the  interest  of  either  the  infant 
or  the  mother ;  (c)  at  the  end  of  the  lactation  ])eriod.  It  should  be  remem- 
hered  that  the  danger  of  drying  up  the  breasts  varies  with  these  periods,  being 
greatest  when  the  functional  activity  of  the  glands  is  at  its  height,  and  least 
dangerous  at  the  end  of  lactation,  when  nature  is  about  prepared  for  the  cessa- 
tion of  this  function. 

Whenever  the  prevention  of  activity  of  the  mammary  glands  is  desired  in 
the  first  peri(Kl,  diminution  of  the  flow  of  milk  can  be  accomplished  by  using 
before  the  first  ai)pearance  of  breast-engorgement  a  firm  compression  binder, 
a  roller  bandage,  or  for  very  threatening  cases  a  dressing  of  contractile  col- 
lodion may  be  employed,  and  also  by  forestalling  the  milk-flow  by  the  early 
administration  of  salines  to  the  extent  of  free  purgation  when  the  patient's 
strength  will  permit.  In  addition  to  compression  and  purgation,  it  will 
usually  be  necessary  to  resort  once  or  twice  daily  to  gentle  massage  of  the 
breasts  or  to  the  use  of  the  breast-pump  to  prevent  dangerous  engorgement — a 
clanger  usually  passed  by  the  fourth  or  fifth  day,  certaiidy  by  the  end  of  the 
week.  The  emj)loyment  of  potassium  iodid  to  arrest  the  secretion  of  milk  is 
of  <loubtful  utility :  used  in  safe  doses,  this  drug  is  without  eff'ect ;  in  a  large 
dose  (30  grains)  it  sometimes  is  apparently  effective,  but  is  often  followed  by 
serious  symptoms  of  poisoning. 

To  arrest  the  milk-flow  in  the  second  period,  after  lactation  is  well  estab- 
lislied,  the  compression  bandage  and  free  i)urgation  will  be  sufficient  when  ihe 
milk  flows  readily  under  the  pressure  and  there  is  no  disposition  of  the  breasts 
to  l)ecome  engorged  and  caked.  Under  these  conditions  it  is  an  advantage  to 
omit  massage  or  the  use  of  the  ])nmp,  since  this  omission  renders  the  treatment 
less  painftd  to  the  patient  and  of  shorter  duration,  for  after  massage  or  suction 


■  -'!^ 

1   ,; 

1 

„  /[m 

*i 

i 

1 

V  :ft 

,.v   . 

.^3:!; 


'I. 

•n 

'i  i  ' 

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I  A  i 


w 


768 


AMEIiJCAN   TEXT-BOOK   OF   OBSTETRICS. 


m 


\ 


I  '  ^f'H 


of  the  milk  by  the  pump  the  breasts  rapidly  refill.     When,  however,  the  breast 

fails  to  drain  under  tiie  bandage  and  n(xlular  manses  are  felt,  it  is  imperative! 

to  relieve  the  tension  by  massage,  on  account  of  the  danger  of  mastitis. 

The  management  in  the  third  [ku'IikI  is  usually  a  simple  matter.     As  the 

child  is  gnulually  taken   from  the  breast  the  slight  tension  of  the  breasts 

observed  when  a  nursing  has  lieen  omittetl  should   be  relieved   by  gently 

stroking  the  breast  or  by  the  use  of  the  breast-pump.     Within  a  few  days 

the  flow  of  milk  usually  disapiMiars.     Should  a  small  amount  of  secretion 

|)ersist,  it  may  be  necessary  to  employ  compression  ;   atropia   administenMl 

internally  will  sometimes  assist  in  further  drying  up  the  secretion  (see  page 

773). 

8.  Anomalies  in  tiik  Milk-hkcuktion. 

In  this  section  will  Ixj  considered  the  following  abnormalities  associated 
with  the  mammary  function  :  (a)  secretion  of  milk  abnormal  in  quality  or 
in  quantity,  and  the  effect  of  either  of  these  changes  upon  the  health  of  the 
mother  or  t)f  the  chihl  ;  {h)  conditions  interfering  with  the  performance  of  the 
mammary  function  ;  (r)  weaning;  and  {d)  the  ill  effects  of  prolonged  lactation. 

Abnoumalitiks  in  (iuALiTY. — The  quality  of  the  milk  of  the  nursing 
mother  is  influenced  by  many  conditions  ;  and  while  variations  may  be  observed 
in  the  proportion  t)f  any  or  of  all  of  its  constituent  elements,  or  even  in  the 
presence  of  foreign  elements,  the  proportion  of  fat  and  albuminoids  under 
ordinary  circumstances  shows  the  greatest  and  most  important  variations. 
The  proportion  of  sugar  is  remarkably  constant  under  all  circumstances,  and 
there  is  very  little  variation  in  the  percentage  of  salts.  A  very  conmiou  cause 
of  impairment  in  the  quality  of  the  milk-secretion  is  a  failure  to  give  proper 
attention  to  the  time  of  putting  the  infant  to  the  breast.  Nursing  at  too  fre- 
quent, prolonged,  or  irregular  intervals  materially  alters  the  condition  of  the 
milk,  and  renders  it  either  difficult  of  digestion  or  of  poor  nutritional  value, 
A  very  common  mistalie  made  by  inex|)erieuced  mothers  is  the  frequent  appli- 
cation of  the  child  to  the  breast  when  it  is  restless,  under  the  mistaken  idea 
that  the  infant  requires  more  food,  when,  as  a  matter  of  fact,  an  excess  of  food, 
with  consequent  indigestion,  or  thirst,  is  the  real  cause  of  the  child's  discom- 
fort. When  the  breast  is  given  to  the  child  at  shorter  intervals  than  two  or 
three  hours,  the  milk  rapidly  becomes  more  concentrated,  and  therefore  is 
digested  with  great  difficulty.  On  the  contrary,  when  a  longer  interval 
between  nursings  is  permitted,  the  solids  of  the  milk  are  so  reduced  as  seri- 
ously to  diminish  its  value  for  nutrition. 

Perhaps  the  most  important  factor  influencing  the  quality  of  the  milk  is  the 
diet  of  the  nursing  mother.  A  diet  largely  vegetable  will  increase  the  pro- 
portion of  sugar  and  diminish  that  of  fat  and  caseinogen,  while  an  excess  of 
albuminous  food  will  increase  the  fat  and  caseinogen  and  diminish  the  proportion 
of  sugar.  In  each  case  the  infant  receives  food  ill  adapted  to  its  needs,  and 
will  either  be  poorly  nourished  or,  when  the  fat  and  caseinogen  are  in  excess, 
there  will  soon  appear  digestive  disturbances  with  their  associated  dangers. 
The  employment  of  alcoholic  and  malt  liquors  will  also  lead  to  an  excess  of 


Itil 


PAT//()U)(.y   i)F    TIIK   PVKliPEIillM. 


rr.o 


^rer,  the  breast 
is  imperative 
astitis. 

itter.  As  the 
jt"  tlie  breast  H 
'ed  by  gently 
in  a  few  «hiys 
it  of  seeretion 
,  administered 
Btion  (see  page 


lities  associated 
1  in  quality  or 
I  health  of  the 
'ormance  of  the 
onged  laetation. 
of  the  nursing 
iiay  be  observed 
1,  or  even  in  the 
uminoids  under 
rtant  variations, 
•cunistances,  and 
[y  common  cause 

to  give  proper 
jrsing  at  too  fre- 
condition  of  the 
jutritional  value. 
e  frequent  appli- 
e  mistaken  idea 
In  excess  of  food, 

child's  discoin- 
'als  than  two  or 
and  therefore  is 

longer  interval 

reduced  as  seri- 

If  the  milk  is  the 
Increase  the  pro- 
lile  an  excess  ot 
Ih  the  proportion 
its  needs,  and 
len  are  in  excess, 
|ociated  dangers. 
to  an  excess  ot 


fat  and  caseinogen.    There  is  a  wides])i-cad  Inflief,  not  only  among  the  laity  but 
also  among  the  profession,  that  tiie  nursing  mother  should  add  to  iier  diet  some 
preparatiou  of  malt  to  improve  the  quality  of  her  milk.     While  it  is  true  that 
in  exceptional  ca-ses  distinct  l>eneHt  is  thus  to  l)e  obtained,  the  indiseriminat)! 
use  of  such   i)reparations  certainly  does   ntore  harm   than  good.      Zaieski** 
lound  that  not  only  were  fat  and  albumin  increased  in  the  milk  of  mothers 
taking  malt,  but  that  the  milk   .sometimes   actually  contained   alcohol   and 
the    micro-organisms  peculiar  to  malt    licpiors.     Klingeman"'  learned  Trom 
iiis   investigations  that  when  the  nursing   mother  took  alcohol  in    moderat(> 
ijuantity  there  was  no  evidence  of  its  presence  in  the  nulk.     When  the  (pian- 
tity  ingested  was  increased,  a  small  amount  (»f  alcohol  passed  into  the  milk, 
which  amount  he  thought  was  usually  insutticient  to  have  an  ill  effect  iq)on 
the  suckling.     The  changes  produced  in  the  constituents  of  the  milk,  how- 
ever,  were  quite    noticeable,  and    Strumpf  is    (juoted   as  authority  for  the 
statement  that  alcohol  Uiken  by  the  mother  so  changes  the  fatty  and  albu- 
minoid contents  as   to   dinunish   the    nutritional  value   of  the   n»ilk.     The 
milk  should  lx>  known  to  contain  too  little  fat  and  caseinogen  before  reconunend- 
ing  the  use  of  malt;  and  when  malt  is  taken,  the  first  api^arance  of  digestive 
disturbance  in  the  infant  calls  for  either  a  reduction  in  the  amonnt  ingested  or 
for  complete  abstinence.     As  a  matter  of  experience  it  is  in  the  latter  half  of 
the  lactation  jieriod  that  the  mother's  milk  is  more  likely  to  be  deficient  in  the 
constituents  for  whose  increase  a  malt  preparation  is  indicated,  and  the  eom- 
inon  practice  of  advising  mothers  to  drink  stout  or  other  malt  liquors  shortly 
after  labor  is  certainly  reprehensible  in  a  very  large  nund)er  of  cases.     Care- 
ful analyses  of  the  milk  may  be  made  at  intervals,  to  determine  the  j)roportion 
of  fat  and  albumin,  and  these  analyses  will  indicate  the  desirability  of  admin- 
istering or  withholding  malt,  and  will  often  indicate  other  desirable  changes 
in  the  diet. 

The  diet  of  the  nursing  woman  should  ordinarily  not  differ  materially 
from  that  to  which  she  has  previously  been  accustomed.  It  should  consist  of 
plain  mixed  food  with  a  moderate  excess  of  fluids.  Of  the  latter,  milk  taken 
between  meals  is  useful ;  tea  and  coffee  are  best  withheld  or  taken  in  mode- 
ration and  largely  diluted  ;  cocoa  is  sometimes  useful. 

When  the  child  does  not  thrive  upon  its  mother's  milk,  or  when  it  ])resents 
serious  digestive  derangements,  a  chemical  analysis  of  the  milk  should  be 
made.  Having  decided  upon  a  chemical  examination  of  the  milk,  it  should  be 
borne  in  mind  that  the  relative  proportion  of  the  constituents  of  the  milk 
varies  with  the  time  of  its  withdrawal  from  the  breast.  The  first  jiortion  re- 
moved contains  a  smaller,  while  the  last  will  show  a  larger,  portion  of  solids, 
hence  the  specimen  should  be  taken  after  the  infant  has  about  half-emptied 
the  breast.  Since  each  mammary  gland  may  yield  a  different  quality  of  milk,"^ 
and  since  the  quality  of  the  milk  al.-jo  varies  at  different  intervals,  several 
specimens  from  both  glands  should  be  subjected  to  analysis  to  obtain  an  abso- 
lutely accurate  estimate  of  the  quality  of  the  milk.* 

"^  If  it  is  impossible  to  obtain  an  analysis  by  an  expert  ciieniist,  the  following  method,  siig- 
49 


770 


AMFJtli'AX    rr.XT-nOitK   OF   (HiSTF/rilTCS. 


Microscopical  oxntiiiimtion  of  the  milk  to  count  tlic  nunilM>r  of  milk- 
^lohiilcs,  as  proposed  by  Hoiiclicrc  and  r«'coniincn<lcd  hy  KIcinwiiclitcr,  Ih  no 
lon^jcr  c(»nsidcr('d  of  practical  value.  This  nu-thod  of  analysis  <'annot  take  tiic 
place  of  careful  chenncal  analysis.  The  niicrosco|)0,  however,  is  sonietinits 
useful — for  example,  to  rocojriii/e  the  presence  of  colostrum-corpusclos  and 
foreifjM  matters,  such  as  pus,  blood,  und  epithelial  cells. 

The  later  and  most  reliable  analyses  of  human  milk  show  an  average  com- 
|M)sition  x\»  follows : 

Wult-r 87-SS. 

Tc.lal  solids Vl-VA. 

l-'i.t :m. 

AllxiiniiKiiilH 1-2. 

Sii){ar 7. 

Ash 0.2. 

Ki'iu-lion Fiiintly  iilkiiline. 

S|H'(ir.c  Kravity 1(I2H-1(«4."» 

If  the  proportion  of  fat  is  below  the  normal  amount  (.'5.1")  per  cent. — 
Temesvilry),""  the  diet  should  be  moditii-d  by  rednciii}^  slitrlitly  the  fatty  timd 
and  incrcasiiij;  the  proteids.  If,  on  the  (contrary,  the  milk  is  too  rich  in  lat 
and  albumin,  less  meat  and  more  vegetables  should  be  given,  and  at  the  same 
tim(!  the  employment  of  additional  muscular  exercise  with  daily  baths  is 
important.  A  change  in  diet  alone  will  not  reduce  the  proportion  of  caseinoncii, 
which  is  commonly  in  excess  in  the  upper  class  of  women,  without  reducing' 
at  the  same  time  tlic  other  constituents  ;  hence  the  resort  to  systematic  muscular 
exercise  is  essential.  Much  can  ofts'U  be  acc(»mplished  by  these  means  to  adjust 
a  proper  (piality  and  (juantity  of  njilk  for  the  child  ;  but  not  infrequently, 
despite  all  eilbrts,  the  child's  condition  fails  to  imj)rove,  and  it  becomes  nec- 
essary for  its  welfare  to  resort  to  artificial  feeding. 

Sudden  fright  or  joy,  great  anxiety,  and  other  emotions  in  the  mother  have 
a  pecidiar  effect  upon  tiie  quality  of  her  milk.  We  have  no  intimate  knowledge 
of  the  changes  thus  brought  about,  beyond  the  clinical  fact  that  indigestion 
and  colic  are  of  frequent  occurrence  in  infants  nursetl  by  emotional  mothers, 
whose  nulk,  it  is  asserted,  is  likely  to  contain  more  water,  less  fat,  and  more 
caseinogen  than  normal.  The  nursing  mother  should  be  made  aware  of  this 
fact,  and  be  cautioned  to  lead  a  life  as  free  as  possible  from  emotional  exciti- 

gcstcd  by  Niiis,  **  and  considered  by  him  sufficiently  accurate  for  clinical  i)urposes,  may  lie  t'ln- 
ployed  to  estimate  the  amount  of  fat  and  albuminoids:  Add  enough  liquor  potiissa  to  the  sample 
of  milk  to  render  it  distinctly  alkaline  ;  place  in  a  test  tube,  boil,  and  set  aside  in  a  warm  niinii  for 
a  lew  boiu's.  The  fat  will  rise  to  the  surface,  and  the  amount  may  be  estimated  by  a  jtradiMicd 
rule  placed  at  the  side  of  the  tube.  To  <leterinine  the  atnoimt  of  albuminoids,  remove  the  Iiivit 
of  fat  with  a  pipette,  add  sufficient  acetic  acid  to  the  remainder  to  render  it  acid,  boil,  and  :iyaiii 
set  aside  in  a  warm  room.  All  the  albimiinoiils  will  be  precipitated,  and  may  Xte  esfiiiinlcil  in 
the  same  manner  as  the  fat.  There  may  be  used  with  a(lvanfa{?e  a  test-tube  graduated  in  liiiii- 
drcdths,  in  which  a  sample  of  milk  known  to  be  normal  has  been  tested  by  this  exaniin:iiii>n, 
and  thus  offers  a  standard  for  comparison.  With  this  modification  the  writer  has  foiiiid  iliis 
method  useful  for  approximate  analysis.  The  method  of  Holt"*  may  also  be  used  for  tlic  <-ti- 
mation  of  the  percentage  of  fat  and  for  detecting  wide  variations  in  the  percentage  of  pmicids. 


■•t^s-u 


1 


PATIIOLOf.V    OF    THE   Pf'h'/fJ'h'JiJf.y. 


771 


iiImt  of  inilK 
iwiiclitiT,  is  111. 
•uiiiiot  take  tlif 
r,  irt  sonu'tlmt> 
(•(irpurtcles  ami 

ill  avt-raj^c  t'<»iii- 


«7-S«. 

:»-». 
l-'-J. 
7. 

0.2. 
ilkalitie. 
l();54."» 

;{.l')   JHT   Cl'llt. — 

tlv  the  fatty  lond 
is  too  rich  in  I'at 
,  aiul  at  tlu'  same 
th  daily  baths  is 
:ion  of  ('asoiun<>,(ii. 
without  mliicin<r 
stoinatic  musc\ilar 
e  nu'aiis  to  a<ljii>t 
not  infroqueiitly. 
1  it  beconK's  luf- 

\\  the  inothor  have 
itiuKito  kiiowlnli:'' 
[t  that  indiiic^tinii 
motional  iiiothi-rs, 
[loss  fat,  ami  more 
liado  awaro  of  this 
omotioual  cxcitc- 

,  purposes,  may  lie  ei»- 
ppotassatotlu'sainpk' 
lae  in  a  warm  room  I'T 
Imatea  by  a  urailuaicl 
loiils,  remove  the  !:'>'''' 
lit  aeiil,  l>oil,  awA  ^I'-^'i" 
ll  may  l>e  estiniatcil  i» 
|ibe  pradtiateil  in  1>'>"- 
by  this  oxamiiKiiioii, 
[writer  has  fouii.l  il>is 
L  lie  used  for  tlu'  '■■li- 
lercentage  of  piot/ul''. 


inoiit.     Fn  cxtrome  c«a«o«  of  emotion  tho  milk  can  1)0  so  fhangcd  as  to  IxHtomc 
actually  a  fatal  poison  to  th(>  child. 

The  aj^o  of  the  mother  and  the  period  of  lactation  modify  the  qnality  of 
the  nulk.  As  the  njj;e  advances  the  pn>portioii  of  albuminoids  j^radnally 
diminishes,  and,  bc^innini;  with  the  sixth  nmnth,  as  lactation  advances  the 
pcnvntaj^e  of  proteids  becomes    somewhat   less  (Kolesiiisky). 

An  excessive  (piantity  of  fat,  according;  t(»  Monti,'™  will  appear  in  the  milk 
when  the  mother  is  att'ectwl  by  serious  acute  ])athol()gical  pnursses,  as  mastitis 
or  any  other  extensive  febrile  process.  The  same  observer  has  sometimes 
noticed  a  (gradual  diininuti<m  in  the  proportion  of  fat  in  the  presence  of 
pathological  prow'sses  of  lonj;  duration.  The  qualitative  chans^es  in  the  milk 
produced  by  acute  febrile  diseases,  by  blood-chanj^es  in  the  mother,  by  the 
presence  in  the  nnik  of  micro-organisms,  and  by  tht;  rea|)pearance  of  eolos- 
tnim-corpuscles  will  be  referred  to  in  a  subsequent  sc»'tion. 

AnNOiiMALlTiES  IN  Qttantity. — Abnormalities  in  the  quantity  of  the 
.  lilk  may  vary  from  an  entire  absence  of  secretion  to  an  i^normonsly  ex- 
cessive supply,  which  may  even  continue  after  the  child  has  been  weaned. 

The  normal  amount  of  milk  secreted  by  the  mammary  glands  is  very  dif- 
licidt  to  determine,  since  there  are  wide  individual  variations  within  the  limits 
of  health.  Temesvikry,'"'^  in  a  long  series  of  examinations  after  lactation  had 
fully  been  established,  found  the  average  amount  of  milk  from  one  breast  to 
l)c  59  cubic  centimeters  (2  ounces),  the  variations  being  between  30  and  70 
cubic  centimeters  (1  to  2^  ounces).  Ordinarily  the  total  (juantity  of  milk 
secreted  in  twenty-four  horn's  is  414  cubic  centimeters  (14  ounces)  at  the  end 
of  the  seventh  day  ;  this  amount  steadily  increases  for  a  month,  when  the 
([iinutity  has  reached  about  2  pints,  after  which  time,  to  meet  the  demands 
ol"  the  growing  infant,  it  has  increased  to  .'i  pints  at  the  seventh  month,  and 
alter  the  eighth  month  the  quantity  gradually  decreases. 

Agalactia. — Complete  absen(;e  of  the  n» ilk-secretion  is  of  such  very  rare 
occurrence  that  its  existence  has  fretpiently  been  doid>ted.  Usually  there  is 
(inly  a  deficiency  which  may  occur  at  the  beginning  and  continue  throughout 
the  whole  ])eriod  of  lactation  ;  or  more  commonly  the  secretion,  at  first  suf- 
ticicnt,  gradually  diminishes  in  amount  or  from  some  intercurrent  atlection 
suddenly  disappears.  The  secretion  of  an  abnormally  small  amoimt  of  milk 
may  be  due  to  an  anomaly  in  the  formation  of  the  mammary  glands,  cither 
congenital  or  acquired  from  faulty  clothing  compressing  the  glands ;  it  is 
oljscrved  also  in  the  very  feeble,  in  women  of  advanced  age,  after  premature 
births  or  stillbirths,  and  iu  women  who  carry  an  excessive  amount  of  adii^se 
tissue. 

Diminution  in  amount  of  a  secretion  previously  abundant  is  a  most  im- 
l)i)rtant  and  very  frequent  anomaly  of  the  man.mary  function.  It  is  often 
oI)served  in  women  of  the  working-classes,  who  shortly  after  confinement  are 
eoin])clled  to  perform  an  excessive  amount  of  work  iu  the  management  of  their 
lioiisohold  affairs,  and  commonly  are  deprived  of  nourishment  suitable  to  the 
formation  of  a  sufficient  quantity  of  milk.     "When   it  is   remembered  that 


'  ) 


i 


'■}■ 


li 


'J.  ';■■'' ,  !.»■ 


M  :  i 


im ; 


I  I, 


ih 


\  -,'»•:■) 


772 


AJUJIilCAX   TEXT-JiOOK   OF   OBSTETRICS. 


niilk-secrctioii  is  a  pliysiological  function  depending,  as  do  other  functioniil 
activities  of  the  organism,  upon  the  condition  of  the  woman's  heahh,  it  will 
readily  be  seen  that  any  condition  unfavorable  to  the  mother's  general  healtli 
will  interrupt  the  activity  of  the  mammary  glands.  Thus,  diminution  of 
the  milk  is  observed  when  there  are  unfavorable  hygienic  surroundings  and 
when  vitality  is  loweretl  from  frequently  recurring  j)regnancies  or  from  inter- 
current diseases,  especially  .such  as  are  accompanied  by  profuse  discharges,  as 
diarrhea  or  excessive  menstruation.  Temporary  diminution  or  disappearance 
of  the  milk  occurs  when  there  is  high  fever  and  when  iuHanuuation  of  tiie 
breast  is  present. 

Trentmcnf. — Insufficient  milk  (hie  to  defective  development  of  the  mam- 
mary gland  ])ractiadly  cannot  be  iricreased.  In  such  cases  the  only  recou>.se 
is  artificial  feeding.  In  very  exceptional  instances  electricity  and  massage 
have  contributed  to  awaken  a  torpid  glaml  to  increased  activity,  but  wIk  ii 
there  exists  extensive  actual  anatomical  defects  even  these  agents  accomplisli 
little  or  nothing.  Mensinga,  however,  recorded  "**  an  interesting  case  in  which 
j)ersisteiit  massage  for  a  week  succeeded  in  establishing  a  flow  of  milk  when  in 
six  successive  pregnancies  there  had  been  an  absence  of  milk.  In  other  cases 
much  may  bo  done;  to  increase  the  (piantity  and  improve  the  quality  of  tiie 
milk  by  criti<!ally  studying  the  mother's  general  condition  and  by  giving 
especial  attention  to  her  diet.  Her  hygienic  surroundings  should  be  im- 
proved. If  there  is  dej)ressed  vitality  or  ill  health  from  any  cause,  this  nuist 
be  removed.  Benefit  often  follows  a  change  of  air  and  scene  with  frceddin 
from  care  and  overwork.  The  diet  should  be  modiJied  by  the  addition  of 
milk,  farinaceous  food,  and  a  proper  (juantity  of  malt,  and  particular  attention 
must  be  given  to  the  patient's  stomach-digestion,  to  ensure  the  proper  assimila- 
tion of  her  modified  and  increased  diet.  Bitter  tonics,  particularly  nux  vomica 
with  pepsin  and  a  mineral  acid,  will  often  be  of  value  in  promoting  digestion. 
More  can  be  accom])lished  by  these  means  than  by  any  of  the  so-called 
"  galactagogues,"  all  of  which  are  of  doubtful   value. 

Polygralactia. — A  supply  of  milk  greatly  exceeding  the  neefl  of  the  infant 
is  of  rare  occiuTcnce.  Sometimes  at  the  beginning  of  lactation  the  milk  is 
formed  in  larger  quantity  than  the  child  requires,  but  this  excess  soon  disip- 
])ears  and  supply  and  demand  are  finally  equalized.  At  times,  however,  in 
vigorous,  plethoric  women  the  milk-secretion  is  so  abundant  and  is  accompanied 
by  so  much  discomfort  to  the  patient  that  means  must  be  employed  todimiiiisli 
the  flow,  '^r'his  diminution  can  be  brought  about  by  restricting  the  diet  iind 
the  amount  of  fluids  ingested,  by  the  administration  of  salines,  by  em|tloyini;' 
compression  of  the  breasts,  and  by  advising  longer  intervals  in  putting  (lie 
child  to  the  breast. 

Galactorrhea. — Very  excessive  secretion  of  milk  of  poor  quality  townrd 
the  end  of  a  prolonged  lactation,  and  the  continuation  of  the  secretion  after  llic 
child  has  been  weaned,  are  included  Ui.uer  the  term  "galactorrhea."  .\-a 
rule,  both  breasts  are  at  fault.  The  quantity  of  milk  secreted  is  usually  >\\'(- 
ficiently  large  seriously  to  impair  the  j)aticnt's  health;   in  some  cases   the 


PATHOLOGY   OF   THE  PrKliPFAilVM. 


773 


m 


er  functiotiiil 
liealth,  it  will 
rcnenil  hoallli 
limimition  of 
miuulings  ami 
or  tVoin  intiT- 

(lischarjic's,  as 

aisai>poaraii<'t' 
imation  of  the 

t  of  the  nian\- 
e  only  re('oi>'^e 
V  and   massaiio 
vity,  but  wlicn 
ents  accoiui>lisli 
ig  case  in  \vhitl» 
jf  milk  when  in 
In  other  eases 
e  quality  of  the 
and  by  },'iv ''>!-,' 
;  should   be  in\- 
cause,  this  must 
.110  with  freedom 
the  addition  of 
•ticular  attentit)n 
proper  assimila- 
arly  nux  vomica 
nioting  digestion. 
of  the  so-ealled 

leed  of  the  infant 
ition  the  milk  is 
jxcess  soon  (li>^:>i)- 
inies,  however,  m 
id  is  accomi>aiiie(l 
loved  to  diminish 
ting  the  diet  aiul 
i.jfjj  by  emi>loyin;j; 
His  in  putting  the 

or  quality  towmd 
secretion  after  t lie 
lictorrhea."  -^^  •' 
ed  is  usually  miI'- 
|i  some  cases  the 


r 


(juantity  secreted  may  Ik;  enormous.  The  cause  of  galactorrhea  is  unknown, 
lielaxation  or  paralysis  of  the  circular  muscular  fibres  surroii  iding  the  milk- 
diicts  has  been  considered  a  cause  by  some  anthors  ;  by  otiicrs  the  condition 
has  been  considered  to  be  an  effect  of  extreme  j)liysical  exiiaustion. 

Si/inj)fomx. — The  symptoms,  aside  from  the  almost  constant  flow  of  milk, 
are  those  to  he  expected  when  so  constant  a  drain  is  made  on  the  individ- 
nal's  strength.  Nutrition  is  interfered  with  ;  extreme  anemia  and  emaciation 
are  ])resent,  and  are  soon  followed  by  some  of  the  nervous  disturbances  ;<> 
be  described  as  accompanying  hyperlactation. 

Traitmvut. — Pronounced  galactoi-rhea  is  a  very  stubborn  affection,  often 
continuing  for  a  very  long  tinie  despite  treatment.  Vigorous  com])ression 
of  tlie  breasts,  free  action  of  the  bowels,  and  the  administration  of  iodid  of 
potassium  are  generally  useful.  Electricity  is  often  disapjiointing.  forgot  has 
given  good  results  in  some  cases,  and  atropia  is  said  to  be  satisfactory  some- 
times, particularly  in  those  luiable  to  stand  free  purgation.  The  treatment 
directed  to  the  patient's  general  ill  health — inm  and  other  tonics  and  nutritious 
diet — has  doubtless  been  a  large  factor  in  accomplishing  the  good  results  claimed 
I'or  various  spe(nal  agents,  as  occurred  in  a  case  under  the  care  of  the  writer, 
who,  from  the  patient's  general  condition,  was  imj)ressed  with  the  belief  tiiat 
galactorrhea  is  perhajis  only  ime  ex])ression  of  a  neurosis. 

Conditions  Interfering  with  Suckling. — Ordinarily,  the  condition  ol'the 
mother  that  interferes  with  the  ])crformance  of  the  mammary  function  is  one 
of  simple  loss  of  strength  and  flesh.  Tiiore  are,  however,  several  more  definite 
conditions  that  may  be  present  at  the  outset  of  the  lactation  period,  or  tiiat  later 
mav  dciveloj)  at  any  stage  of  this  period.  The  more  important  of  these  com- 
plications will  be  considered  briefly  in  the  order  of  their  relative  imjjortanee. 

Faulti/  Development  of  the  Mnminary  (r/antls. — The  anatomical  structure 
of  the  mammary  glands  may  in  some  individuals  be  very  deficient  in  the 
di'vi'iopment  of  tin;  glandular  elenjent,  connective  tissue  having  replaced  the 
giand-structtu'es  to  sudi  an  extent  as  to  ])reclude  the  possibility  of  the  mother 
s!i])|>lving  sufliciont  milk  for  lie  child.  This  defect  is  a])parently  inherited  in 
rare  cases.  It  is  observed  in  women  of  ill-developed  physicpie,  and  may  be 
!i('(|Mire(l  through  undue  conipression  of  tiie  manunary  glands  by  faulty  dotiiing, 
or  where  the  mother  in  each  recurring  pei'iod  of  lactation  refuses  to  nnrse  her 
eliiid.  Little  can  be  done  for  this  condition,  and,  as  a  rule,  artificial  A'eding 
is  necessary.  Where  atrophy  of  the  glandular  elements  is  only  partial,  elec- 
tricity, by  stimulating  the  secretory  function  of  the  epithelial  cells,  accomplishes 
Ml  times  some  improvement,  although  it  is  a  measure  more  often  disappointing, 
'f  he  same  may  be  said  of  massage  of  the  breasts. 

/W(/.sr,s'. — At  any  time  throughout  the  period  of  lactation  temporary  ces- 
sation of  breast-feeding  may  be  necessary  by  reason  of  intercurrent  disease  of 
the  mother.  Tims  a  fissured  nipple  often  requires  tiie  witliholding  of  one 
breast  for  twenty-four  or  forty-eight  hours,  and  a  mammary  abscess  will  inter- 
diet  mu'sing  from  the  diseased  breast  until  complete  convalescence  is  reached. 
Likewise,  the  child  nuist  be  weaned  temporarily  in  any  acute  disease  danger- 


774 


AMERICAN   TEXT-BOOK   OF   OliSTETIlICS. 


11    t 


■'f '  -' 


ously  depressing  the  mother's  strength  or  exposing  the  cliild  to  infeetion,  such 
as  tlie  exanthemata,  erysipelas,  diphtheria,  typhoid  fever,  malaria,  and  grave 
j)uerperal  sepsis.  When  convalescence  has  been  established  the  milk  will 
usually  reappear,  and  the  'jcliild  should  be  returned  to  the  breast. 

The  presence,  from  any  cause,  of  persistently  high  fever  in  the  mother  is 
in  itself  an  indication  for  removal  of  the  child  from  the  breast.  Fortunately, 
Nature  usually  takes  tliis  matter  in  her  own  hands,  for  it  is  a  clinical  fact  that 
the  milk-secretion  soon  disappears  when  the  temperature  is  high  and  when 
the  milk  has  thereby  become  injurious  to  the  child.  Schling'"'  confirmed  the 
experiments  of  Fehling,  who  has  shown  that  within  certain  limits  milk  from 
a  fevered  mother  has  no  ill  effect  upon  the  child.  When  the  temperature  is 
very  high  and  persists  near  104°  F.,  a  corresponding  fever-curve  soon  a])pears 
in  the  child — a  phenomenon  not  to  be  wondered  at  in  the  light  of  investiga- 
tions which  find,  as  in  mastitis,  the  same  micro-orgauisms  in  the  mother's 
milk  and  in  the  child's  intestinal  canal. 

The  experiments  of  many  bacteriologists,  notably  those  of  Konigman  '"*  and 
of  Cohn  and  Xeumann,'"'  disprove  the  notion,  formerly  so  widespread,  that  a 
healthy  mother's  milk  comes  from  the  breast  absolutely  sterile.  On  the  con- 
trary, they  have  found  that  the  milk  of  healthy  nurses  contains  micro-organ- 
isms in  the  vast  majority  of  cases.  The  micro-organism  commonly  found  is 
the  staph ifiococcus  pyogenes  alhiis ;  next  in  frequency,  the  aureus;  and  other 
microbes  very  seldom  and  in  small  number.  The  microbes  find  their  way 
into  the  milk  usually  from  without — probably  from  the  skin  into  the  ducts 
through  their  orifices  on  the  nipple.  Occasionally,  however,  the  blood-current 
of  the  mother  afflicted  with  septic  disease  is  the  medium  of  their  entrance  into 
the  milk  (Escherich,  Longard,  and  Karlinski)."**  Ordinarily  the  milk  con- 
taining the  cocci  commoidy  found  in  breast-milk  produces  no  ill  effect  upon 
the  infant.  The  investigations  above  referred  to  demonstrated  that  the  chilli's 
intestines  are  capable  of  bactericidal  action.  The  stools  of  children  taking 
milk  known  to  contain  cocci  were  examined,  and  it  was  found  that  the  cocci 
luid  been  destroyed  in  the  intestine.  Cohn  and  Neumann  further  remark, 
however,  that  we  must  admit  the  possibility  of  infection  in  weak  children,  to 
which  infection  is  to  be  attributed  some  of  the  cases  occasionally  recorded  of 
abscess-formation  in  the  new-born  infant.  When  the  milk  happens  to  cairv 
micro-organisms  of  more  virulent  character,  as  in  some  cases  of  mastitis,  serious 
disease  in  the  child  may  appear.  Cases  of  gastro-intestinal  disorders,  of  diph- 
theroid stomatitis,  and  of  retropharyngeal  and  submaxillary  abscesses  are  not 
uncommon,  and  even  otitis  media,  dacryocystitis,  and  purulent  ophtlialinia 
have  thus  originated  (Damourette)."" 

The  reappearance  of  the  colostrum-corpuscles  in  the  motlier's  milk,  ])ei'li:i|»s 
the  most  valuable  result  to  be  obtained  by  microscopical  examination  of  ilic 
milk,  is  not  only  a  phenomenon  of  medico-legal  interest,  but  is  also  of  practical 
value  in  determining  the  quality  of  the  milk,  since  the  presence  of  these  coi- 
puscles  after  the  eighth  or  the  tenth  day  indicates  (jualitative  changes  in  the  milk 
which  disagrees  with  the  child.     ^\'e  have  uo  intimate  knowledge  of  iIk'^o 


PATHOLOGY   OF   THE  PUERPERILM. 


775 


ifection,  such 
a,  and  grave 
le  milk  will 
jast. 

the  mother  is 
Fortunately, 
uical  fact  that 
gh  and  when 
confirmed  the 
lits  milk  from 
temperature  is 
e  soon  appears 
t  of  investiga- 
j  the  mother's 

jiiigmau^"®  and 
lespread,  that  a 
;.     On  the  con- 
tis  micro-orgau- 
monly  found  is 
•ms;  and  other 
find  their  way 
1  into  the  ducts 
\w.  blood-curront 
oil-  entrance  into 
y  the  milk  oon- 
10  ill  effect  upon 
|\  that  the  child's 
children  taking 
1(1  that  the  cocci 
further  remarl;, 
iveak  children,  to 
lially  recorded  of 
Ihappens  to  carry 
mastitis,  serious 

lisorders,  of  dipl>- 
abscesses  are  not 
Llont  ophthalmia 

r's  milk,  pi-rluips 
laminatitm  of  tlic 
Isalsoof  practi.'iil 
Luce  of  those  cov- 
langes  in  the  milk 
[owledgc  of  these 


changes,  nor  do  we  know  why  the  corpuscles  reappear.  During  the  first  week 
of  lactation  these  corpuscles  are  numerous,  and  their  presence  at  this  time  is 
physiological.  At  various  periods  tliroughout  lactation  they  reappear,  when 
the  milk  is  found  deficient  in  nutritive  value.  They  have  been  observed  to 
reappear  when  the  mother  has  been  affected  by  some  jn-ofound  nervous  im- 
pression, such  as  excessive  grief,  fright,  fatigue,  or  sexual  excitement.  Inter- 
current diseases,  ])articularly  anemia,  are  often  accompanied  by  their  reappear- 
ance. Occasionally  tl.ey  are  observed  during  a  return  of  menstruation.  It  is 
also  a  curious  fact  that  drugs  administered  to  a  nursing  mother  more  readily 
pass  into  the  milk  during  a  colostrum  |)eriod.  The  reappearance,  therefore, 
of  colostrum-corpuscles  in  large  numbers  after  the  second  week  of  lactation 
is  an  indication  to  at  least  temporarily  discontinue  nursing. 

The  diseases  which  make  permanent  weaning  necessary  are  not  numerous. 
Phthisis,  either  incipient  or  developed,  endangers  the  mother  by  rapid  advance 
of  the  disease,  and  not  only  exposes  the  child  to  infection  by  the  transfer  of 
the  tubercle  bacillus  in  the  milk,  as  in  a  case  clearly  demonstrated  by  Steigen- 
herger,""  but  also  adds  a  risk  of  ill  development  on  account  of  tlie  imjjaired 
nutritive  quality  of  the  milk.  A  mother  known  to  have  syphilis  may  be 
allowed  to  suckle  lier  infant,  provided  the  child  bears  unmistakable  evidences 
of  the  disease,  and  provided  also  her  general  condition  is  such  as  to  furnish  a 
supply  of  milk  of  suitable  quality  and  quantity.  The  testimony  of  the  changes 
in  the  ingredients  of  the  milk  of  syphilitic  women,  apart  from  its  capability 
of  transmitting  the  disease,  is  contradictory,  and  is  doubtless  due  to  the  vary- 
ing condition  of  general  health  in  those  afflicted  with  syphilis.  When,  how- 
ever, the  infant  has  apparently  escaped  infection,  the  mother  should  not  be 
permitted  to  risk  infecting  the  child  by  her  breast-milk.  In  this  connection 
it  is  desirable  to  remind  the  student  of  Colles's  well-known  law  that  a  mother 
may  suckle  her  evidently  syphilitic  child  without  fear  of  being  herself  infected. 
A  syphilitic  child  should  never  be  given  in  charge  of  a  wet-nurse  without 
informing  the  nurse  of  her  danger  of  infection — a  danger  and  risk  so  great 
us  to  induce  Fournier"'  to  make  the  statement  that  the  practice  of  wet-nursing 
syphilitic  infants  should  be  prohibited  by  law.  It  will  often  be  necessary  to 
(lisoontinue  nursing  when  the  temperament  of  the  mother  is  so  highly  emo- 
tional as  repeatedly  to  produce  serious  qualitative  changes  in  her  milk.  The 
existence  of  or  predisposition  to  goitre  contra-indicates  suckling,  since  this 
disease  is  thereby  aggravated ;  in  some  cases  goitre  has  first  appeared  during 
the  lactation  period. 

Anemia. — An  impoverished  condition  of  tlie  blood  after  labor  renders  the 
piierpera  incapable  of  supplying  a  proper  quality  of  milk,  atid  fiu'ther  depletes 
lier  vitality  to  such  an  extent  that  nursing  must  be  omitted  both  for  her  own 
uiul  for  the  child's  best  interests.  It  is  therefore  inadvisable  to  permit  suckling 
to  he  continued  when  a  profuse  hemorrhage  has  occurred  at  the  time  of  deliv- 
ery, or  when  a  condition  of  advanced  anemia  has  developed  dnriiig  pregnancv, 
with  or  without  albuminuria,  in  which  case  the  frequent  tardy  involution  of 
the  blood  will  be  even  more  delayed.     It  is,  moreover,  certainly  rational  to 


U... 


1  'Eia  '■ 


||mf-T 


776 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


3  \ 


n^  ■!  ;i 


V     >      I, 

i  ;  ti 


\w 


\    I! 


li' 


believe  that  the  blood  of  an  albiirnimiric  woman  cannot  supply  the  material 
for  a  perfectly  healthy  milk-secretion. 

Return  of  MenHtruation. — Among  the  laity  the  notion  is  very  widespread 
that  a  return  of  the  menstrual  function  makes  it  imperative  to  discontinue  nuri<- 
ing.  When  the  amount  of  blood  lost  is  sufficient  to  produce  anemia,  it  will 
always  be  desirable  to  wean  the  child.  Ordinarily  the  flow  is  not  excessive 
and  may  be  very  irregular,  and  the  impairment  of  the  milk  is  only  temporary, 
as  shown  by  the  transient  digestive  disturbance  in  the  child.  Under  such  con- 
ditions it  would  certainly  be  unwise  to  resort  to  artificial  feeding  unless  the 
child's  condition  clearly  indicated  that  it  was  not  thriving,  which  sometimes 
will  be  the  case  when  the  menses  return  regularly  and  profusely.  Schlichter'.s"' 
observations,  during  a  period  of  five  and  a  half  months,  of  52  children  suckled 
by  women  in  whom  menstruation  had  appeared,  found  that  only  one  child 
became  dyspeptic,  and  that  this  child  showed  a  normal  gain  in  weiglii. 
Thirty-three  m  'iv-analyses  were  made,  and  they  showed  on  an  average  less 
difference  between  the  milk  of  a  non-menstruating  and  a  menstruating  woman 
than  betweon  the  specimens  of  milk  taken  from  an  individual  at  mornini.% 
noon,  and  evening.  The  advisability  of  discontinuing  nursing  when  tlie 
mensem  return  should  always  be  decided  in  individual  cases  by  a  critical 
study  of  the  health  of  both  mother  and  child. 

Pregnancy. — The  experience  is  universal  that  a  mother  cannot  continue  to 
supply  nutriment  for  botii  her  unborn  and  her  living  child;  and,  leaving  out 
of  consideration  the  possibility  of  the  occurrence  of  miscarriage  througii  the 
intimate  reflex  association  of  the  uterus  and  the  mannnary  glands,  lactation  and 
pregnancy  are  incompatible,  and  are  not  to  be  sanctioned  except  when  scu'ioiis 
illness  in  the  suckling  makes  a  supply  of  breast-milk  specially  urgent  for  a  short 
time. 

Dntg,s. — It  is  recognized  as  a  clinical  as  well  as  an  experimental  fact  tlmt 
various  drugs  are  in  part  eliminated  by  the  mammary  gland,  not  only  wlicn 
the  milk  is  in  a  poar  condition,  but  also  when  the  nursing  mother  is  apparently 
perfectly  healthy.  Alcohol,  quinin,  salicylic  acid,  arsenic,  lead,  iodoform,  potas- 
sium iodid,  mercury,  the  poisonous  alkaloids,  narcotics,  belladonna,  and  a  few 
other  drugs  have  been  found  in  the  milk  of  nursing  women.  Knowledge  (tf 
this  subject  has  largely  been  gathered  from  accidents  occurring  to  the  infant 
when  the  nursing  mother  has  been  treateil  for  intercurrent  diseases. 

Burdel '"  reported  fatal  illness  in  an  infant  whose  mother  had  been  cin- 
chonized,  and  he  advises  withholding  the  breast  until  the  milk  containing 
the  quinin   is  withdrawn. 

V^inay"*  observed  a  distinct  odor  of  nicotin,  though  chemically  it  was  not 
shown  to  be  present,  in  the  milk  of  mothers  exposed  to  the  vapors  of  nicdtin 
in  tobacco-factories,  and  he  noted  the  aj)pearance  of  serious  illness  in  the 
child  upon  the  mother's  return  to  the  factory,  which  illness  disappeared  wlnii 
the  milk  was  given  up.  Doses  of  the  poisonous  alkaloids  physiological  for  the 
mother  may  at  times  ])ass  through  the  milk  in  quantity  sufficient  to  be  poism- 
ous  to  the  child.     This  is  especially  true  of  atropia. 


PATHOLOGY  OF   THE  PUERPERIVM. 


Ill 


the  material 

[•y  widespread 
jontinue  luui^- 
memia,  it  will 
not  excessive 
aly  temporary, 
nder  such  con- 
ing unless  the 
liich  sometimes 
Sehlichter's"= 
liildren  suckled 
only  one  child 
;ain  in  weighi. 
an  average  less 
truating  woman 
iial  at  mornintr, 
rsing  when   the 
on  bv  a  critical 

mnot  continue  to 
and,  leaving  out 
iage  through  the 
Inds,  hictation  and 
pt  wdien  serious 
urgent  for  a  short 


'ini 


iiental  fact  that 
,  not  only  when 
ler  is  apparently 
iodoform,  potas- 
idonna,  and  a  few 
Knowledge  of 
ing  to  the  i"f:mt 
seases. 

er  had  been  ein- 
milk  containing' 

Diically  it  was  not 
vapors  of  nieotin 
Ins  illness  in  the 
Jdisappeared  wli<n 
lysiological  fortlu' 
tent  to  be  poison- 


Fehling '"  and  Schling  "'  have  experimentally  studied  the  action  uj)on  the 
infant  of  various  drugs  in;>;ested  through  the  mother's  milk,  and  they  point  out 
the  fact  that  the  time  required  for  partial  elimination  by  the  mammary  glands 
varies  with  different  drugs. 

The  frequently  observed  laxative  action  upon  the  child  of  salines  or  of 
com])Ound  licorice  powder  administered  to  the  mother  is  sometimes  utilized 
for  the  benefit  of  the  infant,  but  beyond  this  the  writer  is  acquainted  with  no 
exact  experimental  or  clinical  studies  of  the  medicinal  treatment  of  infants 
through  the  breast-milk.  According  to  Barnes,  syphilis  in  the  infant  may 
thus  be  cured. 

Weaning. — As  the  normal  period  of  lactation  is  relative,  often  depending 
upon  individual  capacity  for  the  production  of  milk  and  for  enduring  tlie 
strain  of  lactaticm,  it  is  difficult  to  name  a  period  throughout  which  the  child 
should  be  fed  exclusively  from  the  breast.  Ordinarily  nine  numths  is  the  limit, 
hut  in  some  individuals  lactation  may  be  extended  throughout  a  year  without 
detriment  to  mother  or  child.  After  twelve  months  the  changes  in  the  quality 
and  quantity  of  the  milk,  the  appearance  of  teeth  in  the  child,  indicating 
nature's  preparation  for  other  food,  and  the  beginning  ill  effects  upon  the 
mother  of  prolonged  lactation,  make  it  imperative  to  remove  the  infant  from 
the  breast.  There  are,  of  course,  a  few  conditions  which  will  allow  a  continu- 
ation of  lactation  for  a  brief  period  beyond  twelve  months.  It  would,  for 
example,  be  unwise  to  wean  a  child  at  the  approach  of  midsummer,  or  when  it 
had  r.ecently  recovered  from  a  serious  illness,  or  when  in  the  midst  of  a  dentiil 
period.  Whenever  weaning  is  decided  upon,  it  is  best,  as  a  rule,  though  not 
always  necessary,  to  give  artificial  food  gradually,  substituting  at  first  one  or 
two  bottle-feedings  daily,  and  gradually  increasing  the  mnnber  until  finally, 
in  the  course  of  several  weeks,  the  breast-milk  is  no  longer  used.  At  the  end 
of  the  sixth  month  it  is  a  good  rule  to  investigate  the  quantity  and  quality  of 
the  mother's  milk  and  the  condition  of  the  child,  and  to  observe  the  effect  of 
lactation  upon  the  mother's  health.  If,  as  is  quite  common,  this  investigation 
indicates  the  desirability  of  weaning,  this  should  be  begun,  and  by  the  end  of 
tiie  ninth  month  the  breiust-milk  may  be  omitted. 

Hyperlactation. — Prolongation  of  the  lactation  period  beyond  the  usual 
time  for  weaning — from  the  ninth  to  the  twelfth  month — is  not  at  all  tuicom- 
nmn  among  the  ])oorer  classes.  The  ill  effects  upon  the  mother  and  the  child 
arc  numerous,  and  the  consequences  to  both  are  frequently  very  grave.  These 
offccts  are  more  frequently  seen  in  women  of  weakly  or  strumous  constitutions 
whose  vitality  has  been  depressed  further  by  the  strain  of  pregnancy  and  lacta- 
tion. The  sipnpfoms  of  the  condition,  to  which  has  been  given  the  name  fabes 
htclcd,  are  unmistakable.  The  quantity  and  quality  of  the  blood  are  impaired  ; 
the  patient  is  pale,  emaciated,  and  complains  of  aching  pain  in  the  back  and 
loini-;,  and  in  the  breast  when  the  child  is  suckled.  Tiiere  is  loss  of  appetite, 
and  muscular  and  nervous  weakness  with  insomnia,  headache,  and  vertigo.  In 
niany  cases,  further  neglected,  hysteria  or  more  serious  changes  in  the  nervous 
system  may  be  followed  by  insanity.     Cramps  and  contractions  of  various 


778 


AMERICAN   TEXT-BOOK  OF   OBSTETRICS. 


muscles,  beginuiiig  with  tingling,  are  frequently  observed  ;  even  speechlessness, 
dysphagia,  orthopnea,  and  atta(;ks  of"  syncope  have  been  noted.  Serious 
derangements  of  the  eyes  have  also  been  observed  as  a  result  of  the  extreme 
reduction  ol'  the  vital  powers  and  the  impoverished  condition  of  the  blood, 
varying  from  a  mild  conjunctivitis  to  ulceration  of  the  cornea  or  retinitis  with 
total  loss  of  sight.  In  those  predisposed  to  phthisis  this  disease  frequently 
develops  at  this  time.  Ilyperlactation,  on  account  of  the  associated  debility, 
sometimes  is  an  etiological  factor  in  the  development  or  aggravation  of  skin 
affections,  particularly  psoriasis. 

The  treatment  of  hyperlactation  is  the  prompt  weaning  of  the  child  and 
the  use  of  tonics,  nutritious  food,  and  a  temporary  change  in  the  patient's  sur- 
roundings.    Usually  mpiil  improvement  follows. 


in.  Diseases  op  the  Non-sexual  Organs. 

1.  Fevf:r  due  to  Causes  other  than  Puerperal  Infection, 

While  it  is  true  that  sometimes  a  rise  of  temperature  in  the  puerperium 
occurs  wholly  independent  of  infection,  it  is  also  true  that  from  a  clinical  stand- 
point the  safest  rule  is  to  believe  that  fever  occurring  during  the  puerperal 
period  always  has  an  infectious  origin  until  indubitably  proven  to  be  due  to  some 
other  cause.  There  are,  however,  several  conditions  which  not  infrequently 
are  observed  to  produce  non-infectious  fever  in  the  puerperium.  One  of  the 
most  important  causes  of  fever  having  a  non-infectious  origin  in  the  pucr- 
pera  is,  for  want  of  a  better  explanation,  called  "  reflex  irritation."  Wiien 
it  is  remembered  that  during  the  puerperal  period  the  patient's  nervous 
system  has  not  fairly  begun  to  recover  from  the  nervous  irritability  which 
was  so  pronounced  throughout  pregnancy,  it  is  easy  to  imderstand  that  causes 
which  in  health  would  have  little  if  any  effect  upon  the  patient's  nerve- 
equilibrium  will,  out  of  all  proportion  to  their  magnitude,  produce  marked 
effects  upon  the  peculiarly  nervous  susceptibility  of  the  puerpera.  The  sud- 
den rise  in  temperature  so  commonly  observed  associated  with  congested  and 
engorged  mammary  glands  (Fig.  434)  or  with  a  sore  nipple  is  certainly  in 
large  measure  due  to  reflex  irritation,  although  the  element  of  infection  in 
some  cases  is  partly  responsible  for  the  fever,  especially  if  the  latter  continues, 
in  which  event  mastitis  should  be  suspected. 

Exposure  to  cold,  with  consequent  internal  congestion,  especially  of  tlic; 
breasts  and  of  the  abdomen,  is  also  a  cause  of  transient  fever  in  puerporid 
patients  who  have  beer,  careless  about  jiroper  protection  with  clothing  or 
who  indiscreetly  expose  themselves  soon  after  labor.  The  chart  (Fig.  4.');")) 
illustrates  such  effect  u])()n  a  woman  who  left  her  bed  eight  days  after  licr 
delivery  and  walked  through  an  unprotected  corridor  to  the  closet.  Suoii 
after  her  return  she  was  taken  with  a  chill  and  her  temperature  rose  as  indi- 
cated in  the  chart.  After  the  administration  of  a  hot  punch  and  the  prottr- 
tion  of  an  extra  blanket  the  fever  disappeared. 

Emotion  is  recognized  as  a  cause  of  fever  independent  of  the  puerperimii. 


PATHOLOGY   OF    THE    PUKRPERIUM. 


779 


IWI 


)eechlessness, 
twl.  Serious 
the  extreme 
of  the  blood, 
retiuitis  with 
use  frequently 
iated  debility, 
nation  of  skiu 

the  child  and 
i  patient's  sur- 


^NFECTION. 

the  puerperiuiu 
a  clinical  stand- 
g  the  puerperal 
,o  be  due  to  some 
lot  infrequently 
im.     One  of  the 
pin  in  the  pucr- 
tation."     When 
atient's   nervous 
•ritability  whioli 
;tand  that  causes 
patient's  nerve- 
produce  niark<Hl 
i-pera.     The  sud- 
fh  congested  ami 
le  is  certainly  in 
It  of  infection  in 
latter  continues, 

especially  of  the 
Iver  in  puerperal 
Isvith    clothinji  or 

chart  (Fi[?.  4:55) 
lit  days  after  licr 
ke  closet.  S<»i«i\ 
lure  rose  as  indi- 
li  and  the  proti'c- 

the  puerperiuni. 


That  profound  emotion  markedly  influences  the  temperature  in  the  early  puer- 
perium  is  well  known,  but  the  exact  mechanism  of  the  production  of  fever 
by  this  cause  is  unknown.  The  appended  charts  are  of  two  cases  recently 
observed  by  the  writer.  The  rapid  rise  of  temperature  observed  in  one  (Fig. 
136,  A)  followetl  the  thoughtless  announcement  to  the  patient  that  her  husband 


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Flu.  4;!4.— FfVLT  IblldWiliK  L'xposurf  to 
colli. 


I'di.  !;!.'>.— KlfViitioii  of  toiMpiTUtiiru  (liic  to 
t'ligorgomi'iit  of  till'  iimiiiiiiary  k'hikIs. 


had  been  killed  in  a  railroad  accident.  The  secondary  rise  of  teiiijicrature  was 
due  to  the  i)ati(!nt's  anxiety  about  her  inability  to  provide  for  herself  and 
cliild,  which  anxiety  was  relievetl  by  prcini.seil  assistance.  Figure  43G,  B  is  the 
diart  of  a  patient  who  occupied  a  bed  adjacent  to  a  companion  who  manifested 
.signs  of  mild  puerjM'ral  insanity.    The  insane  patient  declared  that  during  the 


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Fl(i.  436.— Fever  due  to  I'lnotion. 


niojit  hor  infant  had  been  exchanged  for  the  .sane  patient's  cliild,  and  insistefl 
thiit  the  latter  patient  should  surrender  her  child,  wliicli  the  insane  woman 
claiined  as  hers.  The  anxiety  and  trepidation  of  the  patient  whose  chart  is 
here  exhibited  was  .so  great,  and  the  rise  of  temperature  was  so  coincident  and 


i 


780 


AMKIilVAN    TI'LXT-IiOi^K   OF    OliSTKTUICS. 


pronotincctl,  that  tlic  n-lution  of  ciiiisc  and  dU'ct  could  not  ho  mistaken.  Upon 
romoviiig  the  insaiu'  patient  to  anotlicr  room  the  ahirni  of"  thf  anxious  niotlui- 
(h'sa|)iu'ar('d  and  licr  tcnipcratiii'i'  fMl  at  once  to  \\w  nonnah 

Acute  constipation  in  the  pnt-rpcrinn)  is  a  frccpicnt  nniso  of  fcvor,  whicli 
is  doid)tU>s,s  (hie  to  the  irritation  of  retained  animal  all\ah)ids.  This  plic- 
nomenon  is  anotlier  example  of  the  snseeptihility  of  tiie  nervous  system  to 
various  forms  of  irritation  that  at  times  other  tlian  the  puerperium  proihicc 
litth*  or  no  effect. 

When  a  patient,  before  or  durinji;  prejjjnancy,  is  the  subject  of  a  disease 
neeompanied  by  fever,  tlie  elevation  of  temperature  will  usually  be  increased 
din'ing  the  puerperium,  since  an  exacerbation  of  the  disease  is  likely  to  occur. 
The  fever-curves  of  phthisis,  of  j)neiunonia,  of  typhoid  fever,  and  of  other 
serious  diseases  are  thus  modified. 

Very  hif;;h  fever  is  often  observed  when  serious  disturbances  of  the  brain 
complicate  the  puerperium,  such  as  cerebral  heniorrhaf^e  or  embolism  or  eclamp- 
sia. It  is  possible  for  a  puerperal  patient  to  be  stricken  with  thermic  fever, 
and  the  essential  fever  of  syphilis  is  sometimes  observed  in  the  puerperium. 

2.    IiNTKIM^lKUKNT    Dl.SKASKH. 

The  puerperal  patient  may,  of  course,  be  attacked  by  any  acute  disease. 
There  are,  however,  a  few  diseases  which  it  is  desirable  to  mention  briefly,  since 
their  relation  to  the  puerperal  period  is  of  more  than  ordinary  importance. 

Exanthemata. — In  recent  years  the  important  relation  of  the  exan- 
themata to  puerperal  infection  has  been  better  understood,  and  there  is  now- 
little  doubt  that  the  germs  of  the  virulent  infectious  diseases  may  effect  an 
entrance  into  the  puerperal  j)atient  either  throuj^h  their  ordinary  and  peculiar 
modes  of  entrance,  or  throus^h  wounds  of  the  jienitalia,  which  latter  channel 
is  relatively  far  more  frequent,  more  dangerou.s,  and  therefore  more  import- 
ant. When  any  of  the  exanthematous  diseases  occur  as  complications  of  the 
puerperium  without  symptoms  or  signs  of  infection  of  the  genital  organs — a 
very  infrequent  occurrence — the  prof/noKin  is  more  grave  and  the  treatment  is 
the  same  as  under  other  circiunstauces,  with  rigid  antisej)tic  precautions  added 
to  prevent  invasion  through  the  partiirient  canal. 

Scarfd  J'h'ci: — When  scarlet  fever  is  contracted  by  the  puerperal  jwtieiit 
the  j)oisoM  having  been  introduced  through  wounds  in  the  genital  canal, 
the  clinical  course  of  the  disease  is  greatly  modified.  The  incubation  period  is 
shortened  to  twenty-four  or  forty-t^ght  hours.  The  <//Vr7«o.s'/.s  is  usually  ob.«cure(l 
by  the  fact  that  other  forms  of  sej)tic  infection  are  frequently  accompanied  liy 
skin  eruptions  which  are  similar  in  appearance  to  that  of  scarlatina  (see  p.  707). 
This  fact  doubtless  explains  the  erroneous  idea,  formerly  so  widespread,  that 
scarlatina  very  frequently  attacked  puerperal  patients,*  in  whom  it  was  thoutrlit 
there  existed  a  pectiliar  susceptibility  to  this  disease,  and  for  whom  a  previous 
attack  in  early  life  is  said  not  to  be  protective  to  the  same  degree. 

*  Martin  found  only  tlirce  cases  of  scsirlot  fever  in  10,000  patients  in  the  Berlin  clinii's. 
(Sjiiegelberg,  Leitrbuc/i  der  Geburtshulfe,  3d  edition,  1891). 


K 

stakon.    Upon 
mxious  inotlii  1 

of  i'l'vor,  wliich 

vons  systoiu  In 
[K'l-iuin  piothuc 

(H't  of  a  tli^oiisc 
illy  be  iiKTcastd 
^  likely  to  oeciir. 
LH",  iukI  of  other 

COS  of  the  hraiii 
M)lirttn  or  ec'laiiij)- 
[h  thennie  fever, 
le  puerperium. 

my  acute  disensp. 
iition  briefly,  since 
ary  iiiiportanee. 
on   of   the   exan- 
land  there  is  now 
ses  may  efleet  an 
inary  and  peonliar 
ieh  latter  ehanncl 
ore  more  import- 
mplieations  of  the 
geiiital  organs— n 
id  the  treatmnif  is 
precautions  ailded 

puerperal  patient 
the    genital  «'anal, 
Jicubation  period  is 
lis  usually  obscured 
Jy  accompanied  hy 
(latina  (see  p.  707), 
h  widespread,  tliat 
Um  it  was  tlionijlit 
whom  a  previous 
pgree. 
I  in  the  Berlin  I'li"'"'^' 


PATJIOLoaV   OF    THE   PrEIirKRirM. 


781 


When  it  is  known  that  the  patient  lias  been  exposwl  to  the  germs  of  sei..  .<t 
I'cjver,  and  wlien  the  poison  has  entered  tiie  genital  eanal,  the  vagina  may  show 
the  redness,  swelling,  and  })seudo-(liphtheritie  patiiiies  ordinarily  observed  in 
the  throat,  and  the  rash  may  be  most  apparent  in  tlu!  region  of  the  vulva. 
The  later  <K'currenc(!  of  (l(>s(|uamation  wiien  the  patient  survives  will  some- 
times help  to  verify  the  diagnosis. 

Tho  profj/noxis  is,  (»f  course,  grave,  being  very  nmch  worse  ac(!ording  to  the 
extent  of  invasion  of  the  pelvic  or  other  organs.  The  tredtmcnt.  is  that  for  the 
iXrave  forms  of  puerperal  iid'ection. 

Erysipelas. — The  relation  of  erysipelas  to  ])uerperal  iid'ection  is  even  n\ore 
striking  than  that  of  scarlet  fever.  IJarnes  "^  has  said  that  erysipelas  "will 
jierhaps  aeeoimt  for  more  epidemics  of  puerperal  fever  than  any  other  external 
poison."  The  channel  of  infection  is  usually  the  partiu'ient  canal.  Of  l.'i 
cases  observed  by  Ilugeidwrger,  eleven  were  of  the  genitalia,  two  of  the  nates, 
two  of  the  face.  Winekel  saw  86  ease« — twenty-eight  of  the  genitalia,  two 
(if  the  breasts,  six  of  tin;  face  and  scalp.  Of  Fehling's  5  cases,  three  wen;  of 
the  iiice.  It  is  doubtless  true  that  very  many  cases  of  puerperal  inli'ction  are 
of  erysipelatous  origin,  which,  in  the  absence  of  the  usual  synipt<trns  of  this 
disease,  cannot  In;  recognized  without  bacteriological  examination.  The  disease 
develops  mora  frequently  in  the  first  than  in  the  second  week  after  delivery, 
and  death  occurs  oftener  in  the  second  than  in  the  fourth  week.  The  y>/vv//((W« 
(if  facial  erysipelas  in  the  jHierperium  is  comparatively  favorable.  When  the 
disease  attacks  the  parturient  canal  the  mortality  is  high;  twelve  of  Winckel's 
cases  ended  fatally.     The  frcdtincnf  is  that  for  grave  puerperal  infi'ction. 

Diphtheria. — The  relation  of  diphtheria  and  of  other  infectious  diseases  to 
])nerperal  infection  is  similar  to  that  of  erysipelas,  and  the  sanu;  antise2)ti(j 
precautions  against  all  infectious  diseases  are  urgently  demanded. 

Pneumonia ;  Rheumatism. — It  has  been  asserted  that  (he  pu(>rperal  pa- 
tient is  especially  predisposed  to  ])neunu)nia  and  to  rheinuatism.  These  dis- 
eases may  occur  as  intercurrent  affections,  but  it  is  a  flict  that  a  septic  pneu- 
monia or  a  se|)tic  arthritis,  to  both  of  which  diseases  referiiuee  has  been  made 
(pp.  708,  707),  will  account  for  the  relative  fre(iuency  of  the  former  diseases 
in  the  ])uerperal  peritMl.  Pneumonia,  not  of  septic  origin,  occurring  in  the 
puerperal  peri(xl  requires  no  consideration  in  this  work  beyond  the  statement 
that  the  course  of  the  disease  is  more  serious  than  pneumonia  in  non-puerperal 
women,  the  fever  being  especially  high,  and  the  prognosis  is  distinctly  more 
}irave.  When  secondary  to  infection  of  the  parturient  canal,  pneumonia  is 
often  of  embolic  origin,  and  is  frequently  observed  as  a  complication  of  uterine 
pldebitis  or  ])hlegmasia  alba  dolens.  The  course  and  treatment  of  septic  pneu- 
monia are  described  in  the  section  on  Purrpcral  Infection. 

A  sejitic  arthritis  can  be  differentiated  from  true  rheumatism  by  the  history 
of  the  case;  by  the  absence  of  a(!id  sweats,  of  cardiac;  complications,  and  of 
niinked  febrile  reaction ;  and  by  the  fact  that  one  of  the  large  joints,  often  the 
knee,  is  affected  ;  that  other  joints  are  very  rarely  affected  in  succession  ;  that 
it  lias  a  longer  duration  and  a  tendency  to  ankylosis  or  to  suppuration  in  the 


!■'       < 


i 


vi ' 


mm' 


i'iiln 


IR- 


i'T ' 


782 


AMEIUCAS   TEXT- BO  OK   OF   OBSTETUJCS. 


joint,  with  geiioral  septic  iut'cftion ;  aiul  that  arthritis  is  more  apt  to  ooeiir 
in  women  who  liave  had  jjonorrhea  before  labor.  The  cause  of  this  so-ejil led 
"puerperal  rheumatism"  is  probably  a  specific  variety  of  niicro-orgaiiisni 
having  a  predilection  for  the  joints.  Trmtnient  consists  in  a  careful  disinfec- 
tion of  tiie  parturient  tract  and  in  keeping  tiie  joint  at  rest,  in  the  application 
of  iodin  or  ointment  of  belladonna  and  mercury  to  the  joint,  and,  after  acuti; 
inHammaiory  symptoms  sul)si<Ie,  in  the  employment  of  cautious  passive  motion. 

Malaria. — Malaria  is  one  of  the  most  imjKJrtant  intercurrent  diseases  o|' 
the  puerperium,  not  only  because  women  recently  contined  have  an  increascii 
liability  to  this  disease — a  fact  generally  admitted — but  especially  because  this 
disease  so  often  sinudates  sepsis,  from  which  it  is  of  the  utmost  imj)ortaiice  tluit 
malaria  be  differentiated.  Cliniwdly,  women  subject  to  the  malarial  poison 
almost  always,  as  the  result  of  the  traumatism  of  labor,  manifest  this  discasf 
after  delivery,  at  which  time  the  type  of  malaria  ordinarily  is  mild,  but  excep- 
tionally it  may  be  very  severe.  The  disease  usually  appears  on  or  about  tlic 
third  day  after  delivery,  and  often  modifies  the  course  of  the  ]nicrj)eral  period. 
While  malaria,  according  to  Abelin,"*  does  not  modify  the  involution  of  the 
womb,  acute  types  of  the  disea.se,  to  .some  extent,  ])redi.spose  to  puerperal  henioi-- 
rhage  and  to  profuse  and  j)rolonged  bloody  hx'hia. 

The  influence  of  malaria  upon  the  nu Ik-secretion  is  shown  by  a  diminution 
in  the  amount  of  milk  secretetl,  especially  when  the  fever  is  highest.  WhetJK  r 
the  germs  of  the  disease  are  transmitted  in  the  milk  to  the  nursing  infant  is 
by  no  means  certain.  In  some  cases  it  has  been  asserted  that  such  trans- 
mission has  been  observetl. 

IHagncms. — The  diagnosis  of  malaria  occurring  in  the  puerperiiun  is  often 
very  difficult,  and,  as  stated  above,  the  close  resemblance  of  this  disease  to  some 
forms  of  begimiing  sepsis  renders  the  difllerential  diagnosis  the  most  important 
feature  of  malaria  complicating  the  puerperium.  A  safe  clinical  rule  is  to 
reserve  a  diagnosis  until  the  parturient  tract  is  known  to  be  uninfected.  Mliile 
frequently  the  date  of  api)earance  is  the  third  day  after  labor,  wide  variations 
are  observed.  The  duration  and  marked  remissions  of  the  fever,  its  freciiieiit 
but  not  invariable  periodicity,  and  especially  a  morning  elevation  of  tempera- 
ture; the  character  of  the  pulse  and  the  more  evident  relation  of  its  rapidity 
to  the  degree  of  fever ;  the  blood-examination  for  the  malarial  plasmodinni; 
the  enlargement  of  the  spleen  and  of  the  liver;  the  quantity  and  (|uality  of 
the  lochia;  and,  finally,  the  efficacy  of  quinin, — will  often  assist  the  diagnosis 
between  malaria  and  puerperal  sepsis. 

Treatment. — An  early  diagnosis  is  usually  difficult,  and,  in  order  tlmt 
begimiing  .septic  infection  of  the  parturient  canal  may  not  meanwhile  iiain 
headway,  it  is  a  safe  rule  to  disinfect  the  vagina,  or  even  the  uterus,  and  to 
administer  a  calomel,  and  later  a  saline,  purge,  followed  by  one  or  two  iVeo 
doses  of  quinin  (gr.  x,  administered  morning  and  evening).  This  course  of 
treatment  may  further  obscure  the  diagnosis  for  a  time,  but  it  has  the  ad- 
vantage of  promjitly  detecting  and  treating  beginning  infection,  thus  avoid- 
ing delay  in  stopping  its  further  progress.     If  the  disease  is  malaria,  the 


}  apt  to  occur 

f  this  so-call*'i 

jiicro-organisii\ 

iroful  ilisint'ci- 
tho  applit-itidii 

and,  after  aciitr 

passive  motinn. 

rent  diseases  of 

ve  an  increase  I 

illy  because  tlii- 
inipovtance  that 
malarial  poison 

ifest  this  iliseasf 
niiUl,  hut  exccp- 
on  or  about  tlic 

puerperal  perind. 

involution  of  tlu' 

jnierperal  heniuv- 

,  by  a  (liniinutiun 

ligiiest.    ^Vhetllcl• 

i  nursing  infanl  is 

that  such  traiis- 

iierperiuni  is  ofton 
[lis  disease  to  some 
lie  most  iniportimt 
■linical  rule  is  to 
ininfected.    Wli'd^' 
n-,  wide  variations 
jfcver,  its  frccjiuiit 
ation  of  tempi  r:i- 
ion  of  its  rapidity 
.rial  Plasmodium ; 
ity  and  (jnaUty  of 
assist  the  diagiinsis 

Ind,  in  order  thiit 
It  meanwhile  siivi" 
Ithe  uterus,  and  to 
[r  one  or  two  iVue 
This  course  of 
tut  it  has  the  lul- 
ectiou,  thus  avoid- 
se  is  malaria,  tlie 


PAT/roLoav  OF  THE  pri':iiri:nii\yr. 


783 


fever  will  likelv  rccm-,  hut  usuallv  it  will  rcadilv  he  controlled  hv  nninin, 
wliicii  ordinarily  should  he  adniinistcr<!d  in  daily  doses  (»f  from  lo  to  ,'JO 
gi-ains  throughout  a  period  of  ten  days  or  two  weeks.     'I'lie  chart  (Fig.  4.'J7) 


' 

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-,1     ',^\  .  Ni    1  \-l    Mi     Ml     liio'  IIKJ    ,M     Ui;     8-1     S(j  ,  ^l     HG     M  ,  H)     82     70 

!  i      I  :      I     I  i      I  I     i      I      I 

CO  I  fiQ      S(i     7C.     711    102    ins    1(18     SO  '  STi  i  72|  89  I  8:1  '  81  !  82     7!)     84  .  80  ! 
Fl(i. -llw.— Maluriii  in  tlii'  iiiicrjurimu. 


illustrates  this  jdan  of  treatment.  The  notes  of  the  case  arc  as  follows:  Sixth 
(i;iy  :  Tongue  coated,  conitmctivie  yellow  ;  uterus  enlary;ed,  reaching  more  than 
liidfway  to  umhilicus;  bloody  lochia  j)ersistent  and  not  otfcnsive;  a  very  large 


[ST.         \Wi  \A\   "U  IIHJ  iiH   (S.;   m   l-l   7ti  '.KI  in  NI  7ll   7U    71    71   nn  7S   71    S4   Ht)  71    wi   x-1  ':>   im 
JS 
l2  I.  /■-'.  IOC,  108  KKI  W  91    S-l    80    74    70   78  100  122:  80  7'J   SI    72    SJ    80    80    SO    74    80  70^^84 ;  70   70  JO ; 

Fig.  4ii8.— Malaria  in  tlio  |>iu'ri>irium. 

iimount  of  healthy  decidua;  and  blood-clots  removed  with  curette  and  placental 
forceps,  followed  by  douche  and  gauze-packing;  calomel  (gr.  iij) ;  quinine  (gr. 
x),  at  night  and  on  the  following  morning.  Ninth  day  :  Temperature  again 
elevated;  uterine  involution  progressing;  bloody  lochia  diminished;  quinin, 
gr.  X  thrice  daily.  This  dose  of  quinin  was  given  until  the  seventeenth  day, 
when  cinehonisin  first  appeared,  and,  as  i.s  shown  by  the  chart,  the  fever  disap- 
lieiired  and  did  not  return. 

The  writer  has  repeatedly  observed  a  fact  recorded  by  others — namely,  that 


784 


AMI':RI('AN    TKXT-JiOOK    <>/•    OliSrHTlilCi!}. 


i_L  ii 


Ut 


some  puerperal  cases  of  rnalariu  recpiire  exeeptionully  larj^e  doses  of  nuiiiin. 
The  eliurt  (Kif;.  4.'J8)  illustrates  this  fact.  In  this  case,  from  the  thinl  to  the 
tentli  ilay  a  daily  dose  of  16  jrraiiis  was  jj^ivoii,  and,  the  temperature  iiaviiiif 


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71 

Fio.  ■I'.iO.— Mnliiria  in  the  puorpcrlum. 


ceased  to  rise,  the  drug  was  about  to  he  discontinued.  Two  days  later — on  the 
twelfth  day — the  temperature  rose  to  103f°  F.  notwilhstandinj;  tiie  (piiniii ; 
the  daily  dose  was  then  doubled,  .'50  j^rains  beinjj^  j'iven  daily  until  the  Kfteeiitli 
day,  when,  the  fever  apparently  being  controlled,  the  amount  was  reduced  to 


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Fig.  440.— Malaria  in  tiie  puerpurlum. 

lo  grains.  On  the  seventeenth  day  a  chill  occurred  and  the  tem])erature  rose 
to  101i°  F.,  whereupon  30  grains  were  given  daily  until  the  twenty-tliird 
day,  when  cinchonism  occurred  and  the  temperature  became  normal ;  the 
amount  of  the  drug  was  then  reduced  to  a  very  small  daily  dose. 

The  chai't  (Fig.  439)  also  illustrates  the  necessity  of  administering  l;ir<ic 
doses  of  quinin  in  some  jiuerperal  cases  of  malaria.  Whenever  attempt  was 
made  to  reduce  the  dose  from  10  grains  thrice  daily  the  temperature  invarialiiy 


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•jituro  rose 
xMity-thinl 
rmal;   tlie 

rinp;  l;i''S'' 
[tempt  \v:\s 
linvariiiltly 


rAT/i()/j)(;y  or  rni:  rvKiiPKiiiryt. 


(85 


was  elevated,  ami  the  fever  was  filially  c(»iitr(»lle«l  liy  adiiiinifitering  20  jfrains 
tliiice  daily  (20th,  21«t,  22d,  and  2:}d  days). 

The  chart  (Fig.  440)  exemplifies  a  milder  type  of  puerperal  malaria  eon- 
trolled  by  a  (hiily  d<»se  of  0  grains  of  (piiiiiii. 

When  it  is  necessary  to  resort  to  large  doses  of  (|uiiiin  to  control  malarial 
lever  in  the  piierperiiim,  tiie  writi-r's  experii'iice  agrees  witii  that  of  IJiirdel,  that 
(lie  infant  is  likely  to  sutfer  and  should  he  taken  from  the  breast.  A  dailvdoso 
of  from  16  to  20  grains  has,  however,  produced  no  apparent  elfect.  In  eases 
of  chronii!  malarial  cachexia  with  an  acute  exacerl)atioii  after  labor,  arsonie  coin- 
liiiied  with  (piinin  will  often  be  more  etfieient  than  (piinin  a«lmiiiisteied  alone. 

Hemorrhoids. — The  interference  with  the  venous  eireulatioii  of  the  rectum 
(luring  the  last  months  of  pregnancy  very  often  leaves  the  rectal  veins  in  u 
liemorrhoi<lal  condition,  which  fre(pieiitly  occasions  great  discomfort  during 
(•(invalescence.  Relief  may  l)e  obtained  by  'ivw  action  of  the  bowels,  bv  the 
iipplication  of  hot-water  compresses,  or,  if  more  agreeabh;  to  the  patieiit,  bv 
liic  use  of  an  ice-bag.  A  piece  of  cotton  saturated  with  the  distilled  extract 
y\'(  witch-hazel  and  inserted  partially  through  the  anus,  or  the  use  of  an  oint- 
iiieiit  composed  of  ecpial  parts  of  the  ointments  of  galls,  belladonna,  and  stra- 
iiioiiiiim,  will  further  relieve  the  pain. 

Puerperal  Anemia. — According  to  the  investigations  of  Ingerslev,  Feh- 
liiig,  ami  jNIeyer,""  the  average  numlu'r  of  blood-corpuscles  and  the  heuKtglobiu 
value  of  the  blood  are  lessened  during  the  first  four  or  five  days  of  the  puerpe- 
riiim,  but  by  the  fifteenth  day  the  number  of  corpuscles  and  the  quantity  of 
hemoglobin  have  practically  returned  to  normal. 

It  very  frecpijutly  happens,  however,  especially  among  the  poor  and  ill-fed, 
that  the  ])hysiological  changes  occurring  in  the  blood  during  pregnancv  not 
only  fail  to  disai)pear,  but  even  become  aggravated  under  the  strain  of  lac- 
tation, and  a  very  marked  anemia  appears.  This  impoverished  condition  of 
the  blood  is  especially  liable  to  occur  when  the  patient  is  the  subject  of  any 
wasting  or  depressing  disease,  such  as  phthisis,  chorea,  insanity,  or  when  at  the 
time  of,  or  subseciuent  to,  labor  hemorrhage  or  sepsis  has  occurred.  The 
anemia  in  such  cases  may  progress,  if  neglected,  to  a  pernicious  form.  Careful 
lilood-examinations  may  be  made  to  observe  the  effect  of  treatment,  which  is 
usually  efficient  if  not  too  long  neglected.  The  administration  of  iron  and  of 
arsenic  combined  with  hygienic  and  dietetic  treatment  should  be  kept  up  for  a 
long  period. 

.*?.  Diseases  of  the  TTrtxakv  Oiujaxs. 

Functional  disturbances  of  the  bladder,  such  as  inability  to  urinate  and 
uiinaiy  incontinence,  are  of  frequent  occurrence  after  labor,  and  are  some- 
times very  troublesome  affections,  especially  incontinence.  The  loss  of  power 
to  evacuate  the  bladder  may  be  due  to  tlie  inability  of  the  patient  to 
empty  the  bladder  while  lying  in  bed,  or  to  injury  of  the  urethra  and  the 
anterior  vaginal  wall,  the  resulting  edema  diiiiinishing  the  calibre  of  the 
urethra  and  making  its  course  tortuous.     Cases  of  the  latter  class  are  usually 

50 


1 


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•3 


J('.  ^ 


m^ 


786 


AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 


permanently  relieved  by  a  single  pas^sage  of  a  catheter,  which  straightens 
the  tortiions  canal,  and  when  infection  of  the  nrethra  and  bladder  does  nut 
occur  the  swelling  rapidly  subsides  and  there  is  no  further  diflficulty.  The 
diminution  of  intra-abdominal  pressure  and  the  relaxed  condition  of  tlio 
abdominal  walls  also  prevent  the  operation  of  this  pressure  and  the  action  ol" 
the  abdominal  walls  in  emptying  the  bladder;  and,  further,  it  is  asserted  that 
after  labor  the  bladder-walls  admit  of  greater  distention  by  accumulated  n\'\\u\ 
than  can  occur  during  pregnancy.  The  walls  are  thus  slower  to  contract  in 
response  to  the  stimulus  of  the  urine  in  the  bladder,  and  the  physiological 
increase  in  the  amount  of  urine  excreted  early  in  the  pueriwrium  soon  over- 
distends  the  organ.  The  dangers  of  over-distention  are  not  only  the  imme- 
diate injury  to  the  bladder — a  catarrhal  cystitis — but  a  further  and  great-r 
danger  lies  in  the  fact  that  the  bladder-tissues  are  thereby  rendered  loss 
capable  of  resisting  the  destructive  action  of  micro-organisms,  should  the 
latter  effect  an  entrance.  A  simple  catarrhal  cystitis  may  thus  be  converted 
into  a  serious  infective  cystitis.  The  means  to  be  employed  for  emptying  the 
bladder,  and  the  necessity  for  chemical  cleanliness  of  the  catheter  when  it  is 
used,  have  been  referred  to  (p.  660). 

Incontinence  of  urine  in  the  puerpera  is  often  the  incontinence  of  retention. 
The  contimial  dribbling,  however,  may  be  the  result  of  paresis  of  the  sphincter 
nnisde  from  prolongetl  labor  in  head  presentation,  or  it  may  result  from  fistuhu. 
'£\\Q  treatment  will  be  governed  by  the  cause.  Paresis  of  the  bladder-sphincter 
very  often  disaj)pears  s|M)ntaneously,  and  recovery  can  be  hastened  by  the  admin- 
istration of  tonics,  especially  strychnia,  and  by  applications  of  electricity  to  (lie 
base  of  the  bladder.  If  a  fistula  catmot  be  healed  by  stimulating  applications, 
such  as  nitric  acid  or  nitrate  of  silver,  a  plastic  operation  is  necessary  a  tew 
weeks  after  the  patient  leaves  her  bed. 

Cystitis  and  Pyelitis. — The  most  importiint  organic  affection  of  tiie  urin- 
ary organs  after  labor  is  cystitis.  This  disease  commoidy  is  mild  and  of 
short  duration,  but  it  may  be  a  very  grave  complication  when  it  is  due  to 
infection  of  the  bladder.  Some  cases  of  septic  cystitis  assume  a  most  malig- 
nant type. 

Etiolofiy. — A  simply  catarrhal  cystitis  is  frequently  observed  to  follow  injury 
to  the  bladder,  either  from  pressure  of  the  child's  head  or  from  over-distention 
of  the  bladder.  The  symi)toms  in  these  cases  usually  disappear  in  a  few  diiys, 
either  spontaneously  or  after  mild  treatment.  The  great  danger  ';f  the  disease 
is  an  added  infection,  for,  as  ])ointed  out  by  Bumm,  Dubelt,  Rovsing,  and  others, 
a  healthy  iminjured  bladder  car.  resist  the  action  of  micro-organisms;  when, 
on  the  contrary,  a  catarrhal  cystitis  is  present,  the  subsequent  introduction  oi' 
micro-organisms  rapidly  converts  the  catarrhal  into  a  suppurative  iuHainnia- 
tion,  which  may  .spread  along  the  urinary  tract  and  finally  involve  the  kidneys, 
producing  pyelitis,  pyelo-nephrosis,  or  nephritis.  Ascending  infection  of  the 
urinary  tract  usually  begins  in  the  bladder,  the  infecting  })oi.son  gaining  aeeess 
within  this  viscus  in  one  of  several  ways.  Commonly  the  catheter  carries  (lie 
infecting  agent  into  the  bladder,  either  itself  not  being  chemically  clean,  or,  it' 


%     i 


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PATIIOLOdY    OF    THE   PLEIiPKIU CM. 


•87 


n 


;h  straightens 
Ider  (loos  not 
fficulty.     The 
idition  of  tl\o 
I  the  action  of 
s  assertwl  that 
imuUitod  urine 
to  contract  in 
e  physiological 
mn  soon  over- 
)nly  the  inunc- 
cr  and  grcat-r 
'  rendered   less 
ns,   should   the 
us  be  convertt'd 
)!•  emptying  the 
leter  when  it  is 

nee  of  retention, 
of  the  sphincter 

suit  from  fistula;. 

daddcr-sphindcr 

edbytheadmin- 
olectricity  to  the 
ing  applications, 
necessary  a  i'cw 

[tion  of  the  urin- 

is  mild  and  of 

Ihen  it  is  due  to 

ne  a  most  nialig- 

[ito  follow  inj  my 
m  over-distent  ion 
ar  in  a  few  iluys, 
r(>i-  .  ;f  the  disease 
sing,  and  otlu'i's, 
■sranisms ;  whi'ii, 
introduction  ot 
Irative  inflainnui- 
olve  the  kidneys, 
infection  of  the 
)n  gaining  a(cess 
theter  carries  tin' 
ally  clean,  or,  it 


properly  sterilized,  but  improperly  introduced,  it  may,  at  the  time  of  its  intro- 
(hiction  into  the  bhidder,  become  contaminated  by  decomposing  lochia.  Escap- 
ing these  dangers,  there  is  yet  another  danger  of  carrying  into  the  bladder,  on 
the  catheter,  micro-organisms  commoidy  found  in  the  otiierwisc  normal  urethra. 
Garonsky,'^  Uovsing,'^'  and  otliers  have  shown  from  tiicir  investigations  that 
pathogenic  bacteria  are  commonly  found  in  the  urethra.  Exceptionallv  infec- 
tion of  the  bladder  may  occur  independent  of  the  use  of  the  catheter.  Recent 
cHuical  and  exi)crimental  studies  of  cystitis,  particularly  by  Dogen,  Clado, 
ITalle,  Albarran,  Kovsing,  ISIorelle,  Denys,  Schnitzler,  and  Krogius,  apparently 
prove  that  micro-organisms  located  in  any  of  the  pelvic  visc(>ra  may  find  their 
way  into  and  infect  the  bladder.  The  observations  of  Reymond  '^^  are  especially 
interesting.  In  two  cases  of  cystitis,  where  the  micro-organisms  in  the  uterus 
and  bladder  were  identical,  treatment  of  the  bladder  was  without  result,  but 
after  curetting  and  disinfecting  the  uterus  the  cystitis  rapidly  disai>peared.  In 
seven  other  cases  a  cure  of  long-standing  cystitis  followed  removal  of  the  dis- 
eased pelvic  organs.  His  four  experiments  upon  animals  showed  that  the 
introduction  of  bacteria  into  the  pelvis  outside  the  bladder-walls  gave  rise  to 
cystitis  with  the  micro-organisms  in  the  bladder,  and  not  in  the  blood-current 
of  the  pelvis.  In  Wreden's'^  experiments,  intestinal  micro-organisms,  or  those 
intentionally  placed  in  the  bowel,  were  found  in  the  bladder. 

Very  exceptionally  the  bladder  may  escape  serious  inflammation,  but  injury 
to  the  ureters,  with  sul)se(picnt  infection,  may  be  followed  by  inflammatory 
changes  in  the  pelvis  of  the  kidney  or  in  the  kidneys.      Labor  may  also  be 
followed  by  perinephritic  abscesses  due  either  to  infection  of  the  pelvic  connec- 
tive tissue,  and  extension  of  iuHammation  by  continuity  of  tissue,  or  to  infection 
from  rupture  of  a  kidney-abscess  into  the  surrounding  cellular  and  fatty  tissue. 
Dioffuosis. — The  symptoms  of  catarrhal  cy?  titis  in  a  pu(>rpera  are  the  ordi- 
nary symptoms  of  irritation  and  acute  inflanunation  of  the  bladder.     In  septic 
cases  the  early  sym]>toms  are  simi!:;'" ;  later  they  are  very  violent,  when  exfolia- 
tion of  the  mucous  mmub'Tiiic  or  ever  of  the  bladder-walls  may  occur,  and  occa- 
sion severe  tenesmus  or  retention  of   '  ine  by  obstructing  the  urethra.     Fever 
is  usually  moderate  so  long  as  the  inflammation  is  confined  to  the  bladder,  and 
gradually  ilisappears  after  from  three  to  six  days.     Should  this  gi'adual  defer- 
vescence br  followed  for  ten  days  or  two  weeks  by  an  almost  afebrile  cure,  and 
should  the  t.'Muperature  th(>n  rise  rapidly  to  a  ;v,pater  height  than  had  ])revi- 
ously  existed,  and  be  accompanied  by  pain  aid  tenderness  in  the  region  of  the 
kidney,  it  may  be  assumed  that  the  pelvis  oi  tlie  parenchyma  of  the  kidney 
lias  been  invaded.     When  the  teniperatnro  t'coui  the  b(>giimiiig  of  cystitis  is 
very  high — above  103° — rapid  infection  o    the  kidneys  has  likely  occurred. 
Examina  ion  of  the  urine  will  also  help  to  deter'. line  the  extent  of  the 
inflammation  by  the  presence  ol'      i.-  ge  amount  of  albumin,  of  renal  ei»tlie- 
limii,  and  of  easts;  and  bacter';  logical  examination  of  the  urine  will  be  of 
iiirther  assistance  in  recognizi'<!>;  tl:  vo  very  rare  inst;mccs  of  infi-ction  of  the 
urinary  tract  unaccompan'vd  bv  pc'iiiont  urine  and  without  marke  '  bladder 
symptoms. 


I  ' 


^.'  . 


_i> : ■ 


in 


788 


AMEltlCAN    TEXT-BOOK   OF   OBSTETRICS. 


'U' 


Tlie  time  required  for  the  spread  of  the  inflammation  from  the  bladder  or 
adjat'oiit  striietures  along  the  ureters  to  the  kidneys  varies.  The  usual  time  is 
about  ten  tlays  or  two  weeks  after  the  appearanee  of  a  very  mild  or  severe 
cystitis.  It  ean,  however,  in  rare  eases  oeeur  almost  from  the  outset,  before 
or  coineident  with  marked  bladder-symptoms  and  in  srme  cases  pyelitis, 
pyclo-nephrosis,  or  nephritis  becomes  apparent  oidy  after  a  long-standing  and 
persistent  cystitis  or  ureteritis. 

I-'ro(/uuiiix. — The  danger  of  cystitis  occurring  after  labor  depends  largelv 
upon  the  promptness  and  the  care  exercised  in  treatment.  Neglected  cases  with 
ulceration  and  exfoliation  of  the  bladder  will  have  a  mortality  of  38  per  cent., 
and  of  those  who  recover  greater  or  less  permanent  damage  is  done  to  the 
urinary  organs,  from  which  damage  the  patient  may  ultimately  die.  Pyelitis 
persisting  for  months  is  a  not  unconnnon  sequel. 

Treatment. — Prevention  is  of  first  importance.  Catheterization  should  nut 
be  resorted  tt)  uidess  all  other  means  to  secure  urination  fail,  such  as  ro})eatedly 
placing  under  the  patient  a  bed-pan  filled  with  hot  water  ;  the  sound  of  •.  niiDiii!^' 
water;  assisting  the  patient  into  an  upright  position  upon  her  knf:es,  an(i  [  vs- 
sure  over  the  bladder.  While  avoiding  the  catheter,  however,  ihe  dai  ger  ')f 
ovcr-distention  must  not  be  forgotten,  and  the  catheter  must  be  used,  if  other 
means  have  failed,  at  intervals  of  at  least  twelve  hours,  but  always  with  strict- 
est antiseptic  care.  At  the  earliest  appearance  of  cystitis  the  bladder  should 
carefully  be  irrigated  every  four  hours  through  a  two-way  catheter  with  a  ^ 
per  cent,  creolin  solution,  or,  if  this  causes  much  pain,  a  solution  of  boric  acid 
(gr.  XV  to  fl5j)  may  be  substituted.  Warm  applications  over  the  bladder  and 
diluent  drinks  are  also  to  be  used.  Five-  or  ten-grain  dosct  of  salol  three  times 
a  day  will  be  of  service  so  long  as  the  parenchyma  of  the  kidneys  is  n^t 
invaded.  When  constant  dribbling  from  the  bladder  is  replaced  by  retention 
of  urine,  occlusion  of  tiie  urethra  by  an  exfoliated  portion  of  the  bladiler 
shoukl  be  suspected,  and  the  separated  portion  shoidd  be  removed,  dilating 
the  urethra  for  this  purpose  if  necessary.  Large  doses  of  iron,  iidudations 
of  oxygen,  and  the  free  use  of  stimulants  constitute  the  general  treatment  en 
which  most  reliance  can  be  placed  when  the  patient  is  profoundly  septic. 

The  treatment  of  pi/clifiH  following  labor  will  depend  upon  the  chaniet(  r 
of  the  disease.  In  mild  cases  it  may  be  sufticient  to  obtain  drainage  by  uw 
administration  of  diuretics  that  act  niechaiucallv,  such  as  large  drausj-ht  nf 
water,  and  to  attempt  disinfection  of  the  urinary  tract  by  the  administnitidn 
of  salol  or  boric  acid  in  doses  of  5  or  10  grains  every  four  hours.  For  sub- 
acute or  chronic  cases  alterative  and  stimulating  diuretics  will  be  u.seful.  ( 'uses 
that  do  not  respond  promptly  to  these  milder  measures  .shoidd  be  treateu  'v 
surgical  means  to  obtain  free  drainage.  When  a  distinct  collection  of  j-i  i 
the  region  of  the  kidney  is  detected  by  palpation,  the  most  efficient  trcatin-  n' 
is  incision  in  the  loin  and  the  introduction  of  a  drainage-tid)e,  which  siiould 
be  removed  when  disappearance  of  the  purident  dis'.'havgc  and  shrinkage  nf 
the  cavity  indicu  ■•  that  active  inflannnation  I::'  .sulisidrd.  When  palpation 
fails  to  detect  swelling  in  the  region  of  the  kidney,  waeu  ii.ei'e  is  doubt  as  to 


PATHOLOGY   OF    THE   I'i'EnPERlVM. 


789 


:lie  bladilor  or 
2  usual  time  is 
mild  or  sevorc 
:  outset,  before 
cases  pyelitis, 
g-staudiug  and 

lepends  largely 
eeted  cases  with 
of  38  per  cent., 
is  done  to  the 
y  die.     Pyelitis 

ition  should  not 
ch  as  ropentcdly 
ound  of  iunniu!: 
knees,  ant*.  ^  'is- 
•,  ihe  duiiger  'if 
be  used, if  other 
ways  with  strict- 
•  bladder  should 
■athetcr  with  a  .\ 
iun  of  boric  acid 
■  the  bladder  ami 
I  salol  three  times 
kidneys  is  not 
iced  by  retention 
of  tlie  bladder 
removctl,  dilating 
iron,  inhalations 
•al  treatment  rn 
iidly  septic. 
)on  the  character 
drainage  by  tiic 
[U'ge  draught    ot 
10  adndnistration 
lours.     For  sub- 
be  useful.    Cases 
uld  be  treated  '  v 
lection  of  I'l'    'I 
ffieient  treatiu'  »' 
be,  which  sliould 
ind  shrinkage  nt 
When  palpal i'lu 
n'e  is  di)ul)t  as  to 


which  kidney  is  affected,  or  especially  when  vaginal  examination  finds  a  thick- 
ened, tender  ureter,  catheterization  of  the  luvters  will  be  useful  for  both  diag- 
nosis and  treatment.  Jiy  means  of  the  ureteral  catheter  and  an  aspirating 
syringe  tiie  pus  should  be  drawn  from  tlie  pelvis  of  the  kidney  at  intervals 
of  a  few  days,  the  quantity  withdrawn  should  be  noted,  and  the  same  quan- 
tity of  a  weak  antiseptic  solution  should  repeatedly  be  forced  throu*di  the 
catheter  and  withdrawn.  Tlie  treatment  by  incision  in  the  loin  is  less  tedious, 
and  does  not  require  the  special  appliances  and  skill  necessary  for  catheteriza- 
tion of  the  ureters;  moreover,  should  the  fever  and  the  albuminous  and  puru- 
lent urine  be  due  to  small  multiiile  abscesses  in  the  parenchyma  of  the  kid- 
ney, the  opening  in  the  loin  is  more  favorable  for  diagnosis  and  treatment. 

Albuminuria. — Albumin  is  very  frequently  found  in  the  urine  during  the 
first  forty-eight  hours  of  the  jiuerperium,  its  occurrence  at  this  time  being 
considered  jihysiological.  Trautenroth  '**  asserts  that  during  labor  albuminuria 
is  the  rule,  its  absence  the  exception,  and  that  in  from  one-fourth  to  one-third 
of  the  cases  casts  are  present.  Both  casts  and  albiunin  promptly  disappear 
early  in  the  puerperium,  and  their  presence  after  the  first  week  usually  means 
catarrh  of  the  urinary  tract  or  more  serious  disease. 

Etiology. — Various  explanations  have  been  offered  for  the  occurrence  of 
albuminuria  at  a  later  period  of  the  puerperium.  The  most  plausible  theory 
is  that  in  cases  apparently  passing  through  a  physiological  jtuerjieral  period 
the  presence  of  albumin  in  small  quantity  indicates  a  continuation  of  the 
kidney  condition  which  was  }n*esent  diu-ing  the  latter  months  of  pregnancy. 
To  those  who  consider  the  kidney  of  pregnancy  due  to  the  excessive  amoiuit 
of  work  thrown  upo:i  the  kitlneys  throughout  the  jteriod  of  gestation,  the 
similar  demands  upon  tlie  excretory  organs  during  the  lying-in  period  readily 
explain  the  continuance  of  small  amounts  of  I'bumin  in  the  urine  of  the 
puerpera.  The  frequency  of  albuminuria  duo  to  a  continuation  of  the 
kidney  of  pregnancy  has  frequently  been  demonstrated  by  autojjsy,  the  kid- 
neys presenting  the  same  condition  of  anemia  without  inflammatory  changes. 
Albuminuria  in  the  jiucrperium  is  very  often  a  concomitant  symptom  of 
infi'ction  arising  from  the  genitalia.  There  may  be  either  a  simple  catarrhal 
inflammation,  or,  when  infection  is  at  its  height,  true  parenchynuitous  nephritis 
may  be  present,  caused  by  the  excu'etion  of  micro-organisms  or  tiieir  toxins, 
tile  toxins  acting  upon  the  tissue  of  the  kidney  practically  as  mineral  poisons. 
In  even  more  advanced  cases  of  puerperal  sejisis  metastatic  abscesses  in  the 
kidneys  may  occur.  It  has  been  asserted  that  the  albuminuria  increases  and 
(lindnishes  with  the  pelvic  lesions  of  septic  infection.  Sircdey  considers  puer- 
peral nephritis  a  constant  complication  of  puerperal  uterine  jihlebitisor  lymph- 
angitis. The  author  has  observed  nephritis  with  albmninuria  and  casts  develoii 
on  the  fourteenth  day  of  the  puerperium  in  a  jiatient  with  a  very  virulent 
mammary  abscess. 

The  prognosk  of  puerperal  albuminuria  is  determined  by  the  cause.  AVhen 
due  t(»  the  persistence  of  the  kidney  of  pregiuincy,  the  small  amoiuit  of  albu- 
min slowly  but  completely  disappears.     The  symptoms  of  the  kidney-lesion  in 


m'\ 


790 


AMERICAN   TEXT-BOOK    OF   OBSTETltlCS. 


*,      > 


?1  Iq 

I   •:'*       1;'   , 


I    \i\ 


septic  cases  are  usually  obscure,  and  are  often  overshadowed  by,  and  disappear 
more  slowly  than,  the  uterine  symptoms.  The  possibility  of  thus  expluiniii<r 
the  very  rare  occurrence  of  eclampsia  so  late  as  two  weeks  or  longer  after  labor 
should  not  be  forgotten.  Whether  the  kidney  disease  persists  in  kidneys  pre- 
viously normal  is  also  determined  by  the  cause  and  by  the  extent  of  injury 
done  to  the  tissues  of  these  organs.  The  occurrence  of  albuminuritic  retinitis 
and  blindness  in  the  puerporium  would  indicate  an  old  nephritis  antedatini; 
the  pregnancy.  It  should  be  remembered,  however,  that  loss  of  vision  may 
occur  after  labor  wholly  independent  of  kidney  disease.  Very  rarely  tempo- 
rary blindness  may  occur  from  vaso-motor  disturbance  of  the  vessels  of  tlio 
retina.  The  loss  of  vision  may  also  follow  severe  hemorrhage,  and  permanent 
blindness  may  result  from  septic  panophthalmitis. 

Hemai  Tia. — Bloody  urine  is  sometimes  observed  soon  after  labor.  Serious 
contusior  >  i\(^  bladder  during  labor,  either  by  the  child's  head  or  by  forceps, 
will  occasij'  <e  followed  by  this  symptom.     Ordinarily  the  blood  in  tiio 

urine  is  due  to  o  persistence  of  vesical  hemorrhoids  which  developed  duriiio; 
pregnancy.  The  differential  diagnosis  is  made  by  the  history.  The  hemor- 
rhoidal condition,  as  a  rule,  disappears  spontaneously  and  usually  requires  wo 
treatment,  although  exceptionally  it  may  be  necessary  to  employ  astringent  in- 
jections into  the  bladder.  When  bloody  urine  from  injury  to  the  bladder  is 
present,  especial  antiseptic  care  should  be  observed  should  the  use  of  the 
catheter  be  required.  The  possibility  of  the  occurrence  of  fistulae  should  not 
be  overlooked. 

4.  Diseases  of  the  Nervous  System. 

Cerebral  Hemorrhage  and  Embolism  in  the  Puerperium. — Intra- 
cranial accidents  so  serious  as  hemorrhage  or  embolism  are  fortunately  very 
rare,  and  often  are  only  incidental  complications  of  the  puerperium.  A  woman 
predisposed  to  cerebral  hemorrhage  would  a  priori  be  more  likely  to  bo 
stricken  with  this  accident  either  during  pregnancy  or  at  the  time  of  labor. 
Throughout  the  period  of  gestation  the  changes  in  the  blood,  the  physiological 
hypertrophy  of  the  heart,  and  the  accelerated  destructive  changes  of  any  pre- 
existing kidney-lesion  all  combine  to  offer  a  favorable  opportunity  for  cerebral 
apoplexy.  Or,  having  passed  through  pregnancy  safely,  the  physical  strain  of 
labor  would  tax  to  their  utmost  the  cerebral  blood-vessels.  Hemiplegi'^  after 
an  eclamptic  attack  is  a  fiuniliar  illustration  of  diseased  blood-vessels  givintr 
way  under  sudden  and  extraordinary  pressure.  In  the  puerperium,  on  the 
contrary,  the  circulation  at  once  becomes  more  quiet,  arterial  tension  decrease*, 
and  the  danger  of  cerebral  apoplexy  correspondingly  diminishes.  This  explan- 
ation of  the  relative  frequency  of  apoplexy  occurring  during  the  child-bearing 
period  is  borne  out  by  statistics. 

The  increased  relative  frequency  of  cerebral  embolism  in  the  puerperiiun  is 
to  be  found  in  the  fact  that  sepsis,  either  as  endocarditis  or  as  phlebitis,  is  a 
factor  of  great  importance  in  the  etiology  of  cerebral  embolism  in  ]>uerperie. 

The  clinical  features  and  prognosis  of  cerebral  hemorrhage  are  in  uorespdt 


If 


PATTTOLOnY   OF    riTE  rrEliPEUHM. 


791 


^ 


md  disappear 
LIS  explain inii; 
Tcr  after  labm- 
kidneys  pre- 
tent  of  injury 
luritic  retinitis 
lis  antedatini: 
i)f  vision  may 
rarely  tempo- 
vessels  of  tlie 
ind  permanent 

labor.     Serious 
I  or  by  forceps, 
e  blood  in  the 
iveloped  duriuji 
.     The  liemor- 
dly  requires  no 
y  astringent  iu- 
0  the  bladder  is 
the  use   of  the 
tulJB  should  not 


lerium. — Intra- 
fortuuately  vory 
lium,    A  woman 
Ire   likely  to  be 
time  of  labor. 
|he  physiological 
iges  of  any  prc- 
lity  for  cerel)ral 
liysical  strain  of 
^emiplegi'^  after 
■vessels  givini: 
terium,  on  tlic 
msion  deoroasi"*, 
;.    This  explaii- 
lie  child-beariiit!; 


le  puerperium  is 
|s  phlebitis,  is  ii 

in  puerpera'. 
Ivre  in  no  resptct 


different  from  the  disease  as  it  appears  apart  from  child-bearing,  and  therefore 
need  no  further  consideration  here  beyond  the  statement  that  a  paralyzed  preg- 
nant woman  can  pass  through  her  labor  without  her  uterus  sharing  this  loss  of 
power. 

Cerebral  embolism  also  has  the  sjime  clinical  manifestations  in  the  puerpera 
as  in  others,  its  symptoms  depending  upon  the  size  and  distribution  of  the 
vessel  involved,  hemii)legia,  monoplegia,  or  aphasia  developing  according  to 
the  trunk  or  branch  of  the  vessel  receiving  the  embolus.  It  should  be  borne 
in  mind  that  paralysis  in  a  pregnant  or  puerperal  patient  is  sometimes,  although 
rarely,  hysterical,  and  a  critical  diagnosis  should  therefore  always  eliminate 
hysteria.  Within  a  year  the  writer  lias  seen  a  case  of  hysterical  aphonia  in  a 
pregnant  woman  whose  mother  was  similarly  affected.  Immediately  after  laljor 
the  difficulty  at  once  disappeared.  It  is  suggestive,  as  I^loj'd  remarks,'"  that  a 
large  proportion  of  reported  cases  of  paralysis  in  pregnant  women  appear  to 
be  cases  of  aphasia.  The  diagnosis  of  hysterical  paralysis  is  usually  not  diffi- 
cult when  the  inconsis^tency  of  some  of  the  physical  signs  and  the  characteristic 
mental  and  moral  symptoms  are  recognized.  Hemianesthesia,  more  or  less 
involvement  of  the  special  senses,  the  loss  of  voice  rather  than  the  inability  to 
use  words  properly  or  to  comprehend  them,  the  presence  in  only  slight  degree 
of  exaggerated  knee-jerk  and  contractures,  the  absence  generally  of  marked 
involvement  of  the  face,  of  ankle-clonus,  and  of  bed-sores,  will  at  once  arouse 
suspicion  of  the  hysterical  origin  of  the  disease. 

Neural  and  Spinal  Aflfections  Following'  Labor. — Various  forms  of 
l)aralysis  are  sometimes  observed  to  follow  labt»r.  Frequently  a  transient  loss 
of  power  in  one  of  the  lower  extremities  either  is  overlooked  or  is  attributed 
to  rheumatism  or  to  unimportant  pressure  on  a  nerve-trunk ;  the  inconve- 
nience, it  is  thought,  will  soon  disappear,  and  no  further  attention  or  treat- 
ment is  directed  to  a  condition  that  is  by  no  means  trifling,  and  one  that  in 
some  cases  proves  a  most  disastrous  sequel  to  childbirth. 

The  etiology  of  neural  affections  following  labor  may  be  grouped  conveni- 
ently in  two  general  classes :  {a)  Nerve-injuries  due  to  pressiu-e  by  the  child's 
head  or  by  forceps ;  (6)  Disease  of  the  nerves  due  to  septic  infection. 

Of  the  first  class,  there  is  a  type  of  cases,  due  to  slight  injury,  with  only 
l)artial  and  temporary  loss  of  power  accomijanied  by  some  pain  and  discomfort, 
all  of  which  symptoms  disappear  before  the  ])atieut  leaves  her  bed,  the  enforced 
rest  t)f  the  puerperium  being  sufficient  for  nature's  recuperative  power  to  effect 
a  complete  cure.    This  grade  of  injury  is  of  not  very  great  clinical  importance. 

A  very  important  nerve-injury  following  labor  is  one  producing  paralysis 
from  traumatism  of  the  sacral  or  hunbar  plexus,  this  type  of  paralysis,  as  pointed 
out  by  Mills'^®  and  by  Hiinermann,'^  being  usually  peroneal,  and  conunonly 
associated  with  severe  neuritis.  The  great  frequency  of  involvement  of  tiie 
peroneal  nerve  is  explained  by  tlie  anatomical  situation  of  its  origin.  Tlie 
roots  of  the  sacral  plexus  lie  upon  a  cushion  of  muscle,  but  the  lumbo-sacral 
nerve,  arising  from  a  portion  of  the  fourth  and  from  the  fifth  hunbar  nerve, 
soon  passes  over  the  bony  pelvic  wall  at  the  liuea  innominata,  where  it  is 


i 


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m 


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■i     f 


792 


AMERICAN    TEXT- BOOK   OF   OBSTETRICS. 


exposed  to  injury  by  the  cliild's  licnd  (Miloring  the  ])elvic  inlet.  Tiiis  liiniho- 
sacral  nerve  is  maiidy  the  root  for  the  peroneal  nerve,  and  clinically  it  iins 
been  found  that  the  paralysis  of  motion  due  to  trauniatisin  during  labor  is 
often  a  loss  of  power  of  the  muscles  supplied  by  this  nerve.  In  other  words, 
the  type  of  paralysis  in  these  cases  is  commonly  an  inability  to  dorsal-flex  the 
foot,  extend  the  toes,  and  evert  and  rotate  the  foot  outward.  Sometimes  there 
is  also  inability  to  rotate  the  thigh  inward  and  draw  it  forward — movements 
controlled  by  the  superior  gluteal  nerve.  This  additional  loss  of  power  will  lie 
understood  when  it  is  remembered  that  the  superior  gluteal  nerve  arises  from 
the  posterior  part  of  the  hnnbo-sacral  cord,  and  is  therefore  sometimes  atfecldl 
coinciidently  with  the  lumbo-sacral  cord  or  is  secondarily  involved  by  the  sjjread 
of  inflammation.  In  other  cases  the  loss  of  power  Ix^eomes  more  general,  the 
inflammation  in  the  nerves  extending  throughout  the  entire  extremity,  and 
even  to  the  other  limb,  or  along  the  nerve-trunks  to  the  cord,  attacking  the 
ganglion-cells  of  the  cord,  with  the  development  of  trophic  changes. 

The  class  of  cases  most  likely  to  be  followed  by  serious  nerve-injuries  from 
pressure  are  usually  cases  of  jjelvic  deformity,  in  which  the  injury  is  produced 
by  direct  pressure  of  the  child's  head.  Ilimermami  has  shown  that  injuries 
jiiore  f;e(  len'.y  follow  labor  delayed  by  a  generally-contracted  pelvis.  In  the 
simple  flat  and  flat  rachitic  pelves  then  is  more  space  in  the  oblicjue  diameters, 
and  the  nerve-truidv  is  thus  less  exposed  to  pressure,  the  jn'ominent  ])romontorv 
of  the  sacrum  giving  the  pelvic  inlet  a  j)ronounced  cordiform  shape,  the  hollow 
or  bay  to  the  sides  of  the  j)romontory  ofl'ering  greater  protection  to  the  iierve- 
truidvs.  Exceptionally  these  injuries  may  Ibllow  labor  when  the  pelvis  is 
normal,  but  the  j)resentation  is  abnormal — as  a  face  or  a  brow  ])rescntation — 
the  abnormal  prepentatii>n  offering  larger  diameters  and  thereby  increasing  the 
area  of  pressure.  Nerve-injuries  are  also  sometimes  to  be  attributed  to  forceps. 
On  the  one  hand,  failure  to  use  the  instrument  in  ])roper  cases  when  labor  luis 
been  unduly  j)rolonged,  and  on  the  other  hand  pivssure  upon  the  nerve-trunks 
during  extraction  or  by  pendidum  movement  of  the  blades,  are  factors  in  the 
])roduction  of  the  injury  to  the  nerve  that  sometimes  follows  a  difficult  forceps 
delivery.  It  is  usually  not  easy  to  determine  which  is  more  to  be  blamed  lor 
the  injury  received — the  child's  head  or  the  forceps.  To  assist  in  determining 
this  question  Mills  "^*  has  called  attention  to  an  important  fact — namely,  that 
the  ])ressnre  caused  by  forceps  is  more  often  followed  by  injuries  of  the  second 
and  third,  and  even  lower,  sacral  nerves,  and  therefore  the  mus(;les  supplied 
by  the  internal  popliteal — the  posterior  muscles  of  the  calf — are  paralyzed, 
rather  than  the  muscles  supplied  by  the  jieroninil  nerve. 

Neuritis  due  to  septic  infection  may  manifest  itself  in  protean  types,  just  as 
is  observed  in  neuritis  due  to  any  toxic  agent:  it  may  be  multiple  or  diilused, 
or  a  single  nerve  may  be  involved;  it  may  be  partly  or  vhieHy  in  the  upper  ex- 
tremities. When  the  upper  extremities  are  affected,  the  terminal  branches  of 
the  median  or  ulnar  nerves,  or  of  both,  are  commonly  involved,  and  both 
motor  and  sensory  fibres  are  affected.  In  a  case  recorded  by  !^^(■)l)ius,""'  in  which 
the  neuritis  attackeil  the  legs  as  well  as  the  arms,  the  tendon-reflexes  were 


rios  of  the  ^cooitd 


■tin  types,  just  as 


in  tlio  upper  ex- 

linal  bnuiolies  of 

lived,  aiul  b'li'i 


lion-reflexes  wi  re 


I'Ar/ioLor.v  OF  the  prERpKiin :,r. 


793 


aetivc,  tlie  interosseous  muscles  were  atropliiwl,  and  both  liaixls  were  the  soat 
of  a  burning,  priek in jr  sensation.  The  cranial  nerves  were  not  aifected.  Fever 
and  other  signs  of  infection  were  present.  Not  infrecjueiitly  the  predisposing 
causes  of  neuritis  under  other  circumstances,  such  as  alcoholism,  svphilis,  and 
exhaustion,  are  jn-edisposing  factors  in  the  development  of  se])tic  neuritis  fol- 
lowing childbirth.  The  lowered  vitality  and  the  depres,> ..  nei'vous  force  of 
the  puerpera  render  her  nervous  system  an  easy  avenue  for  the  inroads  of 
sepsis. 

The  symptoms  of  septic  multiple,  diffused,  or  isolated  neuritis  are  not  dif- 
ferent from  the  symptoms  of  neuritis  from  other  causes.  Pain,  hyjieresthesia, 
paresthesia,  and  paralysis  or  pseudo-paralysis  are  commonly  ])resent.  Soine- 
tiines  there  is  anesthesia,  and  often  there  are  changes  in  the  reflexes  with 
cramps  and  contractures.  Atrophies  and  the  reactions  of  degeneration  are 
occasionally  present. 

As  a  means  of  differentiating  traumatic  from  septic  cases  ii  is  noteworthv 
that  the  symjitoms  of  sejitic;  cases  usually  appear  in  il.  >  first,  second,  or  third 
week  after  labor,  although  they  may  occnir  earlier  or  later. 

A  form  of  neuritis  following  labor,  of  considerable  importance  and  involving 
])rimarily  the  nerves  in  the  pelvis,  is  that  sometimes  recognized  by  the  gyne- 
cologist a  long  time,  it  may  be,  after  a  labor  that  was  followed  by  traumatism 
or  by  mild  infection.  In  such  cases  there  has  been  left  in  the  jx'lvis  inflam- 
matory exudate  in  which  a  nerve-trunk  or  nerve-filaments  are  iiid)edded  ;  bv 
reason  of  either  the  spread  of  infection  to  the  nerve-slu'uhs  or  the  constant 
]»iessure  of  the  exudate  and  the  displaced  pelvic  viscera  more  or  less  pelvi<! 
pain  and  even  loss  of  power  are  produced. 

Neuritis  and  paresis  of  septic  origin  are  not  infre(piently  associated  with 
septic  phlebitis.  The  intense  pain  and  the  loss  of  power  sometimes  observed 
to  accompany  and  to  be  a  sequel  of  ])hleginasia  alba  dolens  have  been  consid- 
ered due  to  the  accompanying  neuritis.  The  occurrence  of  gangrene  in 
])hlegmasia  has  also  been  attributed  in  part  to  neurotro])hic  changes,  and  has 
i)eon  thought  to  be  not  wholly  the  result  of  an  occluded  circulation.  Septic 
myelitis  has  been  observed  to  complicate  or  follow  jihlegmasia  and  to  give  rise 
to  a  ])arai)legia.  Paralysis  of  a  greater  or  lesser  degree  following  phlegmasia 
has  been  recorded  by  Mtuiriceau,  Boer,  Casper,  an<l  (Jittermann  (quoted  by 
Winckel). 

When  the  spinal  cord  is  attacked  by  the  ravages  of  general  septic  infection, 
tlie  clinical  and  ])athological  evidences  of  the  myelitis  commonly  shv  w  very 
numerous  and  disseminated  foci  of  infection. 

Paralysis  of  reflex  and  hysterical  origin  in  the  pnerperiiuu  has  been 
described  by  most  authors.  Ikrnes  refers  to  the  shock  of  lal)or,  exhausting 
the  spinal  centres,  as  a  cause  of  reflex  ])aralysis,  and  (piotes  nrown-Seciuard's 
belief  that  retroversion  may  also  cause  reflex  paraplegia.  It  is  probable  that 
many  of  the  cases  thought  to  be  reflex  are  in  reality  due  to  the  extension  of  the 
iiifliunmation  to  the  cord  or  are  to  be  attributed  to  sepsis,  the  toxic  agent  reach- 
ing the  nerve-centres  and  nerve-tracts  through  the  circulation. 


•    '''If 

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794 


A3IERICAN   TEXT-BOOK   OF   OBSTETRICS. 


Altliongh  liysterioul  paralysis  may  readily  occur  in  a  puerpera,  the  profound 
norve-changes  throughout  pregnancy  and  in  the  puerperitim  being  sufficient  t(i 
awaken  functional  disturbances  in  individuals  previously  predisposed  tonervou> 
disorders,  it  should  never  be  forgotten  that  organic  disease  may  be  present,  and 
that  a  careful  and  scrutinizing  examination  may  bring  to  light  something  more 
than  hysteria. 

Treatment. — Rest  in  bed  is  of  the  greatest  importance  in  the  treatment  of 
neural  affections  following  labor,  when,  as  is  frequently  the  case,  a  greater  or 
lesser  degree  of  neuritis  accompanies  the  loss  of  power.  The  pain  should  first 
be  relieved  by  the  appropriate  treatment  for  neuritis — absolute  i*est,  alternat(> 
hot  and  cold  applications,  ointments  of  mercury  and  atropin,  the  interiiiil 
administration  of  sodium  salicylate  or  salol ;  the  further  relief  of  pain  by 
phenacetin  or,  if  necessary,  by  opium.  Later,  the  iodids,  and,  after  the  pain 
has  been  relieved  entirely,  active  electrical  treatment  and  massage,  should  bo 
employed.  Pelvic  inflammation  should  be  treated  systematically  over  a  suffi- 
ciently long  period  in  intrapelvic  cases.  In  all  cases  appropriate  general  treat- 
ment, including  strychnia  and  quiniu,  must  not  be  neglected. 

Insanity  in  the  Child-beariner  Woman. — Frequency. — The  statistics  of 
asylums  in  which  mental  derangements  have  l)een  classified  as  following  repro- 
duction show  considerable  variation,  due  to  a  diversity  of  factors,  such  as 
nationality,  social  condition,  reliability  of  history,  etc.,  that  cannot  be  analyzed 
here.  It  is  sufficient  to  say  that  in  from  8  to  10  per  cent,  of  all  insane  females 
the  disease  develojied  in  the  child-bearing  process,  and  that,  on  an  average, 
one  woman  of  four  hundred  confined  becomes  insane.  The  disease  declares 
itself  most  frequently  in  the  puerperium,  usually  within  the  first  two  weeks 
(Esquirol  66  j)cr  cent.,  Toulouse  75  per  cent.,  within  the  first  ten  days),  and  in 
many  cases  prodromic  symptoms  have  been  present  at  some  time  during  ])ivg- 
nancy.  Next  in  frequency  is  the  ]>eriod  of  lactation,  at  any  time  of  wliich 
period  insanity  may  appear,  although  it  is  usually  manifested  ton-ard  the  latter 
half.  The  insanity  of  lactation  is  more  common  in  raultiparfe.  The  insanity 
of  pregnancy,  the  least  frequent  of  all,  usually  begins  after  the  fourth  month, 
and  is  of  about  equal  frequency  in  multiparje  and  in  primiparae. 

Ettoloffi/. — It  is  customary  to  classify  the  causes  of  insanity  in  its  relation 
to  reproduction  as  predisposing  and  exciting,  and  very  many  conditions  have 
been  arrayed  as  belonging  either  to  the  one  or  the  other  class.  It  should  he 
borne  in  mind  that  in  each  individual  case  many  factors  are  indissolubly  asso- 
ciated, the  patient's  mental  break-dowu  being  the  resultant  of  several  complex 
conditions,  each  reacting  upon  and  intensifying  the  other". 

Of  predisposing  elements  common  to  the  three  varieties  of  alienation  under 
consideration,  the  most  important  is  hereditary  predisposition,  which  is  funnd 
in  from  25  to  30  per  cent.  Since  this  is  about  the  proportion  found  in  insanity 
generally,  it  is  evident  that  heredity  is  not  of  greater  importance  in  the 
puerperal  forms  ;  indeed,  some  statistics  show  it  to  be  of  less  importance.  Of 
importance  also  are  other  neuroses,  such  as  chorea,  epilepsy,  and  hysteria.  Alco- 
holism and  the  pre-existence  of  insanity  are  also  frequently  predisposing  facturs. 


PATIIOLOay   OF    THE   PrKRPERH'M. 


795 


.V  woman  with  an  iiiistuMe  ntTvous  py.stcm  from  any  canse  is  haiulicapiiocl  in 
her  passage  tlu'ongh  the  nerve-exaltations  and  storms  that  await  her  tlirough- 
oiit  the  eonrse  of  pregi'-.-ncv,  lahor,  and  laetation.  Individnal  inhibitory 
power  will  have  much  to  do  with  the  Hnal  issue,  and  if  this  power  is  not 
sufficient  tf)  withstand  the  varied  determining  factors  of  mental  disease,  insanity 
is  to  be  expected. 

During  pregnancy  the  most  important  exciting  cause  is  probably  tox- 
emia, y  which  is  meant  a  condition  of  the  blood  st»  surcharged  with  and 
changetl  by  toxic  organic  principles,  the  result  of  faulty  metabolism  and  ex- 
cretion, as  to  render  the  bhxtd  incapable  of  proper  nutrition.  In  the  pathol- 
ogy of  pregnancy  the  great  importance  of  tliese  changes  has  been  insisted 
upon  (see  ]).  202).  The  effect  o*"  faulty  elimination  of  secretions  altered  in 
<|iiality  and  quantity  plays  an  important  rC)lc  in  the  production  of  the  unsta- 
l)le  nervous  system  of  pregnant  women,  and  we  are  not,  tlierefore,  surprised 
almost  invariably  to  find,  i)receding  an  outbreak  of  insanity,  constipation,  inca- 
pacity of  the  liver  to  perform  the  work  thrust  upon  it,  and  failure  of  the  skin 
and  the  kidneys,  with  or  without  albumiimria,  all  of  which  certainly  can  and 
do  induce  faulty  nutrition  of  the  brain.  Of  less  importance,  but  contributory 
more  especially  to  the  insanity  of  pregnancy,  are  moral  factors,  such  as  mental 
anxiety  from  domestic  worry,  desertion,  or  seduction.  The  exciting  causes  of 
insanity  in  the  puerperal  period  have  variously  been  stated  to  be  sepsis,  anemia, 
dystocia,  post-partum  hemorrhage,  eclampsia,  great  exhaustion,  and  profound 
emotion,  and  in  individual  cases  one  or  more  of  these  causes  is  usually  discov- 
erable. The  employment  of  instruments  and  anesthetics  during  labor  has  not 
been  included  as  a  cause,  for  the  reason  that  their  more  general  employment 
without  a  proportionate  increase  in  mental  derangements,  and  their  capacity  to 
relieve  the  suffering  which  otherwise  must  react  unfavorably  upon  the  individ- 
ual's nervous  force,  seem  sufficiently  plain  to  consider  them  prophylactic  rather 
than  exciting  factors. 

The  relative  importance  of  the  causes  just  enumerated  is  difficult  to  deter- 
mine, a  study  of  statistics  furnishing  but  little  light  on  the  subject.  The 
opinions  of  various  authors  are  apt  to  reflect  the  class  of  cases  they  have  indi- 
vidually seen,  and  as  insanity,  after  all,  is  not  so  very  frequent,  an  individ- 
ual's experience  must  be  too  small  to  warrant  general  conclusions.  In  recent 
years,  however,  the  conviction  has  steadily  been  growing  that  sepsis  bears  a 
f:u*  more  frequent  and  important  relation  to  the  insanity  of  the  child-bearing 
woman  than  has  hitherto  been  thought.  This  statement,  if  true,  is  of  greater 
significance  to,  and  calls  for  closer  attention  on  the  part  of,  obstetricians  than 
alienists,  since  to  the  former  the  immediate  or  remote  results  of  infwition  must 
aud  should  always  have  a  deeper  interest.  If  the  toxemia  of  pregnancy  is, 
as  it  appears  to  be,  an  important  element  in  the  insanity  of  pregnancy,  how 
much  greater  ^vill  be  the  tendency  of  an  unstable  nervous  system  to  lose  its 
equilibrium  when,  overtaxed  by  faulty  excretion  during  pregnancy,  there  is 
tiu'ountered  the  additional  strain  of  the  puerperium,  when  the  organs  of  excre- 
tion for  a  time  have  new  demands  upon  them,  aud  when  opportunities  for  septic 


Wm 

f-'     m 

"'■■  i 

I 


*-"•-' ii^.'ia 


ttet 


796 


AMFJirVAX    TEXT-nOOK   OF    OBSTETRICS. 


lui  ^3. 


alworptioii,  in  size  of'tlio  doso  and  in  tiic  viruKjnce  and  intensity  of  the  poJMiii, 
arc  without  parallel  in  the  whole  period  of  the  ri'[)rodnctive  function  ! 

There  are  many  faets  to  support  the  belief  that  sepsis  is  by  far  the  niu>t 
important  cause  of  the  puerpei-al  forms  of  insanity.  First,  let  us  study  tlio 
statistics  of  recent  years.  In  58  cases  Holm  noted  severe  puerperal  processes 
in  thirteen  ;  Hansen  attributed  forty-two  of  49  cases  to  infection  ;'^"  in  40  cass 
Clark  observed  eight  with  septicemia  and  eleven  others  with  inflanniiatniv 
disease  of  the  uterus  and  appendages."'  Hansen  places  the  proportion  of  toxin 
cases  at  86  per  cent.;  Idanof,  at  66  per  cent.;  Lallier,"-  at  70  per  cent. 
Olshausen  in  his  classification  of  puerperal  psychoses  assigns  the  first  place  td 
the  infectious  types.'^  Menzeis  remarks  that  most  alienists  allow  that  some 
jinerperal  cases  are  of  septic  origin,  and  he  furtiier  says  tiiat  it  is  strange  im 
one  has  ventured  to  assert  that  all  puerperal  cases  are  due  to  intoxication  fioni 
either  bacteria  or  toxemic  organic  compounds.  Roiie''^^  asserted  his  belief  that 
few  cases  of  puerperal  insanity  occur  without  preceding  or  coincident  puerperal 
infection. 

A  close  analysis  of  the  symptoms  and  course  of  the  affection  gives  addi- 
tional support  to  Robe's  notion.  From  the  fifth  to  the  tenth  day — the  usual  time 
of  a])pearance  after  labor — is  commonly  the  period  in  which  sepsis  is  manifested. 
In  unquestionable  septic  cases  the  simultaneous  appearance  of  the  mental  and 
local  disorders  and  the  aggravation  of  mental  symptoms  that  may  have  ])!•(■- 
existed  are  surely  significant.  Again,  the  largest  proportion  of  cases  are 
maniacal  with  elevated  temperature.  Clark '^' says  :  "  Rarely  was  a  case  ad- 
mitted that  did  not  exhibit  uterine  or  allied  symptoms  of  abnormal  character, 
the  most  frequent  being  pain  on  ])ressnre  in  the  hypogastrium,  and  scanty, 
extremely  offensive  lochia."  ^Menzeis  remarks  that  the  improvement  which 
follows  when  the  lochia,  having  ceased,  return  ;  the  invariably  delayed  invohi- 
tion  of  the  womb;  the  (piick  production  of  anemia  and  profound  blood-alter- 
ations with  wasting;  the  benefit  from  purges;  the  widespread  objection  to 
o])ium  ;  and  the  imi)rovement  from  local  uterine  treatment, — all  testify  to  the 
septic  character  of  the  disease  and  jioint  to  a  primary  blood-condition  rather 
than  a  cerebro-cortical  condition.  He  further  believes  that  this  poisoned  blood 
can  cause,  in  certain  individuals  of  low  compensation,  changes  in  the  chemical 
constitution  of  cells,  by  which  changes  nerve-energy  is  disordered  and  insanity 
is  produced,  the  type  and  result  being  dependent  upon  the  ])roducts  of  infiani- 
mation  and  the  degree  of  their  absorption. 

Pathological  evidence  is  not  wanting  to  substantiate  further  the  septic  oriuiii 
of  the  insanity  of  the  pnerperium.  As  will  be  pointed  out  later,  no  distinctive 
pathological  changes  in  the  brain  have  yet  been  found  to  demonstrate  satisliic- 
torily  the  etiology  of  the  affection ;  whereas,  on  the  contrary,  the  pathological 
findings  in  the  i)elvic  organs  of  acute  cases  are  almost  invariably  those  of  in- 
fection, and  in  chronic  cases  the  remote  results  of  sepsis  are  often  apparent  in 
old  inflammatory  pelvic  disease.  Autopsy-records  for  which  the  most  scrnti- 
iiizing  anatomical  and  microscopical  investigations  of  the  brain  and  the  spina! 
cord  have  been  made  are  frequently  summarized,  as  in  the  case  most  minntily 


fl 


'.V. 

y  of  the  poison, 
net  ion  ! 

by  far  the  iiio~l 
let  nrt  t^tntly  the 
I'penil  processes 
n  ;""  in  40  cums 
h  infltunniivtoiy 
oportionot'to.\i(! 
at  70    per  cent. 
:\ni  first  place  to 
allow  that  sonic 
it  is  strange  no 
ntoxication  from 
lhI  his  belief  that 
icident  puerperal 

ction  gives  addi- 
v — the  usual  time 
psis  is  manifested. 
»f  the  mental  and 
vt  may  have  \)\v- 
tiou  of  cases  arc 
jly  was  a  case  ad- 
Lnormal  character, 
rium,  and  scanty, 
provemcnt  which 
Iv  delayed  invohi- 
x)und  blood-altcr- 
iread  objection  to 
all  testify  to  the 
ll-condition  rather 
his  poisoned  blood 
es  in  the  chemicil 
hered  and  insanity 
Toducts  of  intlam- 

U' the  septic  orii:in 
liter,  no  distinctivi' 
luonstrate  satisfac- 
},  the  patholoiiical 
[•iably  those  of  in- 
often  apparent  in 
)i  the  most  scrnti- 
lain  and  the  spinal 
ise  most  minut.'ly 


PATirOLOaV   OF    THE   PVKRPFAilVM. 


t97 


and  carefully  studied  by  Feist,''"  in  which  case  the  brain-examination  was  neg- 
ative, while  tlie  spinal  cord  showed  in  the  posterior  columns  the  lesions  pro- 
duced in  this  location  by  toxic  agents.  The  writer  is  not  aware  of  any  extensive 
chemical  or  micro-chenucal  investigations  with  the  view  of  shedding  more  light 
on  this  subject,  but  recent  advances  in  bacteriology  warrant  the  belief  that  some 
(lay  proof  will  be  abundant  of  the  universal  belief  that  either  toxenua  or  septic 
infection  is  a  primary  factor  in  all  the  psychoses  of  childbirth. 

As  determining  elements  of  lactation  cases,  anemia,  prolonged  lactation, 
repeated  child-bearing,  or  other  bodily  ccmditions  productive  of  exhaustion  are 
most  important ;  and  among  these  the  remote  effects  of  sej)sis  also  should  have 
a  i)lace. 

Patholofiy, — Numerous  pathological  changes  have  been  found  in  the  bodies 
of  those  dying  with  puerperal  insanity,  but,  as  has  previously  been  stated,  none 
ot"  these  changes  offers  a  wholly  satisfactory  explanation  for  the  morbid  pro- 
cesses of  the  brain.  Congestion  of  the  brain  and  its  membranes  is  usually 
found  in  the  more  active  types,  and  in  evident  septic  cases  inflammatory 
cliangos  with  capillary  eniboli  have  been  observed.  In  other  cases  the  brain- 
substance  has  been  pale,  and  in  some  chronic  cases  its  convolutions  were 
shrunken.  The  evidences  of  anenna  throughout  the  body  were  widespread. 
Si/mptoms. — The  forms  of  psychical  disturbance  met  with  are  mania  with 
or  without  delirimn,  melancholia,  and  dementia,  the  latter  being  the  final  stage 
of  cases  that  become  chronic.  Mania  and  melancholia  are  the  prevailing  types, 
mania  being  the  most  fre(iuent  type  and  occurring  oftenest  in  the  puerperiinn, 
and  more  often  in  lactation  than  in  pregnancy.  Melancholia  is  more  connuon 
in  pregnancy,  at  which  jieriod  active  delirium  is  very  rare. 

ImanUji  of  Pre(/nan('i/. — In  a  large  proportion  of  cases  of  insanity  of  preg- 
nancv  the  alienation  is  of  a  mild  type  and  is  preceded  by  prodromal  symptoms. 
The  physiological  changes  in  the  nervous  system  characteristic  of  pregnancy 
are  heightened.  The  alterations  in  disposition,  the  irritability  of  temper,  the 
pecidiar  whims,  and  the  depression  are  often  followed  by  a  condition  of  high 
nci'voiis  tension  with  loss  of  memory  and  of  self-control,  and  after  a  period  of 
insomnia  the  coiulition  gradually  merges  through  sadniss,  distrust,  and  appre- 
lunsion  into  established  melancholia.  The  patient  becomes  reserved  and  indis- 
])osed  to  nnngle  with  her  friends  or  her  family,  and  i-  'li  ;trustful  of  all  around 
her.  Reliir'jus  or  erotic  impulses  may  develop,  auvi  :  [I'trts  at  self-destruction 
may  be  made  on  account  of  an  imagined  unpardonable  sin.  This  tendency 
to  commit  suicide  calls  for  constant  watchfulness.  The  patient  may  indulge 
in  lewd  and  obscene  language  or  may  make  improper  overtures  to  male 
aciiuaintances.     Active  delirium  occurs  in  rare  cases. 

ItmniUy  of  Labor. — Every  obstetrician  has  observed  the  varied  capacity  of 
ills  patients  to  endure  the  agonies  of  childbirth,  and  there  are  but  few  who 
liave  not  witnessed,  in  individuals  practically  maddened  by  their  supreme  suf- 
fering, acts  of  nervous  exaltation,  which  force  the  conviction  that  for  the  time 
mental  inhibition  is  lost  and  that  the  ])atient  is  no  longer  responsible  for  her 
uds.    Without  previous  indication  for  the  use  of  an  anesthetic  the  writer  has 


m 


798 


AMKIUi'AX    Tl':XT-It<)i>K    ()/'   OliSTiynilCS, 


^  {< 


jlj 


(■  : 


olxsiTvcd,  JIM  (lid  Ilcrvii'nx,  a  pationt  rise  siiddcnly  from  her  hod,  and  witli 
wild  screams  attempt  to  jump  from  her  hedroom  window.  In  another  ea.«i' 
the  patient's  lond  cries  of  "  Help!"  "  Mnrder!"  hrou^ht  to  hand  two  otlireiN 
whose  protection  the  writer  was  compelled  to  claim  aijainst  the  fnry  of  ;iii 
ignorant  hnshand.  Usually  anil  fortunately,  the  insanity  of  labor  (lisappe;irs 
after  <lelivery.  Its  treatment  should  be  the  termination  of  labor  by  forceps  or 
by  version  under  anesthesia  when  labor  is  unduly  delayed. 

Insunii}!  of  the  Pucrpcniuii. — When  the  disease  develops  at  tl  k,  delir- 

ium is  common,  particularly  in  the  ca-sm  occurring;  early — before  the  four- 
teenth (lav.  Here  also  there  are  in  at  least  half  the  cases  doselv  observed 
prodromal  symptonis  during  pregnancy.  These  symptoms  may  have  l)etii 
overlooked,  or  the  onset  may  arise  with  startling  snddenness  iiceompanied  by  sui- 
cidal or  homicidal  tendencies.  Fever,  which  is  commoidy  present,  may  l)e  viry 
high  in  severe  septic  cases.  If  the  patient  is  maniacal,  which  is  the  most  cmn- 
mon  type,  she  is  sleepless  and  violent  and  attempts  to  destroy  those  around  licr. 
There  are  delusions  and  hallucinations.  The  ideas  and  language  of  the  paticni 
flash  from  her  with  remarkable  rapidity  and  incessant  change.  Now  sensuous, 
oI)S(^one,  profane,  and  making  attempts  at  self-exposure,  in  an  instant  she  in.iy 
revert  to  religions  ideas,  to  indulge  in  prayer  and  the  singing  of  hymns.  In 
one  case,  that  a  an  illegitimately  pregnant  colored  girl  of  nineteen,  the  writer 
Wiis  thought  to  be  the  Almighty,  from  whom  the  girl  piteously  bes  lit  i)ar(l(iii 
for  her  sins.    The  next  moment,  while  counting  her  pulse,  he  w  led  upon 

with  a  frenzy  from  which  he  barely  escaped,  the  patient,  now  terroi  i/ed  by  iiis 
presence,  believing  him  to  be  Satan  himself,  upon  whom  .she  spat  with  fury. 
Within  a  very  short  time  he  left  her  singing  a  Sunday-school  song,  which  was 
soon  followed  by  word-pictures  of  obscene  situations  mingled  M'ith  revoltiiiij 
profanity.  Melancholia  in  the  puerperium  occurs  less  fr(>quently  than  mania 
— usually  after  the  fourteenth  day — and  it  is  very  apt  to  be  accompunied  liy 
jiersistent  attempts  at  suicide,  re(iniring  unremitting  watchfulness  on  the  part 
of  attendants.  Delusions  involving  freipiently  the  husband's  fidelity,  and  hal- 
lucinations of  sight  and  hearing,  are  commonly  present. 

Insanity  of  Lactation. — Mania  and  maniacal  deliriunj  are  c()mj>arativ('ly 
rare  in  this  type  of  insanity.  The  patient  is  usually  melancholic,  (piiet,  list- 
less, and  depressed,  with  frequent  delusions  of  persecution.  In  the  later  stagis 
the  mental  faculties  are  at  a  low  ebb,  dementia  supervenes,  and  the  patient  can 
with  difficulty  be  aroused  from  her  listless,  almost  lethargic,  condition. 

It  should  be  borne  in  mind  that  any  type  of  childbirth  insanity  may  occur 
at  any  period  of  the  child-bearing  process.  In  the  j)receding  description  an 
attempt  has  been  made  to  give  a  brief  outline  of  the  .symptoms  of  the  type 
most  frequently  met  with  in  each  period.  A  classification  of  the  type  iiidi- 
pendent  of  the  periods  of  occurrence,  very  convenient  and  practical  for  closely 
studying  the  progress  of  symptoms  in  individual  cases,  is  that  made  by  Mcn- 
zeis,'''^  based  upon  the  fact  that  any  given  case  may  pass  through  six  stage- — 
namely:  (1)  Prodromal  disturbance;  (2)  early  delirium;  (3)  melancholia; 
(4)  stupor ;  (5)  mania ;  (6)  dementia. 


&    ! 


V. 

bed,  iiml  witli 
H  unotlu'r  CUM' 
lul  two  otVu'ti> 
111"  t'liry  «)t'  :iii 
ilmr  (lis!»i)|M'iirs 
)!•  by  t'orcL'p.s  or 

tl  !>.,  (U'lir- 

M'tbrc  the  i'niii- 
•losi'ly  obsirvrtl 
miiy  liavi!  been 
mipaiiii'd  by  ^iii- 
nit,  iniiy  lu-  vny 
IS  the  most  i-niii- 
hose  iinmiul  In  r. 
iro  of  the  patient 
Now  sensuous, 
instant  she  lu.iy 
r  of  hymns.     In 
iieteen,  the  writer 
bes       lit  pardon 
w:  led  npon 

terroiizcd  by  liis 
e  spat  whh  fury. 
1  sonj;,  wliii'li  was 
d  with  revolting: 
ently  than  mania 
\  aeeonipanied  Il- 
lness on  the  part 
fidelity,  and  lial- 

ire  comparatively 

|eh(die,  (piiet,  list- 
n  the  hiter  sta,u;e?* 

hd  the  jiatient  ean 

Icondition. 
isanity  may  oeeiir 
|i<>;  deseriptioii  an 
^toms  of  the  type 
»f  the  type  inde- 
kietical  for  eUisely 
it  made  by  >b'n- 
)Ugh  six  staiTc-— 
(3)  melancholia ; 


j'A'n/()ij)(,y  or  riit:  rrKumurM. 


•})!» 


IHot/noniH. — Usually  tiiere  is  no  ditticiilty  in  re<'oj;nizinjf  tiie  various  w^wh 
of  in.sanity  in  the  chihl-lM'arinf^  woman.  The  deiirinm  of  fever  or  delirium 
iremensi'omplicatinjj  the  pnerperium  mip;ht  otter  some  diflicidty  at  the  onset  <if 
the  symptoms.  In  the  former  ease  it  will  sometimes  be  necessary  to  wait  for 
the  decline  of  the  fever  before  rt'achine;  a  definite  conclusion,  and  in  the  latt«'r 
the  history  will  go  far  towarti  clearinj^  away  any  doubt. 

I'votjtwH'm, — As  a  ).M'neral  statement,  it  may  be  said  that  alH)nt  two-thirds 
of  all  eases  recover  within  five  or  six  months;  of  the  other  third,  from  2  to 
it)  per  cent,  die  from  septic;  inlirtion,  exhaustion,  or  intercurrent  diseases  ;  the 
rest  remain  permanently  insane.  Viewed  with  reference  to  the  period  of  oc- 
currence, the  in.sanity  of  the  pnerperium,  particularly  the  nearer  to  labor  it 
oanirs,  shows  the  largest  perc^eutage  of  recoveries,  while  that  of  jircguancy  is 
least  favorable,  excluding  from  the  latter  the  very  mild  cases  of  early  |»regnancv 
in  which  the  symptoms  are  merely  an  aggravation  of  the  ordinarily  considered 
physiological  changes  of  gestation.  In  Mcnzeis'  cases  the  recoveries  were  as 
follows:  In  pregnancy,  4.'i..'J  j)er  cent. ;  during  the  pnerperium,  75  per  cent.; 
during  lactation,  50.5  ])cr  cent.  Melancholia  is  more  favorable  than  mania  in 
pregnancy,  while  the  reverse  is  true  in  the  jxierperiuni. 

The  type  of  the  disease,  however,  i  of  as  great  importance  as  the  ju-riod 
of  its  oc(;urrence.  The  life  of  the  patient  is  in  greater  danger  fmm  mania,  while 
lier  mental  faculties  are  more  likely  to  be  disabled  or  ])ermancntly  lost  from 
melancholia,  in  which  type  there  is  also  a  longer  duration. 

Again,  the  older  the  patient,  the  greater  the  number  of  pregnancies,  and  the 
more  depression  with  extreme  rapidity  of  pulse  and  persistent  eleviition  of  tem- 
perature, the  graver  is  the  prognosis.  Intemperance  also  adds  a  risk  to  the  dis- 
ease. In  cases  clearly  dtie  to  infection  and  in  those  in  which  hereditary  predis- 
jKisition  to  nervous  disease  i>  largely  absent  the  duration  is  shortest  and  the 
outcome  is  most  favorable  (Toidonse).  When  eclampsia  bears  a  causal  relation 
to  the  puerperal  form  the  prognosis  is  distiiuitly  more  favorable,  the  patient 
recovering  sooner  than  in  any  other  variety  (Hop])c)."^^  The  causes  of  death 
in  fatal  cases,  apart  from  sepsis,  which  certainly  is  found  in  a  large  propor- 
tion, may  be  intercurrent  or  pre-existing  disease,  esiiecially  of  the  lungs,  the 
kidneys,  and  the  heart.  Acccu'ding  to  iMenzeis,  tubercle  is  found  in  one-third 
(if  the  cases,  not  so  much  arising  from  family  predisposition  as  from  Ibllow- 
ing  a  traumatic  pneuinoina  due  to  fi)rced  feeding  and  stupor. 

Trcatmciif. — It  is  generally  agreed  that  practically  all  cases  of  puerperal 
insanity  should  be  asylum  patients  ;  that  as  such  even  the  milder  cases  are 
hotter  cared  for,  and  that  convalescence!  is  more  raj)id  and  complete,  is  the 
helief  of  most  alienists.  An  additional  reason  for  asylum  treatment  is  finnid 
in  the  fact  that  even  these  milder  forms  may  develop  into  graver  ones  with 
nnexpected  suddenness.  When  delirium  and  suicidal  t)r  homicidal  tendencies 
are  present  there  is  no  adecjuate  security  to  the  patient,  her  fanuly,  or  her 
attendants  outside  the  walls  of  an  asylum. 

Contrary  to  the  bestadvice,  the  family  and  friends  often  insist  upon  keeping 
tile  patient  at  home,  and  are  unwilling  to  be  instrumental,  as  they  say,  iu  en- 


ii'l, 


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graftinf:;  upon  (he  piiticnt's  t'litiiri!  existence  tlu;  popular  and  unlortunate  sti<;iii;i 
tliat  attaches  to  the  briefest  sojourn  in  a  hinaticasyhini.  Therefore  it  has  been 
thougiit  appropriate  to  outline  briefly  the  in<lications  in  inanagin<r  these  case-. 
Skilled  attendants  with  experience  in  carina;  for  insane  patients  shoidd  al\\a\  s 
be  secured.  Absolute  rest,  (piiet,  and  isolation  must  be  obtained,  and  even 
MUMubers  of  the  ininicdiate  family  should  not  be  pennitted  access  to  tiic 
patient. 

As  the  treatment  of  insanity  ffenerally  is  larifely  symptomatic,  so  in  tin' 
cliildldrth  form  measures  directed  to  the  improvement  of  the  {)atient's  ticncr.il 
condition  Jire  to  be  i'mpl(»yed,  ton'cther  witii  special  treatment  for  symploins 
and  complications  tiiat  may  be  ))resent  in  individual  cases.  The  j;cncrai  tnni- 
ment  is  all-important.  Its  aim  shoidd  be,  first,  to  correct  disordered  s.atcs  n| 
the  hepatic!  and  •^astro-intestinal  functions,  so  connnoidy  present,  in  older  lo 
ensure  the  proper  di<;estion  and  assimilation  of  fotHl.  An  opcniniij  enema,  ful- 
lowed  by  courses  of  a  mercurial  with  a  subsecpicnt  saline,  is  <;enerally  the  I'oiiiiiic 
beginniuii-  in  asylum  practice.  I'roper  and  snHi<'ienl  food,  usually  liipiid  and 
often  predin'csted,  (on'cther  with  moderate  stimidation,  is  of  paramount  impcut- 
ance.  The  (juanlity  of  stinudants  to  be  employed  in  individual  cases  is  \n-\ 
determined  l»y  principles  similar  to  those  which  jiovern  their  use  in  "typlidid" 
states.  Forced  feedini;'  by  the  esophageal  tube  shoidd  be  resorted  toonly  wIkm 
al).-<olutely  necessary,  and  it  may  be  replaced  at  intervals  by  nutritive  eneinaia. 
The  almost  constantly  associated  dei»raved  condition  of  the  blood  clearly  call^ 
for  the  use  of  iron  and  arsenic,  which  may  Ik'  given  in  the  form  of  iJlaml's 
pills  and  Fowler's  solution.  The  C(Mnbination  oi  the  "four  chlorids"  is  a 
particularly  valuable  pre|)ara)ion.  Often  there  must  be  selected  preparations  of 
iran  that  are  least  likely  to  disorder  the  gastro-intestinal  secretions,  sncli  as 
the  all)iinnnates,  Nerv(!-sedatives  are  not  to  be  used  indiscriminately.  Xiiiri- 
tion  is  the  indication,  not  sedation.  Hromiils  are  of  little  value  exce[)t  in  casc^ 
in  which  liysteiia  of  sthenic  type  is  pronnnent.  ( )pitiiii  in  any  forni  is  generally 
not  to  be  employed,  ♦■specially  on  account  ot"  its  action  upon  the  se;  reiinn^. 
Wiieii  it  is  necessary  to  j»rocure  sleep,  alcohol,  chloral,  or  |)araKlehyd  is  pntrr- 
able.  To  reduce  high  temperature,  (|innin  and  cold,  the  latter  either  as  a 
pack  or  as  a   bath,  are  to  be  employed. 

In  view  of  the  growing  belief  that  pelvic  iidlammations  of  septic  oiigin  arc 
of  greatest  importance  in  the  etiology  of  the  puerperal  forms  of  the  diseax',  a 
earelid  study  of  the  uterus  and  its  appendages  should  always  be  made  in  this 
class  of  cases,  and  usually  local  antiseptic  treatment  is  to  be  employed,  (lark 
remarks:  "In  no  class  of  e;ises  is  gyneccdogical  investigation  of  more  ini|Hiit- 
ance  tiian  in  the  study  of  puerperal  i?isanity."  ""  In  many  cases  opcraiivr 
means  will  aiford  relief  and  even  cure — a  (act  urgently  insist(<l  upon  by  luilir."" 
Sucii  radical  treatment,  to  accomplish  its  best  result,  nmst  not  be  delaycil  imi 
long.  Tiiat  it  is  pnu'tically  futile  to  remove  old  diseased  appendages  for  llir 
permanent  ri'lief  of  long-standing  nervous  alVections  is  an  axiom  begoldu  >A' 
desperate  struggle  between  gynecologists  and  alienists. 

When    tlu'    milk-secretion    has    not    disappeared    spontaneously,  mcasiiics 


S'. 

irtiuuito  stigma 
ore  it  lias  httii 
inn  tlu'sc  rase-. 

should  always 
iiicd,  ami  cvrii 

access   ti»   tlif 

uatic,  si»  ill  tlir 
Kitioiil's  liciicral 
L  fur  syiuplniii- 
lio  jicncral  trcul- 
)r(lcro(l  slates  <it 
^t'llt,  ill   order  lo 
"iiinsj;  ciuMua,  l'"!- 
cndly  till-  niiiiiiii' 
sually  liquid  and 
ininiouiit  iiiipcrt- 
Uial  cases  is  luM 
use  in  "  tyi»li«>i«r' 
rtcd  to  only  wluii 
lutritivc  ciicmata. 
)lood  dearly  ealU 
>  iorni  oi"  lUaiulV 
nr  dilorids"  is  a 
led  |>irparatioiis  di' 

rcrelioiis,  siidi  -.1^ 

iniiiately.     NnH'i- 

cxcept  in  ea-c- 

"onu  is  jrcniMally 

on  the  secretions. 

■aldehyd  is  pivlrr- 
atter  either  as  a 

>t"  septic  oi'i;j;iii  aiv 
IS  oi'  the  disea-r.  a 
vs  he  made  in  llu< 
Mnployetl.  t'liii'li 
n  of  more  inii«nit- 

nv  cases  operaiivc 

1      i>  1  •  11' 
«l  upon  by  Ivolu'. 

not  he  delaye.1  t^" 

ippciida;j;es  for  tlio 

axiom  heootf"  el" 


PATHOLOdY  or  Tin-:  /'('/■: /{/>/■: /{KM. 


KOI 


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lineoui 


dv,   iiieasnir: 


should  at  onco  ho  taken  to  accuniplisli  this  end,  and  watchful  care  must  he 
exercised  to  prevent  the  occurrence  of  mammary  ahscess. 

While  the  patient  is  kept  in  bed  the  j^jreat  liahilily  to  the  formation  of  hed- 
-ores  siiould  he  home  in  mind,  and  ell'ort.s  shoidd  l)e  made  to  prevent  tiieir 
(leeurrence.  In  chronic;  crises,  and  in  acute  cases  after  the  suhsidence  of  urjrent 
symptoms,  out-door  exercise  in  the  company  of  a  watchful  attendant  should  he 
insisted  upon  and  he  jjraduated  to  the  patient's  streiiffth. 

Acute  Tympanites. — In  neuroti<i  women  enormous  accumulation  of  ilatiis 
is  sometimes  ol).served  in  the  puerperium.  The  distention  ^>i'  the  ahdomen 
may  not  only  occasion  preat  distress,  hut,  wdien  it  is  actiompanicd  hy  complete 
l>aralysis  of  the  mr.scular  coat  of  the  howel,  with  persi.stent  vomitinji;  and 
obstinate  (foiistipation,  such  as  are  seen  in  intestinal  obstruction,  there  is  also 
imminent  danfjer  to  tin;  patient's  life,  a  ermination  of  which  beiiij;  avoided 
l>y  most  active  treatment  of  the  condition.  It  should  bo  remembered  that  this 
acute  paralysis  of  the  intestines  occurs  without  any  sifijns  of  peritonitis  or  other 
evidences  of  iidection,  tlu;  symptom  apparently  beintii;  due  to  a  purely  nervous 
influence.  Fiarfje  doses  of  strychnia  administered  hypodermatically  are  indi- 
cated, and,  should  the  |)atient's  distress  not  promptly  be  relieved  hv  rectal 
injections  of  asafetida  or  hy  the  introduction  of  a  rectal  tube  and  by  the 
ap|)licatiou  of  a  firm  abdominal  hinder  from  the  trochanters  to  the;  ribs, 
llie  larf;(!  howel  may  he  punctured  thronjfh  the  abdominal  wall,  or  the 
al)domeu  may  be  opened  and  the  intestines  Ik;  incised  and  .stitched  at 
several  point.«. 

IV.  Rapid  or  Sudden  Death  in  the  Puerperium. 

No  accident  can  hajtpen  to  a  woman  that  carries  with  it  so  much  horror 
as  rapid  or  sudden  death  at  any  period  "f  the  jinerpcrium,  nnd  no  physician, 
however  p'oat  his  reputation,  can  c.scajM'  the  criticism  which  invariably  follows 
oven  when  this  accident  is  absolulelv  bevond  his  control,  ile  should  always 
know  the  causes  of  rapid  or  sudden  deatii  in  the  puerperium,  and  by  explain- 
intj  the  utter  impossibility  in  most  ca.ses  of  foroseeiiifr  or  eonibatiii}i;  the;  <lealh 
he  can  partially  avert  unju.st  and  unkind  criticism.  It  is  desirable  in  this  work 
to  omit  the  detailed  histories  of  cases  of  sudden  d«'ath  that  have  been  recorded 
in  the  literature  of  obstetrics,  the  most  important  causes  of  this  accident  oidy 
heiiiff  hero  eniunerated.  The  eau.ses  of  ra|>id  death  may  properly  be  .separated 
from  tho,so  of  .sudden  death,  since  nipid  death  will  usually  be  preceded  by  an 
accident  or  j<;ravo  di.seasc;  which  will  tiuible  the  physician  to  foretell  the  probable 
c.  currence  of  death,  while  sudden  death  conies  with  a  lij;htninji-like  stroke  and 
without  a  moment's  waruiu};  to  a  patient  often  previously  enjoying  apparent 
health. 

The  eau.ses  of  rapid  dcaih  in  the  puerperium  may  be  any  of  th<'  follow- 
ing :  Accidents  of  labor,  such  as  hemorrha^t!  and  shock  Ibllowiiifj  placenta 
[inevia,  accidental  or  |)ost-|)artum  hemorrhaffc,  rupture  or  inversion  of  the 
uterus;  rupture  of  a  hematoma  situate<l  either  externally  on  l!ie  vulva  or  within 
the  pelvic  cavity;  rupture  of  peritoneal  adhesions  or  of  a  broad  li<:;ament  or  an 


in 


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J  H' 


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802 


AMERICAN    TKXT-JiOOK   OF   OBSTETRICS, 


ovarian  vein ;  acute  i)urj)uni  liieniorrliagica ;  ecrcbral  embolism  or  apoploxv ; 
liomoptyj^i'^ ;  i)re-exi,sting  diseases  of  the  respiratory  or  circulatory  system  sd 
grave  as  not  to  withstand  the  strain  of  labor,  which  is  followed  by  extrciiif 
exhaustion  and  rapid  death. 

Analyses  of  the  recorded  cases  oi'  touJdoi  (Jcntli  include  the  following  causes : 
Heart  failiu'e  which  has  residted  from  rupture  of  the  heart  due  to  fatty  degen- 
eration, to  a  patch  of  Hbroid  degeneration,  to  ai'Ute  myocarditis.  kSuddcn  arrest 
«)f  the  heart's  action  has  followed  a  primary  thrombosis  in  the  right  side  oC 
the  heart,  the  thrombus  extending  into  the  ptdm(»nary  artery,  or  more  fre- 
quently the  cause  of  death  has  been  embolism  of  the  pidmonary  artery.  Rupture 
of  a  cyst  in  the  auricular  septum  of  the  heart,  of  an  aneurysm,  of  the  auria 
itself,  and  an  attack  of  angina  pectoris  have  can;  lunediate  death.  Mental 
emotion,  such  as  a  [)rofound  impression  of  sorrt.  ^  of  joy,  of  anger,  of  exag- 
gerated shame,  of  excessive  pain,  or  of  fear,  has  caused  sudden  death  by  pro- 
ducing syncope,  tiie  heart's  action  being  interrupted  by  energetic  and  persistent 
excitation  of  the  inhibitory  nerves  of  the  heart.  Sudden  death  has  followed 
the  entrance  of  air  into  the  uterine  sinuses;  a  faUil  ease  has  been  recorded 
from  embolus  of  fat  from  the  pelvic  connective  tissue,  and  <li'ath  in  the  piier- 
]>eriinn  has  followed  rupture  of  a  giistric  ulcer  and  of  a  liver-abscess.  Tlie 
most  fre<i|uent  causes  of  sudden  death  in  the  |)uerj)erium,  arranged  in  the  order 
of  their  relative  freepiency,  are  embolism,  entrance  of  air  into  the  uterine  veins, 
and  heart  failure,  due  usually  to  organic  disease. 

Embolism  and  Thrombosis  of  the  Pulmonary  Artery. — Some  authors — 
notably  Playfair  and  Jiarker — insist  that  primary  and  spontaneous  coagulatietii 
of  the  blowl  in  the  jndmonary  artery  occurs,  and  they  attribute  this  accident  in 
the  puerperium  to  the  excess  of  fibrin  and  water  in  the  blood,  to  hemorrhage,  to 
syncope  and  the  diminished  ibrceof  the  blood-current,  and  to  the  quality  of  the 
bhxxl  changed  by  ettete  materials,  by  sepsis,  or  by  blood-dyscrasia.  On  the 
contrary,  other  writers  favor  the  notion  that  embolism  usually,  if  not  alwiiys, 
j)recedes  the  occurrence  of  throndwsis,  and  they  support  this  belief  by  the  uncer- 
tainty of  the  pathologist's  knowledge  of  a  primary  throndiosis  in  the  right  side 
of  the  heart  and  in  the  pulmonary  artery,  and  by  the  iacts  that  in  aiM.iit  luilf 
of  the  eases  a  pcripiieral  thrombus  has  been  demonstrated  ;  that  the  accident 
commonly  occurs  after  dislodgement  of  a  peripheral  thrombus  in  either  a  fcinoriil, 
an  iliac,  or  a  uterine  vein  following  a  sudden  etlbrt,such  as  assuming  an  uprigiit 
posture,  laughing,  straining  at  stool,  the  administration  of  a  vaginal  itr  an  intra- 
uterine douche,  etc.,  any  of  which  ciforts  do  not  cause  thrombosis,  but  niiiy 
hxisen  a  thrombus;  and,  finally,  that  thrombosis  of  the  pulmonary  artery  simnld 
occur  more  freepiently,  since  the  asserted  predis|)osing  causes  are  so  conirnonly 
observed  in  the  jHierperiuni.  It  is  certaiidy  true  that  in  many  recorded  antdp- 
sies,  when  thrond)osis  has  been  found  in  the  pidmonary  artery  a  scriitini/Ini: 
.search  for  a  peripheral  thrombus  has  not  been  mentioned.  Whenever  iiii 
autopsy  is  made,  as  should  always  be  done  upon  a  woman  dying  suddeidy  in 
the  jnierperium  with  symptoms  of  pulmonary  obstruction,  a  most  careful  search 
for  a  peripheral  thrombus  should  never  be  neglected. 


PATHOLOGY   OF    THE   PUERPERIUM. 


':o3 


lUv,  if  not  al\\lly^ 


1  tluit  in  uUuut  halt' 
tliilt  tlio  accident 
liiicitliorarciiKMai, 
jsnminii;  an  u|)ri,Ldit 
laiiinal  <»r  an  iiitra- 
mibosis,  l)nt  may 
ary  artery  siioiiM 
HIT  so  conmioiily 
V  recorded  aiitdp- 
I'terv  a  serntiiii/injj; 
d.     Whenever  an 
Idvin""  suddenly  in 


Prognosis  and  Diagnonis. — When  a  larji;e-size(l  thronilms  ohstniets  the 
pulmonary  artery,  death  may  be  instantaneous,  or  it  may  he  preceded  by  pre- 
rordial  oppression,  great  fear  of  impending  death,  extrenie  dyspnea,  cyanosis, 
and  a  raj)id  loss  of  body-heat.  The  iieart's  action  is  violent  ;  the  pulse  is 
small,  rajjid,  and  irregular.  Sometimes  a  niurmin-  is  heaid  over  the  orifice  of 
die  pulmonary  artery,  and  in  one  case  the  patient  was  able  to  breathe  belter 
lying  prone;  in  another  case  respiration  was  easier  in  the  supine  posture.  In 
other  eases,  if  the  end)olus  is  small  the  onset  oi'  symptoms  is  not  so  sudden, 
and  the  symj)toms  are  similar  but  not  so  severe,  in  which  «'ases  death  mav  occm* 
alter  several  days,  or  V(!ry  rarely  recovery  may  follow.  From  a  study  of 
twenty-five  cases  IMayfair  conchuh'd  that  when  the  accident  occurs  before  the 
nineteenth  day  of  the  puerp(M-ium  the  obstruction  of  the  pidmoiiary  artery  is 
most  likely  due  to  a  ])rimary  throndxjsis;  after  the  nineteenth  day,  to  end)olism. 

Treatment. — Little  can  be  done  for  an  accident  so  grave  as  obstruction  of  tiu; 
piduKmary  artery.  The  patient  should  be  kept  absolutely  at  rest,  and  stim- 
ulants, including  the  carbonate  of  ammonium,  shoidd  be  administered.  Pro- 
phylaxis is  of  far  greater  value.  Early  exertion  on  the  ])art  of  the  puerperal 
patient  nmst  always  be  avoided,  especially  during  and  after  intra-uterine  manip- 
ulations, and  especially  when  phlegmasia  exists;  and  massage  for  the  latter 
disease,  as  frequently  advised  during  the  stage  of  convalescence,  nmst  be  under- 
taken with  the  greatest  caution. 

Entrance  of  Air  into  the  Uterine  Sinuses. — Although  exp(>riments  upon 
animals  have  shown  that  the  direct  injection  ol'  large  quantities  of  air  into  the 
circulation  is  not  fatal  (Hare),  the  clinical  evidence  of  deaths  from  this  cause 
in  ()l)stetricai  and  surgical  practice  is  incontestable.  liaiilVs'^'  collected  43  cases 
(if  death  following  air-embolism  in  the  uterine  veins.  In  seventeen  cases  the 
entrance  of  the  air  was  caused  by  injections  into  the  birth-canal  ;  in  eighteen 
the  entrance  of  air  into  the  uterus  was  sjjontaneous  ;  in  eight  gas  was  formed 
ill  the  uterus.  Post-mortem  examinations  proved  the  i>resence  ol  air  in  thirty- 
()ii(!  of  the  39  fatal  cases.  In  the  reported  cases  of  sudden  death  from  a  large 
quantity  of  air  entering  the  veins  of  the  uterus  death  occurred  immediately  or 
within  twenty-four  hours  after  delivery. 

J'Jtiolof/i/. — From  experiments  and  from  observation  of  cases  it  is  believed 
that  air  very  rarely  enters  spontaneously  into  the  veins  of  the  uterus,  and  that 
to  cause  speedy  death  the  quantity  of  air  must  be  (!onsiderable  and  the  air  nmst 
inter  the  eireulation  with  fierce,  as  may  happen  during  uterine  contraction  when 
the  air  has  entered  and  the  cervix  is  obstructed  by  the  placenta  or  by  a  clot.  The 
entrance  of  air  into  the  uterus  is  elfected  during  intra-uterine  manipulations, 
siieli  as  the  introduction  of  the  hand;  the  giving  of  an  intra-utcrinc  douche  ;  by 
aspiration  following  a  change  in  the  posture  of  the  patient.  It  has  been 
!issert(;d  that  air  may  be  aspirated  into  the  uterus  by  the  movements  of  ordinary 
respiration  (.\niussat),  or  that  its  presence  in  the  uterus  may  be  due  to  decom- 
piwitiiMi  (Churchill)  or  to  alternate  contractions  and  relaxations  of  the  uterus 
following  delivery  (Simpson),  Winekcl '^-  mentions  a  case  uf  air-embolism 
and  sudden  death  due  to  carcinoma  complicating  labor. 


804 


AMERICAN    TEXT-BOOK    OF    OBSTETRICS. 


;.t. 


m  I 


Symptoms. — There  may  be  difficulty  in  breathing  and  a  temporary  loss  <if 
consciousness  when  the  quantity  of  air  entering  the  veins  is  small ;  whoii  a 
large  amount  rapidly  enters  the  veins,  respiration  and  circulation  are  immedi- 
ately and  desperately  embarrassed ;  the  patient  may  utter  a  cry  of  alarm,  anil 
at  once  becomes  unconscious  with  or  without  convulsions.  The  cause  of  doatli 
is  probably  mechanical  interference  with  the  circulation. 

Ti'catment. — Very  little  can  be  done  for  the  patient  even  when  assistaino 
is  close  at  hand.  The  cervix  should  be  cleared  of  clots;  artificial  respiratidii 
and  the  hypodermatic  administration  of  stimulants  should  promptly  be  em- 
ployed. Tracheotomy  and  the  inhalation  of  oxygen  gas  in  order  to  inflate  tlie 
lungs  and  to  expel  the  air-emboli  have  been  suggested. 


REFERENCE    LIST. 


f'i  '.•'< 


1.  Cornil :  Cenlralblatt  fiir  Gynukoloyie,  1889,     21. 

p.  223.  ' 

2.  Clivio  and  Monti :  ibid.,  1889,  p.  245.  '  22. 

3.  Liistig:  ibid.,  1889,  p.  246. 

4.  Biimm :  ibid.,  1889,  p.  723. 

5.  Mironow:  ibid.,  1890,  p.  (J79.  23. 

6.  Doyen,  C'ushing :  ibid.,  1889,  p.  246. 

7.  Doderlein  :  ibid.,  1891,  p.  39.  24. 

8.  Bumm:  il)id.,  1891,  p.  1036.  25. 

9.  Harold  C.  Ernst :  American  Si/stem  of  Ob-    26. 

stetricH,  Phila.,  1889,  vol.  ii.  p.  427. 

10.  Oliver  Wendell  Holmes :  Easay  on  Puer- 

per<d  Fever  n.s  a  Private  Pestilenee,  Bos-     27. 
ton,     1855,    originally    printed    its    an 
article  on  the  "Contagiousness  of  Pner-    28. 
peral  Fever,"  in  the  New  Eiigtaitd  Quar- 
terUj  .Jourmd,  1843.  29. 

11.  Semmelweiss :     Wiener    ZeitKchrift,     Dec,     30. 

1847  ;  Sclimidt's  Jahrbiicher,  1848,  vol. 
Iviii.  p.  196. 

12.  Cliius.  I).  Meigs  :    Woman,  her  /)(Vo.sc<s  and    31. 

ItemedieK,  2d  ed.,    I'liiladelphia,    1851, 
p.  608. 

13.  R.  P.   H(arris)  :   American  Journal  of  the    32. 

Medical  iScienre.i,  April,  1875,  )>.  474.       | 

14.  Sir^dey  :   Leu  Maladie-i  puerperulc^,   Paris, 

1884,  p.  99.  33. 

15.  Cenlralblatt  fiir  (ij/niikolof/ie,  1891,  p.  797. 

16.  Sir^dey  :  Leu  Maladies  pnerperalex,  p.  98.        34. 

17.  Archiv  fiir  Gynlikologie,   1888,  vol.  xxii.  p. 

433. 

18.  Carl  Braun  :    Centralblatt  fiir  (hjniikologie, 

1889,  vol.  xiii.  p.  636.  35. 

19.  Bumm  :  Centralblatt  fiir  Gyncikulogie,  1889, 

p.  723.  36. 

20.  Depaul :    De  la   Fihre  puerperale,    Paris, 

1858,  p.  31. 


C.  S.  Credd  :  Archiv  fiir  Gymikologie,  1S,S4, 

vol.  xxiii.,  No.  1,  p.  77. 
Buscil  :  Netie  Zeilachrift  fiir  Geburl-ikiinde, 

vol.    xxxii..    No.    3;    Schmidt's  Jalir- 

bilcher,  1853,  vol.  Ixxvii.  p.  40. 
Bunmi :  Centralblatt  fur  Gyniikoloyle,  Iss',), 

p.  724;  Doderlein:  ibid.,  1891,  p.  tl',1. 
Doderlein  :  ibid.,  1891,  p.  1020. 
Mironow:  ibid.,  1890,  p.  678. 
H.  A.  Kelly:  "Hand  Disinfection,"  .limr- 

lean    Joanud  of   Obstetrics,    1891,    vdl. 

xxiv..  No.  12,  p.  1415. 
Doderlein :     Centralblatt  fiir    Gyniiknlniiu-^ 

1892,  p.  214. 
Barker :  The  Puerperal  Diseases,  4tli  edi- 
tion, 1878,  p.  476. 
Gazette  de.'<  Ilopitaur,  1866,  p.  151. 
Semmelweiss :   Die,  yEliolocjie,  der  liciiriif, 

und  die  Prophylaxis   des  Kiiulbeltliilniy, 

Wien,  1861,  p.  3. 
Billet :    De  la  Fitfvre  puerperale  el  il,-  h 

Eeforme    des    Maternites,     Paris,    \f<li, 

p.  59. 
Die   Arbeiten   der    Puerperallivber-('niiiin!i'- 

sion    in    Berlin,    Stuttgart,    187s,   pp. 

28,  81. 
Ehlers :    Zeitschrift  fiir    Gebiirtsliiil/r    mul 

Gyndkologie,   1889,   vol.  xvi.   p.  I')!. 
E.  Ingerslev :  Comple  remlu  des   Tivntit/ 

de  la  Section  d' Ohstetriipie  et  de  (iijiii- 

cologie  de  la  Huitihiu;  Sessuin  dii  ('(iii<iii.< 

tnteriMtiomd,  1884,  p.  106  et  .vc*/. 
A.    Hcgar:     Centralblatt  fiir    Gyiiiil.ulniili', 

1890,  p.  629. 
Garrigues .    Transartion.t  of  the  .{iinrmiii 

Gynecological  Society,   1885,  vol.  x.  pp. 

96-116. 


REFERENCE   LIST. 


805 


iiporary  loss  (if 
small ;  when  a 
ion  are  immcdi- 
y  of  alarm,  and 
e  cause  of  death 

when  assistance 
ficial  respiration 
>romptly  bo  cni- 
der  to  inflate  the 


nd  Diseasen,  4tli  eili- 

18()fi,  p.  l-')!- 
JEtuibvjii',  (kr  Ih'ill 
w   des  Kimlhetlliiliirf, 

re  puerpemle  <(  ''>   I" 
ternilh,    Paris,    If^T'J, 

''nerperalfifber-Cdinini.-'- 
Stuttgart,    IKTS,   pj.. 

fur    r,eburtshiilf<-    ""<' 
1),  vol.  xvi.  p.  -l''!- 
l)(,.    rendu  (/ex    TraMiu 
^hxtctriqite  it  <li'   '.'i/"t'- 
fhiie  Srmiiii  ''"  '  "".'/'■'■•' 

4,  p.  lOli  el  .■"■'/. 

tb/(i«  /iJi-    fli/'i'f /."'"'/'■'•. 

LoH,s   «/  Me   .lm.nV(r« 
lely,   188.J,  v.-l.  ^.  !'!'■ 


'M.  A.  Stadfeldt:  Des  MalernileH,  Copenhof^en,  1 
187ti,  p.  12;  IJischoH':  Znr  I'rophi/kuin  • 
des  I'uerpendjiebers,  JSusul,  1870  ;  lliind- 
scliin  :  C'enlndblutt  fiir  (ii/ndkotogie,  1889, 
vol.  xiii.  p.  828. 

:i8.  Stadfeldt:  loc.  cit.  ;  Eiirendorfer :  Areldv 
fiir  (ijjndknIiH/if,  188(i,  vol.  xxviii.  p.  193 

;19.  II.  J.  Garrigues:  "Corrosive  Sublimate  and 
Creolin  in  Obstetric  Practice,"  ylmmcan 
Jourmd  of  the  Medieid  Sciences,  Aug., 
1889,  vol.  xviii.  pp.  109-128. 

■10.  Abegg  and  Menge :  Ventralblatt  fiir  Gyna- 
k-olui/ie,  189.S,  vol.  xvii.  p.  980. 

U.  Bumm  :  ibid.,  1893,  vol.  vii..  No.  42,  p. 975. 

42.  Adrian  Schucking;  ibid.,  1877,  vol.  i.  p.  33; 

Sclirader:  ibid.,  1893,  vol.  xvii.  p.  379. 

43.  Pippingskjold :  ibid.,  1891,  p.  680. 

44.  Schrader :  ibid.,  1893,  p.  379. 

4.}.  Bumm :  ibid.,  1893,  No.  42,  p.  975. 
4(1.  Frank:  ibid.,  1893,  p.  978. 
47.  Kroenig :  Md.,  p.  979. 

45.  Koland:  Md.,  1891,  p.  30. 
411.  Frank:  ibid.,  1893,  p.  978. 

50,  Zweifel :  Archiv  fiir  Gyndkologie,  1885,  vol. 

xxvii.  p.  315. 
ol.  Binz  :   Grundziige  der  ArzneimiUellehre,  ^t- 

lin,  1874,  p.  109. 
.")2.  Baclie  McE.  Emmet :   New  York  Medical 

Record,  March  19,  1892. 

53.  II.  J.  Garrigues :  "The  Opium  Plan  in 

Puerperal  Peritonitia,"  New  York  Med- 
ical Journal,  Jan.  24, 1885,  vol.  xli.  p.  98. 

54.  liottschalk :    Centralblalt  fiir   Gyniiknlogie, 

1889,  p.  554. 

55.  Frank  :  ibid.,  1893,  vol.  xvi.,  No.  42,  p.  979. 
5ti.  Knnge :  Archiv  fiir  Gyniikolngie,  1888,  vol. 

xxxiii..  No.  1,  p.  39. 

57.  Maury  :  Medical  News,  Oct.  3, 1891  ;  Outer- 

bridge  :  New  York  Jouriud  of  Gynecology 
and  ObMetries,  April,  1892. 

58.  Bnrchard :    New    York    Medical    Journal, 

Aug.  15,  1885. 
51t,  Thierry  :  Centralblalt  fiir  Gynakologie,  1893, 

vol.  xvii.  p.  1518,  from  Lyon  Medical, 

June  26,  1892. 
60.  Parvin'B  Science  and  Art  of  Obstetric.^,  1886, 

p.  532. 
(JI,  .Miinchener  medicinitche  Wochenschrift,  1888, 

p.  653. 
0'.',  Zeihehrifl  fiir  Gelmrt.'<hiilfe,  Bd.  ii.  p.  225. 
tin.  Siinger:  GeA.fiir  Gyndkologie  zu  Bonn,  Bd. 

iv.,  1891,  p.  333. 
•14.  Archiren  de  Tocologie,  1891,  p.  81. 
05,  Loc.  cit. 

66,  Ceutralblatt  fiir  Gyniiknlogie,  1894,  No,  21. 

67.  Mediciiiiache  JahrbUch,  iii.  887. 


68.  Puerperal  Convalescence  and  Diseusen  of  thi 

Puerperium,  New  York,  1886,  p.  79. 

69.  Centralblalt  fiir  Allgenieine   Pathologic  u. 

patliologische   Anutoniie,    Bd.   ii..  No.  1, 
1891. 

70.  Berliner  klinische  Woehenschrift,  No.  vi. 

71.  American  Journal  of  Obstetrics  and  Disea.'(ei 

of  Homed  and  Children,  May,  1895. 

72.  Archives   de    Tocologie   el   de    Gynecologic, 

1891,  xviii.  p.  28. 

73.  Pathologic  u.  Therapie  des  Wochensbell. 

74.  Holmes:  System  of  Surgery,  vol.  iii.,  1883, 

p.  435. 

75.  Journal  of  Anatomy  and  Physiology,  Lon- 

don, 1890  and  1891,  p.  304. 

76.  Thise    de    Paris,    1894;    Contributions   A 

V Elude  de  I' Allaitment  maternal, 

77.  Miiller:  Handbuch  der  GeburlshiUfe. 

78.  Diseases  of  the  Breasts,  London,  1894,  p. 

544. 

79.  London  Lancet,  vol.  ii.,  1889,  p.  12. 

80.  Davis:   "The  Preventive  Treatment  of 

Mastitis,"  Ajnerican  Journal  of  Obstetrics, 
vol.  XXV   p.  476. 

81.  American  System  of  Obstetrics,  vol.  ii.  p. 

380. 

82.  Velpeau :    Traite  des  Maladies  du  Sein, 

Paris,  1854,  pp.  15,  16. 

83.  Munchener  medicinische  Woehenschrift,  No, 

25,  1888. 

84.  Pathologien,  Therapie  des  Wochenshetl,  1878. 

85.  Inaugural  Dissertation,  Heidelberg,  1889. 

86.  Zeitschrifl  fiir  Hygiene  und  Infeclionskrank- 

heilen,  Bd,  xiv.,  1893. 

87.  Loc.  eil. 

88.  Archiv  fiir  Gyndkologie,  Bd.  xxiv.,  1884, 

S.  262. 

89.  Tliise  de  Paris,  1891. 

90.  Ijoc.  cit. 

91.  Fortschritte  der  Medicin,  Band  iii.  S.  231. 

92.  Satnmlung   klinischer    Vorlrlige,    No.   282, 

1886. 

93.  C'orscn:    "The  Trealment  of  Miimtnary 

Abscess,"  American  Journal  of  ObHlelric", 
Jan.,  1881. 

94.  American  Journal  of  Obstetrics,  vol.  xxvii. 

p|).  58,  414. 

95.  Berliner  klinische  Woehenschrift,  1888. 

96.  Virchou's  Archie,  Bd.  cxxvi.,  Oct.,  1801. 

97.  Ilamniarsten:      Physinlogienl      Chemistry, 

translated  by  Mandel,  New  York,  1893. 

98.  Lnneet,  Nov.  15,  1800. 

99.  Archives  of  Pediatries,  vol.  i.,  1803,  p.  199. 
100.  Koating's    Cyelopa-dia   of  the   Diseases  of 

Children,  arti(4e  by  T.  M.  Uotcb,  vol. 
i.  p.  275. 


t,  i*  '^ 


fi 


li  • 


AAflJllICAN    TEXT- HOOK   OF   OliSfETUIC^'. 


80G 

101.  Gy6(t>/iszut,  1892,  Xo«.  48,40.  |  122. 

102.  Atrhiv /.  Kinda-hiilkundc,  M.  xiii.  II.  1 

mid  2.  123. 

103.  />()<•.  <(V.  124. 

104.  I'hiiinKinl,  1S92,  M.  vii.  ji.  491. 

10").   (iitzrtle   lie    Gi/iicciihxjii;    I'siris,    Fi-b.    15,  125. 

1S91. 

lOli.  Zt'ihchrifl  fiir  Ifuf/inic  and  fnfniuiiinkmnk-  120. 

hcilni,  1S93,  li(i.  xiv.  pp.  207-249.  127. 

107.  riVc/ioicV  vlir/iiV,  No.  12ti,  1.S9I. 

108.  I'mr/er  mcdieitiiiiirhe  Wnchcmrlirifl,  KS90,  p.  128. 

279.  129. 

109.  lirritf  dfs  Sciiiices  mrilical,  July,  1894. 

110.  l\'!<lir  mrdlriiiiKchc  chintrgiselw  PrexKe,  Bii-  |  130. 

(lapust,  1890.  '  131. 

111.  Kditorial  in  Indian  Medical  lieroid,  ,]n\y, 

1890.  j  132. 

112.  ll'iViKT  klinischr  Wochennchrift,  Xos.  51  and 

52,  1888.  I  133. 

113.  Aiivard:  Accoiirhcmentx,  y>.  ^iu. 

114.  Tniifr   (/('   Midddien  dc  la  GromteMC  ct  dc  '  134. 

Siiilen  de  Couclny,  Paris,  1894. 

115.  Mi'dical  /V(W  and  Circular,  May  9,  1888.       13,5. 
lit).   Gaztllc    de    Gynirnloyic,    Paris,    Fel).    15,     130. 

1891.  137. 

117.  Olmlilrir  Medicine  and  Siiri/rnj,  vol.  ii.  p.      138. 

470,  18S.5. 

118.  Archives  dc    TocoUxjie   ct   de    Gijnecoloyic,     139. 

sviii.,  1891.  140. 

119.  Miiller,    Ilandbuch   dcr   GcburUhiUfe,  vol. 

iii.  p.  533.  141. 

120.  Miinchc'r.    ,.:■■>.  Wochenschrift,  March  13, 

1894,  p.  204. 

121.  CiMilis:  fis  Htioloi/ij,  PatholiH/n,  and  Treat-     142. 

meni,  liorlin,  1890.  | 


Anmdcx  des  Maladlcx  des  Orijanes  f)cnilii- 

urinaircti,  .\pril,  1H93. 
Ccntralhlatt  filr  Vhirunjie,  No.  27,  1893. 
Zeituchrift  f.  Gehnrl.  uml  GyniilKolofiie,  I!;iiii| 

.\.\x.  Holt  1,  1894. 
American   Syntem  of  Ob.-iletrici',  vol.   ii.  |. 

(i28. 
Unirernity  Medical  Mayazine,  1893. 
Archie  /lie  (lyniikolayie,   vol.    .xiii,,    IS'.i'J, 

jiart  .3. 

/,()('.  cil. 

Miinchener  mtdicinische  WochenKchrij'l,  Nd. 

14,  1890. 
MiilU'r's  llandbnch. 
American  dimrnal  itf  Medical  Science,  Vdl. 

xxxiii.,  1893. 
Nourcllcs  ArchiecK  d' Obstctriqnc  et  de  (iijnf. 

coleiyie,  1893. 
Zeituchrift  filr  Gebnrtnliiiljc  and  Gyniikaldiiie, 

1891,  p.  371. 
Jimrnal  of  the  American   Medical   Ai'.-'nei- 

((//()»,  .Inly  19,  1892. 
IjOC.  cil. 

Vin-iiow's  Archie,  Hd.  cxxx.  p.  453. 
American  Journal  of  Iniianily,  Oot.,  ISIt:!, 
Archie   fiir   PKychialric   nnd   Acrrcnkninh- 

heiten,  xxv.,  1893. 
Loc.  cil. 
Journal   of  the  American  ^fe(lic(d  As^ioci- 

atwn,  July,  1892,  xix.  p.  59. 
Ueber  Kintritt  ron   Luff  in  die  I'eueii  iln- 

Gebiirmutler   bei   und   nach   der    Gehnrl, 

Bonn,  1885. 
Text-Hook  of  Midwifery,  AnuT.  id.,  IS'iO, 

p.  543. 


a  Oryitne.i  (j!'n\li>- 


tMfli-iiv,  vol.   ii.  I' 


V.  THE  NEWBORN  INFANT. 


T.  PHY8I(^L(XiY  OF  THE  NEW-P.ORN  INFANT. 


W 


1 


mi 


Wor.hemchi-ij't,  Ni 


rii,  AnitT.  id.,  ISIHI, 


TliK  pliysiolojjy  of  the  now-born  infant  diil'ors  in  many  ossontial  rtspocts 
iVoni  tliat  of"  tlio  adnlt.  A  bt'ttei'  nn(i»'ivtan<lin<>;  of"  tlicso  (liH'LToncc's  than  we 
now  possess  wonUl  no  donbt  aid  ns  greatly  in  (iu;  proper  interpretation  of"  the 
,-iiffns  of"  approaching  and  of"  exi.'^ting  di.seasc,  as  well  as  in  the  nianagenient 
and  treatment  of"  the  disorilers  of  infancy.  In  the  pre.sent  articile  only  those 
physiological  differences  between  the  new-born  and  the  adult  will  be  con- 
sidercil  that  are  of  special  importance. 

Growth:  Wc'Kjht, — Tlu;  new-born  child  weighs,  upon  the  average,  seven 
lutnnds  (.'548.'}  grains),  boys  weighing,  as  a  rnle,  about  half  a  pound  more 
than  girls.  A  considerably  less  weight  than  this  is  frccpiently  observed  in 
|)('rf"eetly  .sound,  woll-develo|)ed  babies,  pi^rticularly  in  the  case  of  twins,  while 
ten-  and  tw(!lve-pound  babies  are  not  uncommon.  Tho.se  weighing  over 
twelve  poinids  are  occasionally  seen,  and  if  published  records  are  to  bo  trii.sted 
(liildren  have  been  born  weighing* as  much  as  twenty-four  pounds.  It  has 
been  shown  that  the  weight  of  tlu;  child  is  greatly  influenced  by — 1,  the 
length  of  gestation  and  the  nourishment  of  the  f"etus  ;  2,  the  age  of  the  mother 
(very  young  mothers  giving  birth,  as  a  rule,  to  small  babies);  .'{,  the  size  of 
tli(!  mother  (the  weight  of  the  child  being  5.23  per  cent,  of  that  of  the 
iiiotlier) ;  4,  the  inunber  of  previous  pregnancies  (the  weight  often  progress- 
ively increasing  up  to  the  fourth  or  fifth  pregnancy)  ;  and  o,  the  intluenco  of 
nice  and  climate.  For  two  or  three  days  after  birth  there  is  usually  a  lo.><s  in 
weight  of  from  three  to  six  (»iuices,  which  lo.<s  is  probably  <luc  to  an  ab.sence 
of  imtritive  material  from  the  maternal  manuuary  secretion  during  this  time, 
as  well  as  to  the  increased  ti.ssue-change  con.<e(|uont  upon  the  cireidatory 
changes  and  upon  the  establishment  of  respiration.  The  l(».><s  is  greater  in 
small  than  in  large  children,  and  they  do  not  so  (piicUly  recover.  After  the 
establishment  of  the  flow  of  milk  the  child  begins  to  gain,  and  u.sually  by  the 
end  of  the  first  week  it  weighs  about  as  much  as  it  did  at  birth.  The  gain  is 
somewhat  .slower  in  those  babies  fed  on  artificial  f"ood  or  oven  upon  (!ow's  milk. 
TJio  increa.se  after  the  first  week  varies  considerably,  and  it  is  dependent  upon 
a  ninnber  of  conditions,  such  as  sex,  race,  nutrition,  etc.  The  increase  may  be 
very  irregular,  an  interval  in  which  there  may  bo  neither  loss  nor  gain  follow- 
ing or  preceding  a  ([uite  rapid  increase  in  weight.  Approximately,  however, 
it  has  been  computed  that  an  average-sized  healthy  child  will  gain  about  .78 
ounces  daily  for  the  first  throe  months,  .Go  ounces  daily  for  the  second  throe 
iiKinths,  .45  ounces  daily  for  the  third  three  months,  and  ..")()  ounces  daily  f"()r 
the  fourth  three  months.     The  total  weight  would  therefore  be,  at  the  end 

H(I7 


I 


■i=:r 


\ 

1 

[ 

fe'i  ' 

' 

r,     1 

\.-i 

Kl' 

**  ; 

;■:  'V 

f' 

m  : 


n 


"M 


i:' 


i\m 


8()H 


AMKJilCAN    TKXT-nOOh'   OF   OBSTETRICS. 


of  throe  months,  ten  ])oiin(ls  ;  at  the  end  of  six  montlis,  from  tliirteen  to  four- 
teen pounds;  at  nine  niontlis,  from  .sixteen  to  seventeen  pounds;  and  at  twelve 
months  from  nineteen  to  twenty  poiuids,  the  inerease  in  weiglit  being  doubiud 
in  tiie  first  six  months  and  trebled  in  the  seeond  six  months. 

Li'U()th. — At  birth  the  average  healthy  child  measures  between  nineteen 
and  twenty  inehes  (oO  (!m.)  in  length,  the  male  being  slightly  longer  than  tlic 
female.  ]Jy  the  end  of  the  first  month  the  ehild  will  show  a  length  of  'I'D, 
inehes;  at  the  third  month,  25J  inches;  at  the  sixth  month,  281  inehes;  at  tlie 
tenth  month,  .'Ml  inehes  ;  at  the  fifteenth  month,  34^  inches,  etc.,  thus  showiiicf 
an  inerease  in  length  of  3  inches  during  these  periods.  During  the  first  year 
there  is  generally  a  gain  in  length  of  from  G  to  10  inehes.  There  may  »• 
times  be  a  rapid  increase  in  weight  with  no  inerease  in  length,  and  at  other 
times  an  inerease  in  length  with  no  corresponding  gain  in  weight.  In  making 
accurate  observations  the  growth  in  weight  and  in  length  should  be  compared 
and  due  allowance  l)e  made  for  the  jiassage  of  feces  and  urine. 

Size  and  Gnmfh  of  the.  Head,  Thorax,  etc. — The  oeeipito-frontal  circumf(!r- 
enee  of  the  head  of  an  average-sized  new-born  infant  is  about  13f  inehes  for 
males  and  \'^\  inches  for  females  (34.5  cm.).  At  the  end  of  twenty-one 
months  the  circumference  has  increased  to  about  19^  inches.  The  anterior 
fontanelle  continues  to  increase  in  size  until  the  ninth  month ;  then  it 
gradually  closes,  finally  becoming  completely  closed  in,  ossification  taking 
place  from  the  borders  in  from  sixteen  to  eighteen  months. 

The  average  circumference  of  the  chest  at  birth  is  about  12^  inches;  tlii^ 
increases  to  16|-  inches  in  twenty-one  months.  The  rate  of  chest-growth  is 
more  rajiid  than  that  of  the  head.  The  body  is  proportionately  wider  in  tlie 
infant  than  in  the  adult.  The  antero-posterior  measurements  of  the  head  and 
the  pelvis  are  the  same  at  birth  in  males  and  females. 

Respiration. — In  response  to  stinndation  of  the  respiratory  centres  tlie 
child  iminediately  after  birth,  sometimes  before  and  sometimes  aller  the  cessa- 
tion of  pulsation  in  the  cord,  makes  its  first  inspiratory  effort.  After  one  or 
more  such  efforts  many  of  the  collapsed  vesicles  are  distended  and  filled  witli 
air.  Generally  the  eom])lete  unfolding  of  the  alveoli  does  not  take  place  until 
the  second  day.  This  first  inspiration  is  followed  immediately  by  exjiiration, 
and  the  mechanism  of  pidmonary  respiration  is  established.  The  new-born 
child  breathes  about  forty  times  a  minute.  Its  respirations  are,  however, 
irregular,  and  they  may  be  influencetl  considerably  by  slight  causes;  ilir 
instance,  there  may  be  a  suspension  for  eomj)aratively  long  intervals  by  atten- 
tion, by  nuiscular  effort  of  various  kinds,  by  fright,  etc.  Respiration  is  most 
regular  during  sleep,  and  this  is  the  only  time  in  which  it  may  accurately  he 
observed.  A  much  larger  pereentage  of  the  respired  air  is  exchanged  in 
infancy  than  in  adult  life,  the  amount  being  one-fourth  in  the  former  to  one- 
tenth  in  the  latter.  The  exchange  is  generally  feeble  at  first,  being  a  third 
more  at  the  end  of  the  first  week  than  on  the  first  day.  In  respiration  the 
thorax  is  elevated  progressively  from  above  downward,  the  work  being  done 
largely  by  the  diaphragm. 


{    < 


PHYSIOLOGY   OF    THE   NEW-HORN  INFANT. 


SO!) 


lirtecn  to  four- 
;  and  at  twolvc 

being  douljltil 
s, 

twecn  ninotccii 
longer  than  tin' 

length  of  22  i 
\  inches  ;  at  llic 
;.,  thus  showiiiii 
g  the  first  yt'iir 
There  may  a* 
h,  and  at  other 
ht.  In  niakini!; 
lid  be  compared 

'ontal  circumfer- 
t  13f  inches  for 
I  of  t^venty-0IU' 
^.  The  anterior 
month ;  then  it 
isification  taking 

12^  inches ;  this 

f  chest-growth  is 

tely  wider  in  tlie 

of  the  head  and 

itory  centres  tlie 
s  after  the  cessii- 
rt.     After  one  or 
d  and  filled  witli 
t  take  place  until 
ily  by  expiration, 
The  new-born 
lis  are,  however, 
light  causes;  for 
tervals  by  att(>n- 
spiration  is  must 
nay  accurately  Ix' 
is  exchanged  in 
le  former  to  one- 
st,  being  a  tliinl 
n  respiration  the 
work  being  done 


Circulatory  System. — With  the  first  inspiration  of  the  new-born  child 
there  is  a  complete  alteration  of  the  circidation  of  the  blood.  The  pulmonary 
arteries,  until  now  containing  oidy  sufficient  blood  to  supply  the  pulmonary 
nutrient  vessels,  become  fully  distended  with  blood  to  be  carrii'tl  to  the  lungs 
for  ae'ration.  The  flow  of  blood  being  diverted  from  the  ductus  arteriosus  to 
the  pulmonary  arteries,  largely  by  the  enlargement  of  the  thorax  in  the  first 
act  of  inspiration,  the  duet  partially  colla|)ses,  thrombi  fi)rm  within  it,  and  it 
rapidly  becomes  obliterated.  When  the  umbilical  cord  is  tie<l  or  the  circula- 
tion through  it  ceases  spontaneously,  the  umbilical  arteries  and  vein  and  the 
ductus  venosus  become  at  once  greatly  nKluced  in  size,  fill  with  thrombi,  and 
finally  become  converted  into  fibrous  cords.  The  foramen  ovale  is  more 
gradually  closed,  the  edge  of  the  Eustachian  valve  remaining  free  for  some 
time,  but  at  the  saine  time  affording  complete  protection  to  the  foramen. 

(3wing  to  the  niore  rapid  growth  of  the  upper  part  of  the  body  and  to  the 
])roj)ortionatelv  large  atnount  of  work  thrown  upon  the  lungs,  the  carotid, 
subclavian,  and  pulmonary  arteries  are  comparatively  large.  At  the  same 
time  the  heart  is  small,  so  that  the  systemic  blood-pressure  in  the  new-born 
is  low.  The  pulnionary  artery  is  much  wider  than  the  aorta  in  iniancy — 
more  so  than  in  later  life — so  that  the  pulmonary  blood-pressure  is  greater  in 
the  infant's  than  in  the  adult's  lungs.  The  size  of  the  heart  is  to  the  width 
of  the  ascending  aorta  as  25  :  20  in  the  new-born ;  in  the  adult,  290  :  61. 
The  systemic  blood-jjressurc  is  raised  as  the  heart  increases  in  size  and  the 
aorta  becomes  relatively  smaller. 

The  blood  of  the  new-born  is  comparatively  less  in  amount  than  that  in 
the  adult,  but  after  a  few  months  the  proportion  of  blood  to  body-weight  is 
more  than  in  the  adult,  but  with  a  low  specific  gravity  (1045-1049).  At  birth 
the  amount  of  hemoglobin  is  large  (22  per  cent.),  but  the  amount  of  fibrin 
is  small.  The  hemoglobin  begins  at  (mce  to  diminish  in  amount,  reaching 
its  minimum  at  the  sixth  month.  The  fibrin  rapidly  increases  in  amount. 
The  infant's  blood  contains  more  white  corpuscles  than  does  that  of  the  adult, 
less  salts,  and  less  soluble  albumin. 

The  pulse  for  a  few  weeks  after  birth  is  very  feeble  and  rapid,  and  it  is 
easily  disturbed  and  accelerated  by  slight  causes.  During  sleep  in  the  first 
week  it  averages  about  120  beats  to  the  minute;  while  awake,  120  ;  and  under 
excitement,  148  to  150.  I^ater  the  number  of  pulsations  diminish  during 
sleep,  while  the  number  under  excitement  increase.  Posture  has  but  little 
effect  upon  the  fre(]uency  of  the  pulse. 

Digestive  System. — Saliva  is  secreted  immediately  after  birili,  but 
in  very  small  quantities  and  of  weak  diastatie  action.  The  salivary  glands 
arc  poorly  developed,  and  fi)r  a  few  weeks  at  least  the  saliva  is  furnished 
almost  wholly  by  the  parotid  gland.  After  two  months  the  amount  secreted 
is  considerably  increased,  and  it  shows  much  greater  diastatie  jjower.  At 
eleven  months  the  diastatie  ])ower  of  the  salivary  secretion  is  nearly  equal  to 
that  of  the  adult. 

Tlie  stomach  is  relatively  smaller,  more  cylindrical,  and  more  vertically 


I 

i 

1 

I 

^M 

«■ 

1 

■ 

810 


AMERICAN   TEXT-BOOK   OF   OBSTETItrCS. 


situated  than  in  tiie  adult,  and  its  nuiHoular  structure  is  poorly  developed.  At 
birth  tiie  capacity  of  the  stomach  is  about  one  ounce,  and  there  is  an  increase 
of  one  ounce  per  month  up  to  the  sixth  ni<mth,  after  which  the  increase  is  not 
so  rapid.  The  healthy  stomach  contains  saliva,  mucus,  iiematin,  and  blo(xl-cor- 
j)uscles.  During  the  first  two  months  of  life  the  normal  acid  for  the  stomacii 
is  hydrochloric  acid.  The  (piantity  of  food  in  the  stonuich  diminishes  rapidly 
during  the  first  hour,  and  in  from  two  to  two  and  a  half  hours  the  bahuico 
entirely  disappears.  The  contents  of  the  stomach  are  not  so  decidedly  acid  ;is 
in  that  of  adults.  Albinnin  is  seldom  found  in  the  stomach,  and  only  during 
the  first  hour  of  digestion.     Water  assists  in  the  digestion  of  casein. 

The  pancreuti  remains  in  an  undeveloped  condition  for  five  or  six  months 
after  birth,  and  the  action,  therefore,  of  its  secretion  is  very  feeble  indeed. 
The  livri'  is  of  very  large  relative  size  at  birth,  occupying  more  than  half 
of  the  entire  abdominal  cavity.  Bife,  light  brown  in  color,  is  secreted  early, 
and  gives  to  the  feces  their  orange-yellow  color. 

The  Hmall  infedine  is  comparatively  long,  being  at  birth  about  9  feet  .5 
inches  in  length,  and  it  grows  at  the  rate  of  2  feet  per  month  for  two  months. 
Tiie  intestinal  villi  are  numerous,  are  as  large  as  those  in  adults,  and  arc 
supplied  with  very  large  capillaries,  through  which  absorption  is  quite  rapid. 
The  glands  of  Lieberkiihn  and  Peyer's  glands  are  few  in  number  and  arc 
poorly  developed.  There  is  a  very  copious  secretion  of  mucus,  which  readily 
undergoes  acid  fermentation,  especially  in  the  presence  of  particles  of 
undigested  food,  the  feebly  alkaline  secretions  of  the  liver,  pancreas,  and 
intestines  being  easily  neutralized. 

The  large  ititentine  is  also  of  relatively  great  length,  measuring  1  foot  30 
inches  at  birth.  The  ascending  and  transverse  colons  are  short  compared 
with  the  descending  colon,  especially  the  sigmoid  flexure.  This  structure  is 
bent  upon  itself  from  one  to  three  times,  and  it  is  the  cause  of  congenital 
constipation.  Later  readjustment  takes  place,  the  ascending  and  transverse 
portions  increasing  in  length  at  the  expense  of  the  descending  colon. 

The  feces  of  the  new-born  consist,  during  the  first  two  or  three  days,  of 
meconium.  The  meconium,  which  has  been  accumulating  in  the  intestines 
during  fetal  life,  is  a  thick,  tarry,  greenish-black  substance  resembliDsr 
thick  poppy-juice.  It  consists  of  bile  and  mucus,  together  with  epitlieliiil 
cells,  fine  hairs,  and  fat-globules  from  swallowed  amniotic  fluid.  On  the  third 
or  the  fourth  day  the  feces  consist  of  a  mixture  of  meconium  and  digested 
milk.  After  the  fourth  day  the  feces  are  light  orange-yellow  in  color  and 
they  consist  of  the  residue  of  digested  milk.  They  are  passed  from  two  to 
four  times  a  day. 

Urinary  System. — At  birth  the  kidneys  are  lobulated,  fully  developed, 
and  functionally  active,  the  secretion  of  urine  taking  place  before  birth.  A 
gradual  change  takes  jilace  in  the  form  of  the  kidney,  so  that  in  about  two 
vears  it  loses  its  lobulated  form  and  resembles  the  adult  kidney,  being  rela- 
tively somewhat  larger. 

The  Skin. — Owing  to  more  or  less   obstruction   of  the  fetal  circulation 


PIIYSIOLOiiY    OF    THE   NFAV-ItOltX  INFANT. 


Hll 


I 

l^F 

'  •  1 ; 

f  11 

;< 

letal  circulation 


(luring  delivery  the  child's  skiu  is  at  first  of  a  livid  hue.  Hpou  the  cstahlisii- 
uient  of  respiration  this  hue  is  changed  to  a  deep  red,  due  to  the  irritant 
action  of  the  air.  In  a  few  days  the  color  is  changed  from  red  to  a  yellowish 
or  icteric  tint,  which  is  said  to  l»c  caused  l>y  the  deposit  of  l)lood-j)igtnont 
during  the  preceding  (longested  condition  of  the  skin.  The  yellowish  color 
gradually  fades,  the  skin  becomes  paler,  and  finally,  within  three  weeks,  the 
normal  rosy  tint  is  established.  More  or  less  des(iuamation  takes  place  during 
this  time  as  a  result  of  the  early  congestion. 

The  8H<forii)(iroHs  gldiidn,  on  the  one  hand,  are  almost  if  not  quite  inacitive 
at  birth  ;  the  ttclxurom  glands,  on  the  other  hand,  are  very  active  during 
fetal  life  and  up  to  the  end  of  the  first  year.  The  body  of  the  infant  at  birth 
is  covered  with  the  vernix  caseosa,  which  is  com|)osod  of  the  secn-etion  from 
the  sebaceous  glands.  The  hair  of  the  scalp  is  strong  and  from  1  to  2 
inches  long;  it  falls  out  later,  and  is  replaced  i)y  hair  finer  in  texture  and 
generally  lighter  in  color.  The  short,  fine,  downy  hair  with  which  the  whole 
body  is  covered  at  birth  drops  out  in  about  three  weeks,  and  is  not  re|>laced. 

Lymphatic  System. — The  lymphatic  system  is  relatively  better  developed 
and  more  active,  and  the  glands  larger  and  more  niunerous,  at  birth  than  in 
adult  life.  The  relation  between  the  lymphatics  and  the  other  tissues  and 
organs  of  the  body  is  very  close,  ;Mid  absorption  is  very  raj)id. 

The  temperature  falls  directly  after  birth,  but  by  the  end  of  the  second 
day  it  rises  to  the  maxinumi  again  (97.5°  to  98°  F.),  where  it  remains 
stationary. 

Pat  is  generally  absent  from  the  interior  of  the  body,  but  it  is  abundantly 
present  in  the  subcutaneous  tissues. 

The  muscles  at  birth  are  small  and  soft,  but  they  become  better  de- 
veloped, firmer,  and  more  resisting  by  the  sixth  month.  They  contain  more 
water  and  l(!ss  myosin  than  do  the  muscles  of  adults,  and  more  extractive 
matters,  fats,  and  inorganic  constituents. 

The  bones  are  less  brittle  than  later  in  life,  containing  a  large  percentage 
of  organic  matter. 

The  Nervous  System. — The  rate  and  degree  of  development  of  the 
nervous  system  and  of  its  various  functions  are  largely  influenced  by  heredity, 
environment,  and  by  the  health  of  the  child.  The  faculties  and  senses  are 
more  or  less  dependent  upon  each  other  for  their  perfect  development,  as  is  so 
clearly  shown  in  the  slow,  tardy,  and  incomplete  development  of  the  mental 
faculties  when  hearing  is  absent  or  defective,  and  in  the  non-appearance  of 
articulate  speech  when  the  sense  of  hearing  is  absent. 

Not  until  the  first  month  after  birth  does  the  gray  matter  appear  on  the  brain 
convolutions  ;  before  this  the  cerebrum  is  soft  and  of  a  uniform  color.  The 
niedulla  and  cord-centres  are  much  better  developed  at  birth  than  those  of  the 
bruin,  and  they  remain  more  active  throughout  infancy.  The  inotor  centres 
in  the  anterior  cornua  are  more  highly  developed  than  are  the  sensory  centres 
in  the  posterior  portions  of  the  cord.  The  extreme  reflex  excitability  in  the 
new-born  is  thus  a  physiological  process. 


i 


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f^.    ■'  ■ 

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•■J 

l.[  ii' 


!i: 


812 


AMKIIICAN    TEXT-nOOK   OF    OnSTi:TJiICS. 


Special  Senses. — The  spcfial  soiisos  all  rospoiid  to  stiinuli  at  biitli  or 
shortly  after,  but  to  a  liiiiit(><l  oxtoiit,  and  to  briiijr  out  these  reflexes  to  aiiv 
inarkcd  degree  the  stiiiudi  must  be  more  intense  or  nuist  be  applied  over  a 
larj^er  area  than  is  required  later. 

The  nenxe  of  xiiwll  responds  to  strong  stimuli  very  soon  after  birth,  and  the 
ability  to  distinguish  between  agreeable  and  <lisagreeable  <Mlors  is  aecpiiriMl 
early. 

Tantc  exists  even  at  an  earlier  period  than  does  smell,  and  the  response  to 
sweet  and  bitter  substances  is  different  immediately  after  birth,  the  child 
being  .soon  able  to  judge  between  the  difl'erent  forms  of  food  offered. 

Hearing  is  very  imperfect  at  first,  and  at  least  several  hours  elapse  before 
even  very  loud  or  sharp  noises  are  capable  of  exciting  responsive  movements. 
The  horizontal  position  of  the  tympanum,  the  as  yet  closed  Eustachian  tube, 
and  the  absentie  of  air  in  the  middle  ear  are  offered  as  reasons  for  the  imper- 
fection of  this  sense.  In  two  or  three  months  the  infant  is  able  to  determine 
from  which  direction  a  sound  conus.  The  projwr  development  of  the  mentiil 
faculties  depends  more  uj)on  the  sense  of  hearing  than  upon  any  of  the  other 
special  senses. 

SigJd  is  only  developed  at  birth  to  the  extent  of  a  feeble  response  to  very 
strong  lights.  Up  to  the  sixth  week  there  is  inability  at  co-ordination  of  tlio 
ocular  muscles.  After  this  time  the  eyes  begin  to  move  in  an  orderly  manner, 
and  they  will  follow  a  bright  object  moved  slowly  in  front  of  them.  At 
about  the  second  month  rapid  movements  are  perceived,  as  is  evidenced  by 
the  child  closing  its  eyes  quickly  on  an  object  suddenly  approaching  it. 
At  three  months  the  development  of  sight  goes  on  more  rapidly  and  tlio 
child  begins  to  separate  colors.  The  first  colors  recognized  are  yellow,  nul, 
pure  white,  gray,  and  black.  The  recognition  of  green  and  blue  comes  later. 
The  faculty  of  distinguishing  between  the  various  colors,  however,  is  not 
perfected  until  after  the  third  year.  The  estimation  of  size  and  distance  is 
gradually  developed  after  the  sixth  month.  The  mother  is  recognized  about 
the  third  month. 

TItc  senxe  of  feeling  or  touch  reacts  very  feebly  to  stimuli,  owing  to  the 
imperfect  development  of  the  brain  and  the  skin,  uidess  aj)pli<'d  over  a 
relatively  large  area.  Pleasurable  sensations  existing  'liirii'  the  m>i  thn>t> 
months  are  those  created  by  the  taking  of  food  wlier  '  the  act  of  suck- 

ing, the  sweet  taste  of  the  milk,  and  the  staying  igcr,  each  bi    "j;  in 

itself  a  i)leasurable  sensation.  A  little  later  the  1.  thy  ba'*'  who  is  not 
hinigry  enjoys  the  warm  bath,  the  stimulation  of  attention  b-  bright  objects, 
and  in  having  its  limbs  unconfined  by  clothing.  The  developing  ability  for 
grasping  after  three  months  gives  the  infant  additional  pleasure. 

Muscular  action  in  the  new-born  is  entirely  involuntary,  there  being  no 
voluntary  act  until  about  the  end  of  the  third  month.  Sucking  and  licking 
arc  not  dependent  entirely  upon  reflex  action,  but  are  largely  instinctive. 
The  stretching  and  bending  of  the  extremities  are  impulsive  acts,  and  occur 
during  sleep,  as  they  did  during  intra-uterine  life.     Straightening  of  the  legs 


.^fS 


J'ATI/O/JXn'    OF    Till':   XEW'-liOltN    INFANT. 


8i:i 


after  awakinj;  is  noticed  during  the  seeoiid  week.  Vocal  sounds  are  also 
inipidsive.  KeHex  movements  arc  not  so  strongly  marked  at  l)irtli  as  they 
are  a  little  later  on.  These  involnntary  movements  are  purposeless  and  show 
lack  of  co-ordination.  The  act  of  raising  the  head,  which  is  attempted 
toward  the  fourth  m.)nth  in  healthy  children,  is  volitional,  recpiiring  not  so 
much  added  strength  of  nniscle  as  power  of  co-ordimttion.  As  volition  de- 
velops the  power  of  co-ordination  gradually  increases,  and  the  child  learns  to 
jwrform  voluntary  or  purpttseful  acts,  V^oluntary  grasping  is  done  after  the 
fourth  month.  As  the  child  learns  to  halancjc  its  head  it  attempts  to  sit  up. 
This  act  is  not  suceessftilly  accomplished  until  about  the  fortieth  week ;  the 
chihl  sits  firmly  alone  when  ten  or  eleven  months  old.  Those  children  that 
creep  do  so  at  about  the  ninth  month.  Standing,  which  is  attempted  at  about 
the  ninth  month,  is  usually  successftd  at  the  end  of  the  first  year  or  a  little 
earlier.  Some  children  walk  as  early  as  the  eighth  month,  many  by  the 
twelfth  mouth,  while  some  do  not  walk  until  much  later.  Most  children  will 
walk  alone  by  the  sixteenth  month. 

Speech  is  very  gradiudly  developed,  distinct  words  not  being  uttered 
nuich  before  the  end  of  the  first  year,  often  considerably  later.  The  use  of 
vowels  and  of  inarticulate  sounds,  together  with  gestures,  answer  the  child's 
purpose  of  making  its  wishes  known.  As  the  will  develops  and  the  power  of 
mimicry  is  established  vocal  sounds  and  gestures  become  more  and  more 
intelligible,  and  finally  articulate  words  are  added.  Single  words  are  used  for 
some  time  to  express  several  ideas,  then  two  words  are  put  together,  and 
finally  short  sentences  are  formed. 


''  W'M 


p    t 


^^^ 


II.  PATHOLOGY  OF  THE  NEW-BORN  INFANT. 

1.  Medical  and  Surgical  Diseases  Incident  to  the  Birth  op  the 

Child. 

Asphyxia  op  the  New-born. — The  respiration  of  a  child  immediately 
after  birth  is  usually  somewhat  irregular,  but  it  soon  beconujs  rhythmic,  and 
within  a  short  time  inspiration  and  expiration  take  ])lace  in  a  normal  manner. 
Any  deviations  from  this,  as  indicated  by  slight  difiieuity  in  breathing  on 
account  of  a  large  amount  of  mucus  in  the  trachea  or  the  bronchial  ttdjes,  to 
absolute  apnea,  in  which  there  is  no  attempt  on  the  part  of  the  child  to  respire, 
represent  the  dit!'erent  grades  of  what  is  called  "asphyxia  of  the  new-born." 

The  phenomenon  dcscribe<l  is  entirely  due  to  imperfect  aeration  of  the 
blood.  It  is  because  there  has  not  been  proper  interchange  of  oxygen  and 
carbonic  acid  gas  in  the  blood  of  the  new-born — a  condition  which  may  arise 
from  causes  that  have  been  operating  for  some  time  in  the  uterus  or  on  acx'ount 
of  some  delay  or  unavoidable  process  in  the  birth  of  the  child.  It  is  hardly 
necessary  to  speak  of  the  physiology  of  the  circulation  in  the  placenta,  that 
wonderful  and  perfect  arrangement  by  which  oxygen  is  received  by  the  fetus 
and  carbonic  acid  is  thrown  off  by  the  mother. 


i'r 


814 


AJIKRJCA.X    TEXT-BOOK    OF   OBSTETRICS. 


\ 


The  {loiieral  stihjoct  of  nspliyxia  of  the  new-born  may  bo  divided  into  twn 
subdivisions:  first,  intra-utcrinc  (iKpln/xid  ;  secoiul,  (•xti'a-H(t'ri)U'  (tup/n/.via,  iw 
tiiat  form  wliieh  jn'esonts  itself  immediately  or  a  short  time  after  birth. 

Three  divisions  or  three  different  jjrades  of  asphyxia  of  the  new-born  will 
be  made,  and  they  will  be  named  in  the  order  of  their  severity  :  Firxf,  sijoht 
diflicnlty  in  breathing:;  from  the  eolleefion  of  nmeus  or  any  foreign  substaiui' 
in  any  part  of  the  respiratory  appartns ;  xccomlli/,  an  asphyxia  which  is  pic-,- 
ent  in  the  ehild,  who  when  born  is  strong  and  robust  and  full-blooded;  iliinl/i/. 
a  ehild  born  asphyxiated,  pale,  limp,  and  apparently  lifeless.  The  seeond  and 
third  elassifieations  have  by  some  of  the  older  authors  been  spoken  of  respec- 
tively as  "sthenie"  and  "  asthenic,"  or  the  apoplectic  and  anenjic  varieties. 
The  first  class  is  quite  insignificant,  and  usually  respiration  is  established  with- 
out any  treatment  whatever.  The  exposure  to  the  irritation  <»f  the  atmosplieie 
or  occasionally  a  smart  slap  on  the  buttocks  is  all  that  is  neetleil  in  the  simple 
variety.  The  other  two  classes,  which  are  exceedingly  imj)ortant,  and  n-:iiiv 
times  very  dangerous,  will  now  b(>  considered  in  their  proper  order. 

Intra-uterine  Asphyxia. —  Efio/iu/i/. — The  causes  of  the  intra-titeriiic  liirni 
of  asphyxia  arise  from  two  soiu'ces — those  originating  from  the  mother  and  those 
originating  from  the  fetus.  The  causes  present  in  the  mother  that  mav  pni- 
duce  this  dangerous  diHieulty  in  her  child  are  maiidy  disturbances  of  j)laceiital 
eirculation,  either  from  ju'culiarity  of  pain  or  from  diseases  which  lead  to  a 
small  supply  of  oxygen  to  her  child.  The  causes  which  originate  in  the  fetus 
are  interferences  with  the  cord  and  the  placenta,  ])ressure  upon  the  head,  and  a 
natural  or  an  accpiired  feebleness  which  n  .y  be  producnl  because  the  parents 
are  either  inniuiture  or  aged,  or  because  the  delivery  is  j)re!nature. 

T/w  p<ith()/i)(/ii'(i/  ch(in(/cf<  in  intra-uterine  asphyxia  are  about  the  same  :is 
those  that  follow  when  suffocation  takes  place  from  other  causes.  Tlie  l)l(i(Mi 
is  thin,  the  sinuses  of  the  brain  are  filled  with  bhod,  with  some  edema  of  the 
membranes,  and  extravasations  and  slight  ecchymoses  are  found  in  dill'ereiit 
parts  of  the  several  organs.  The  lungs  are  dark  in  color,  are  somewhat  iimre 
firm  than  usual,  and  appear  to  be  filled  with  blood.  The  air-passages  ;ire 
quite  uniforndy  filled  with  mucus,  meeonium.  and  amniotic  fluid.  This 
condition  suggests  the  (piestion  which  is  fri'»piently  asked  as  to  whet  her  the 
child  inspires  //;  xfcro.  In  some  obstetrical  operations,  or  when  the  hand  is 
iutrodueed  into  the  uterus  to  perforui  version,  air  enters  the  cavity  and  pin- 
duees  its  reflex  irritation,  and  the  ehild  makes  an  effort  to  inspire,  and  in  this 
manner  draws  meconium  and  amniotic  fluid  into  its  respiratory  passages. 

Sj/iiipfoiiiK  of  the  intra-uterin(>  form  of  as])hyxia,  of  eours(>,  are  diflieult  tu 
be  observed,  and  they  can  be  det<'rmin(Hl  oidy  by  xcry  close  observation  of  tJM 
ehild  //)   litem.     A  very  slow  or  a  very  rapid  pulse,  a  synqitom  to  wliieli  we 

oil       Ml' 


attach  the  <>'reatest    i 


mportanc(\   intimates  either    pneumogastric  irntati 


paralysis  Tlu>n  follows  iiicr(>ase(l  intestinal  peristalsis,  and  finally  miixiihir 
spasm,  to  which,  it  appears  to  the  writer,  should  be  added  umisiial  iiove- 
ments  of  the  child.  In  all  prolonged  labors  and  before  prolonged  obstctrieni 
operations  it  is  always  well  to  examine  carefully  the  heart-beat  of  the  cliild, 


1  I  i 


'■ii 


PATIIOLOCiY    OF    THE   NFAV-liOIiX  IXFANT. 


815 


mcwliiit  iiKnv 


)    WilCtluM-  till' 


•('   iuitl  111  tin- 


irnt:iti(»ii  nr 
liUv  iiiiiM'iilar 


l)w;ause  in  cjusos  of  asphyxia  it  is  iinportaiit  to  know  wliether  any  symptoms 
existed  })rovions  to  the  birth  of  a  ciiihl.  or  whi'thiT  the  condition  obtainwl  is 
tho  result  «)f  its  passaj;e  thi'ou>>;h  tlie  parturient  oanal. 

DUuiuoxix. — It  will  be  I'rom  sueli  examinations  as  above  sufxgosled  tliat 
we  shall  be  able  to  anticipate  danger  to  the  child,  so  that  in  all  tedious  and 
particularly  dilHcnlt  labors  these  «)bservations  should  be  instituted.  W  the 
iieart-beat  is  either  unusually  slow  or  fast,  we  shoidd  conclude  that  there  is 
commencing  danger  to  the  child.  The  appearance  of  meconium,  it  seems  to 
the  writer,  has  been  over-estimated,  as  in  a  mnnber  of  cases  he  has  seen  this 
discharge  before  the  delivery  of  (he  child,  and  yet  there  has  been  born  a  per- 
fectly healthy  and  non-asphyxiatinl  child.  In  breech  labors  it  is  certainly  not 
to  be  regarded  as  a  sign  of  threatened  asphxyia.  Any  mnisnal  hemorrhage 
beibre  birth,  indicating  ])artial  d(tachment  of  the  placenta,  is  a  very  significant 
symptom  and  deserves  earnest  attention. 

l*ro</noKit<. — The  prognosis  will  also  depend  u])on  the  condition  of  (he  child 
and  the  possibilities  of  an  easy  and  rapid  delivery. 

Tiratmvut. — In  threatened  asphyxia  of  the  child  the  indication  is  to  delivei 
with  all  pt)ssible  rapidity  consistent  with  the  safety  of  the  mother. 

Extra-uterine  Asphyxia. — I'Jfiolof/i/. — In  a  vast  majority  of  cases  of  extra- 
uterine asphyxia  there  is  no  interference  with  the  placental  circidatioii  ;  the 
watchfulness  with  which  the  child  in  nfero  has  b(>en  «ibserved  has  revealed 
nothing,  yet  upon  the  birth  of  the  child  breathing  does  not  take  place.  As- 
phyxia has  developed  from  causes  o|»erativo  while  the  child  is  passing  through 
the  parturient  canal  or  from  diseases  which  interfere  with  the  original  process 
of  respiration.  Those  causes  are  malformations  of  the  respiratory  or  circu- 
latory organs,  intra-uterine  (liscase  of  the  fetus,  or  premature  birth.  Among 
the  (liseases  which  operate  more  frcciueiitly  in  the  production  of  extra-uterine 
asphyxia  may  be  mentioned  particularly  (he  diseases  ot"  (he  lungs,  such  as  ate- 
lectasis, j)neumonia,  syphilitic  <liseases  of  the  lungs,  large  ])leural  exudates, 
compression  of  the  air-passages  by  large  glands,  and  injuries  to  the  respiratory 
centres  f.om  ddlicult  labors. 

Path(>lo;i;i. — Kxternal  marks  and  conditions  that  have  operateil  to  produce 
asphyxia  wil'.  readily  be  seen.  The  iiead  also  shows  signs  of  com|>ression  and 
perhaps  unnatural  moulding.  The  lungs  are  frc(|ueiitly  not  I'ully  expau<lc<l ; 
indeed,  in  some  instances  large  areas  are  Ibtmd  in  the  condition  known  as 
dclccf'ixix. 

Sii)nj)fomn. — When  a  child  is  boi-n  na(urally  it  begins  to  breathe,  and  usually 
to  cry  (piite  lustily.  It  opens  its  eyes,  makes  a  face  as  if  disgusted  with 
the  surroundings,  moves  its  extremiti(>s,  and  (he  intcgunieut  assumes  a  rosy 
line.  .\  child  born  asphyxiated  pnseuts  one  (>f  two  conditions  altogether  dii- 
t'crent  I'rom  those  above  described.  The  child  is  either  large  and  robust,  the 
skin  is  of  a  livid  color,  and  without  doubt  it  is  a  strong  child  (sthenic),  or  it 
it  is  pale,  wan,  and  anemic  (astluMiii-).  There  is  but  little  U"  any  attempt  at 
respiration.  To  all  intents  am,  pur|)oses  th(>  child  is  deail.  In  many  cases 
there  is  no  heart-beat  percepdble.      In  (he  lirst  grad(>  the  child  is  deeply  cya- 


if 


1 


t 


?i 


I 


'i 


816 


AMERICAN  TEXT-BOOK  OF  OBNTETIilCS. 


ii      I 


i^ 


Mw/ 


11080(1;  tlio  cord  is  piil.satiiig  violently  ;  tiie  roHexos  arc  not  wholly  aholisiitMl. 
In  the  second,  an  atlvanced  staii;e  ot'asj)hyxia,  the  pulsation  may  not  he  disiii:- 
giiishahle;  the  surface  of  the  hody  is  extremely  pallid;  the  extremities  arc 
motionless ;  rcHexes  and  muscular  tone  are  absent. 

J)i(i(/iioi:iis. — It  is  of  great  importance  to  know  whether  the  asphyxia  took 
place  from  causes  intra-uterine  or  later,  and  it  is  also  important  to  know  wiiich 
of  the  two  forms  of  asphyxia,  the  mild  or  the  grave,  is  present  in  each  indi- 
vidual case.  If  very  great  pressure  has  been  made  upon  the  head  of  thecliild, 
either  because  the  labor  has  been  long  and  tedious  or  because  instruments  )kivc 
been  used  for  a  long  time,  or  if  a  visible  hemorrhage  is  present,  the  asphyxia  is 
in  all  probability  due  to  causes  operating  during  the  })assage  through  the  pai-- 
turient  canal.  Observations  which  have  been  made  during  labor,  then,  are 
very  important  in  deternu'ning  the  probable  cause  of  asphyxia.  If,  however, 
we  know  that  there  has  been  partial  separation  of  the  placenta  before  biitli, 
and  if  we  find  the  air-passages  of  the  child  filled  with  inspired  foreign  mate- 
rial, the  asphyxiated  condition  of  the  child  is  in  all  probability  due  to  intra- 
uterine causes. 

Prof/no.six. — In  the  first  form — that  is,  where  the  child  is  strong  and  tlie 
muscidar  tone  and  nervous  irritability  are  not  lost — if  there  are  no  other  com- 
plications, the  prognosis  is  generally  good.  In  the  second  form  it  is  alwavs 
doid)tfid.  If  pressure  on  the  head  has  been  long  and  severe,  and  hemorrliage 
takes  place  at  the  l)as(.'  of  the  brain,  the  prognosis  is  bad.  If  the  hemorrhage 
takes  place  on  tiie  convexity  of  the  brain,  the  child  may  live  longer,  but  tiie 
mental  condition  is  usually  bad. 

How  to  Determine  the  (irade  of  Afijihi/.ri((. — The  grade  of  asphyxia  can  he 
determined  by  irritation  of  the  palate.  If  upon  the  introduction  of  the  fiiinvr 
to  remove  the  nnicus  there  art  choking  and  convulsive  movements,  and  conse- 
([iiently  attempts  to  breathe,  and  the  ]iresence  of  the  reflexes  is  shown,  it  is 
asphyxia  of  the  first  grade,  and  the  prognosis  is  good.  If  this  irritation  of 
the  ])alate  produces  no  action,  but  the  palate  remains  soft,  then  the  asj)li\xia 
is  of  the  second  grade,  and  the  ])ri)gnosis  is  bad. 

Ti'fdtiiu'nf. — In  every  case  of  labor  where  it  is  known  to  be  serious  or 
tedious,  ])reparations  for  the  reception  of  an  asphyxiated  child  should  be  made 
before  its  birth.  A  table  should  be  ])laecd  in  the  lying-in  chamber,  and 
upon  it  a  pillow  and  a  waterproof  sheet  should  be  in  readiness;  hot  and  euld 
water  in  proper  receptacles  should  be  at  hand,  and  also  a  soft  catiieter  nv 
some  other  a])pliance  for  the  withdrawal  of  mucus  and  other  substances  t'luni 
the  respiratory  passages  ;  an  electric  battery  may  be  of  use. 

Treatment  of  the  Fird  (h-(ule  of  Axphji.ria. — The  chief  indications  in  the 
treatment  of  the  first  grade  of  aspiiyxia  are — remove  all  obstruction  from  the 
air-passages,  and  by  the  application  of  reflex  stimuli  excite  res])iratory  elluit-:. 
Remove  mucus  from  the  throat  and  month  of  the  child  ;  irritate  the  skin  hy 
slapping  the  buttocks  and  rubbing;  pass  before  the  respiratory  organs  snme 
of  tlu!  dilVusive  stimulants,  such  as  camphor  or  preparations  of  ammonia.  To 
remove  foreign  material  from  the  trachea  and  the  bronchial  tubes  grsisp  the 


rATHOLOGY   OF    THE   NEW-BORN  INFANT. 


817 


f  abdlisln'ii, 
)t  be  disiiii- 
roniitiis  luc 

[)hyxi;i  tudk 
know  which 
n  oai'h  iiitli- 
ofthocliild, 
ninoMts  luivc 
e  iis|)hyxia  i< 
ugh  tho  jtar- 
)or,  then,  are 
If,  however, 
before  birtli, 
tbreijin  inatc- 
lUie  to  iiitni- 

rong  and  tlie 
no  other  cuiu- 
1  it  is  always 
id  hemorrhiijie 
lie  hemorrhaire 
longer,  bnt  tlie 

kphyxia  can  lie 
1  of  the  fniiicr 
its,  and  eonse- 
s  shown,  it  is 
irritation  of 
the  as])hyxia 

be  serions  or 
lioiild  be  made 
|ehanib(>r,  and 
I;  liot  and  I'tild 
Ift  eathetcr  or 

ibstanees  fnmi 

jcations  in  the 
Iction  from  the 
tratory  etlbrt-;, 
i(>  the  skin  by 
|v  organs  smiie 
Inunonia.  I'* 
Ibcs  grasp  iln' 


iliild  by  its  feet,  the  head  hanging  downward  ;  pass  the  little  finger  into  the 
throat  and  wipe  out  the  niiicus.  Care  should  be  taken  not  to  produce  trautna- 
tisni  in  the  post-pharyngeal  space,  and  so  ojien  an  entrance  for  infection, 
l-'urther  to  remove  the  nineus  from  the  trachea,  press  upon  the  trachea  with 
ihe  finger  as  low  down  as  the  bifurcation,  and  gently  s(pieeze  the  trachea  toward 
the  larynx.  This  forces  the  mucus  into  the  back  part  of  the  pharynx  or  post- 
iKisal  space,  and  it  can  now  be  forced  through  the  nose  of  tin;  chikl  bv  blow- 
ing into  its  mouth  ;  the  obstetrician  should  protect  his  mouth  with  a  haiid- 


Fkj.  111.— Schultze's  method  of  nrtilicial  ri'spirntion  :  A,  inspiration ;  15,  expiration. 

kerchief.  If  now  the  child  does  not  begin  to  breathe,  give  it  a  warm  bath 
or  jtossibly  alternate  between  a  warm  and  a  cool  bath.  Repeat  all  these 
iiicasiircs,  and  watch  the  child  carefully  until  respiration  is  fully  and  per- 
I'lrtly  established. 

Trcdtiiinif  nf  t/ic  Scc())nl  (ri'dde  nf  ANp/ij/ria. —  If  it  is  found  by  irritatifm  of 
the  throat  that  the  rcHexes  are  aUsent  and  tliat  the  child  is  in  this  .severe  and 
(hingerous  form  of  asphyxia,  our  treatment  must  be  more  heroic  from  the  fir.st. 
Of  course  the  air-passages  .should  be  cleared  of  mucus.  It  is  n.seiess.  how- 
over,  with  a  child  in  this  grade  of  asphyxia  to  attempt  to  make  it  breathe  by 
irritation  of  the  skin,  and,  while  many  of  the  procedures  suggested  in  the  first 
grade  may  be  u.sed,  artificial  respiration,  by  means  of  which  air  may  be  forced 
intd  the  che.st,  mu.st  very  soon  be  resorted  to;  while  the  method  of  jMarslial 
Ilall  or  of  Sylvester  may  be  used,  the  proceeding  as  laid  down  by  Schultzo, 

62 


f 


I 


(  ■ 


\.n  I 


818 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


and  briefly  described  below,  has,  tlie  writer  believes,  been  followed  by  the  bc-t 
results  (Fig.  441). 

The  p!:ysician  seizes  the  child's  shoulders  by  putting  an  index  finger  in  the 
axillary  space  and  his  thumbs  so  curved  forward  and  over  the  shoulders  as  to 
strike  the  end  of  the  finger,  so  that  the  entire  weight  of  the  child's  body  is  rest- 
ing upon  or  within  the  circles  made  by  the  thumb  and  the  first  finger  of  cadi 
hand.  "While  the  child's  body  is  hanging  perpendicularly  the  ribs  are  being  lil'tid 
out,  the  chest  is  expanded,  and  mechanical  inspiration  is  produced.  To  ])ro- 
duce,  now,  a  mechanical  expiration,  the  body  of  the  child  is  swung  forward 
with  some  little  force  at  arm's  length  until  the  operator's  arms  are  a  little  ahovo 
a  horizontal  line.  A  somewhat  abrupt  termination  of  this  motion  causes  tlio 
thorax  of  the  child  to  become  stationary,  while  the  lower  limbs  topple  over 
upward  and  forward  upon  the  child's  abdomen.  The  abdominal  viscera,  in 
the  position  in  which  the  chest  is  at  this  moment,  press  against  the  diaphragm 
and  produce  expiration.  The  child's  body  is  now  returned  to  its  orignal  ])osi- 
tion  by  nearly  reverse  motions ;  the  entire  manenvre  occupies  from  seven  to 
eight  seconds  and  is  repeated  eight  or  ten  times  each  minute.  After  pi'aotisiii<r 
this  method  for  two  or  three  minutes  it  is  desirable  to  place  the  child  in  a 
warm  bath  to  restore  the  body-heat  lost  during  the  swinging  movements. 

Mouth-to-niouth  insufflation  is  also  a  valuable  method  to  seouro  tlio 
entrance  of  air  into  the  child's  lungs.  A  towel  is  placed  over  the  cliild's 
mouth,  and  the  operator,  after  taking  a  deep  inspiration,  quickly  but  gcntiv 
blows  into  the  mouth  of  the  child,  and  then  gently  compresses  its  chest.  In 
this  manner  the  child's  lungs  should  alternately  be  inflated  and  emptied  ten 
or  fifteen  times  a  minute.  To  prevent  injury  to  the  air-vesicles  the  inntrs 
should  be  inflated  gently,  and  the  nasal  passages  shoidd  not,  as  sonietiincs 
advised,  be  dosed  by  pressure  with  the  fingers.  Sometimes  insufflation 
through  a  catheter  passed  into  the  larynx  is  of  service. 

In  the  severe  form  of  asphyxia  and  in  ])rematurely  born  children  most 
remarkable  results  are  sometimes  obtained  by  keeping  these  children  in  some 
kind  of  a  warming  apparatus  or  incubator  (see  Figs.  444-448,  \i.  863). 

Caput  Succedaneum. — In  quite  a  luunber  of  cases  there  are  seen  iiiunc- 
diately  or  very  soon  after  birth  enlargements,  contusions,  or  ecchymoses  on  tlie 
head  or  the  presenting  part  of  the  ciiild.  It  is  not  difficult  to  nnderstaml  why 
or  how  those  afteetions  are  ])rodMC(>d,  but  one  does  have  some  troid)lo  in  dctcr- 
miiiing  whether  they  should  be  arranged  under  medical  or  under  surgical  mIVcc- 
tious.  It  is  quite  possii)le,  then,  that  the  present  arrangement  may  not  lio 
absolutely  correct,  but  this,  it  ap])ears  to  the  writer,  is  not  jiarticularly  iin])oit- 
ant  if  the  main  facts  are  presented,  inasnnich  as  a  description  of  these  diseases 
or  affections  will  be  quite  as  instructive  whether  they  are  or  are  not  arranged 
under  their  |)roper  headings. 

One  of  the  most  frequent  enlargements  noticed  is  named  capxf  xucci'ildiicinii. 
This  phenomenon,  which  is  rather  constant,  consists  of  a  swelling,  of  varviiiL' 
sliape  and  size,  noticed  upon  the  ])resenting  part,  especially  the  iiead.  I'lic 
swelling  is  produced  usually  by  pressure  of  the  dilating  os  uteri,  but  the  .-aiiic 


PATHOLOGY   OF   THE  NEW-BORN  INFANT. 


819 


k1  by  the  Ijc^t 

c  finger  in  tho 
houklers  as  to 
s  body  is  nst- 
finger  of  each 
ire  being  li It cil 
iced.     To  pro- 
wling forward 
e  a  little  above 
ion  causes  the 
lbs  topple  over 
inal  viscera,  in 
the  diapliragm 
ts  orignal  ])osi- 

froni  seven  to 
rVfter  practising 
c  the  child  in  a 
lovenients. 

to  secure  tho 
3ver  the  child's 
-kly  but  gently 
s  its  chest.  In 
md  emptied  ton 
sides  the  lungs 
•t,  as  sonietinios 
nies   insutflatiou 

II  children  most 
hildrcn  in  some 
p.  8G3). 
nre  seen  innno- 
chvinoses  on  the 
understand  wliy 
rouble  in  dotcr- 
er  surgical  alVec- 
ent  may  not  lie 
icularly  inipnrt- 
|of  these  diseases 
re  not  arranged 

lliug,  of  varviii^r 
Ithe  head.  Th" 
l>ri,  but  the  ^ainc 


Idnd  of  a  swelling  has  been  noticed  upon  the  breech  or  the  shoulder.  The 
phenomena  produced  vary  somewhat  with  the  differences  of  position  and  extent 
and  severity  of  the  pressure. 

Eliolofjif. — The  cause,  as  remarked  above,  has  always  been  ascribal  to  pres- 
sure upon  tlie  unyielding  os  uteri,  causing  an  infiltration  of  bloody  serum  in 
the  tissues  of  the  scalp  below  the  constricting  ring  of  the  cervix  ;  but  inas- 
much as  this  enlargement  and  the  blood-tumor  which  will  presently  be 
described  have  been  found  on  other  than  the  presenting  ]>art,  we  must  at  this 
time  confess  that  the  cause  is  not  always  clear.  It  is  jiossible  that  difficult 
labors  with  jirolonged  pressure  by  different  parts  of  tlie  uterus  may  be  an 
etiological  factor. 

The  pathology  consists  of  a  localized  edematous  condition  of  tho  soft  parts 
of  the  scalp  i.nd  the  connective  tissue  with  some  extravasations  of  blood. 

Diagnosis. — The  diagnosis  is  not  always  easy,  for  there  are  found  upon  the 
head  of  a  child  several  other  enlargements  from  which  the  swelling  must  be 
differentiated.  Chief  among  these  enlargements  are  cei)halhcmatoma,  hernise 
cerebri,  vascular  tumors,  meningocele,  encephalocelo,  and  hydrencephalocele. 
A  full  description  of  cephalhematoma  is  given  below,  and  hernia;  of  the 
brain  and  vascidar  tumors  are  treated  on  page  304.  A  brief  description 
oi'  the  remaining  tlirce  is  as  follows  :  Meningocde  is  a  tumor  of  the  scalp 
into  which  the  meninges  protrude ;  an  cneephaloccle  contains  in  addition  to 
the  meninges  a  small  amount  of  brain-substanee;  and  a  hydrencephalocele 
contains  a  small  amount  of  liquid  in  addition  to  brain-sid)stancc  and  the 
membrane. 

Prognosis. — In  caput  succedaneuni  the  prognosis  is  always  good.  If  left 
alone,  it  almost  entirely  disappears  within  a  short  time. 

Treatment. — Caput  succedanoum  will  in  every  instance  disappear  without 

interference.     In  a  case,  however,  where  there  is  very  extensive  ecchymosis, 

which  makes  this  the  vulnerable  point  of  the  baby's  body,  care  shotdd  be  taken 

against   infection.      In   this   case   an    antiseptic 

dressing  should  be  used  as  a  protection. 

Cephalhematoma.  —  Cephalhematoma    is   a 

soft,  elastic,  fluctuating  tumor,  generally  ])ainless 

and  situated  upon  one  of  the  cranial  bones  (Fig. 

4 12).    It  is  stated  by  some  writers  that  the  tumor 

ooeurs  more  frequently  upon  the  right  parietal 

hone,  but  of  the  six  cases  seen  during  the  first 

twelve  years  of  the  writer's  practice  five  were 

upon    the  left    ])arietal   bone.     The  tumors  are 

usually  single,  although  a  few  observers,  among 

them    the   writer's   eminent   ju'cceptor,  the   late 

I'lof.  William  II.  Ikford,  noticed  one  upon  each  side  of  the  heail.     Hol'mohl 

oi)served  2(5  bilateral  cases,  each  with  fbiitanelle  Ijctwcen  as  a  deep  ('.epression. 

This  variety  of  tuunn',  it  seems  to  the  writer,  shonld  be  confined  to  those 

cjMs  where  the  collection  of  blood  is  upon  the  outside  of  the  cranial  bone, 


I'm.  If.'.— I'l'iiliiinn'iiiiitcimii. 


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AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


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i  , 


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while  those  upon  the  inside  between  the  brain  and  the  dura  mater  should  l.e 
spoken  of  as  "intracranial"  hemorrhage  and  should  be  considered  uiidt r  a 
ditierent  heading.  There  must  at  least  be  a  very  wide  difference  in  the  clin- 
ical history  of  an  external  and  an  internal  cephalhematoma.  The  first  is 
rather  insignificant,  while  the  second  would  in  many  cases  prove  fatal. 

Frequency. — Cephalhematoma  occurs  with  greater  frequency  than  writers 
would  lead  us  to  suppose.  When  first  writing  upon  this  subject,  at  the  end  of 
twelve  years'  practice,  the  writer  had  seen  six  cases,  and  in  the  first  1000  lalxirs 
which  he  attendetl  twenty  cases  of  cephalhematoma  occurred.  Henning 
had  230  out  of  53,606  cases,  or  0.43  per  cent.,  and  Hofmohl  371  in  59,885 
cases,  or  0.6  per  cent.  The  percentage  was  about  2  in  the  writer's  cases.  The 
disease  is  said  to  be  more  frequent  in  males. 

Etiology. — This  difficulty  has  in  almost  all  instances  been  ascribed  to  jiros- 
sure  upon  the  cranial  surface  by  the  cervix  uteri.  Without  doubt  a  great  major- 
ity of  cases  are  caused  by  this  pressure,  but  from  the  fact  that  cephalhematoiiiata 
have  been  observed  in  breech  births,  it  must  be  admitted  that  in  every  case  the 
rigidity  of  the  os  uteri  does  not  produce  the  tumor.  It  has  appeared  to  the 
writer  that,  in  addition  to  the  pressure  exertetl  either  by  an  unyielding  os  or  l)y 
forceps,  there  may  exist  a  tendency  on  the  part  of  the  blood-vessels  to  rupture; 
there  is  an  undue  thinness,  which  makes  this  difficulty  more  likely  to  occur. 

Symptoms. — This  form  of  head  tumor  is  not  present  usually  at  the  birth 
of  a  child ;  indeed,  from  one  to  four  days  elapse  before  attention  is  called  to 
this  difficulty.  When  first  noticed  it  is  usually  a  sofl,  painless  enlargement, 
situated  upon  a  parietal  bone,  varying  from  the  size  of  a  hazelnut  to  that  of  an 
apple.  It  may  so  extend  as  to  include  the  surface  of  the  entire  cranial  bone, 
but  it  never  crosses  a  suture  or  a  fontanelle.  There  is  no  discoloration  of  the 
skin  in  cases  observed  by  the  writer,  and  neither  the  pulse  nor  the  circulation 
of  the  child  is  accelerated  to  an  extent  that  would  denote  any  disease  or  com- 
plication. The  greatest  size  of  the  tumor  is  usually  reachetl  at  the  end  of  a 
week ;  it  then  remains  stationary  for  a  few  days,  and  then  begins  the  subsi- 
dence and  diminution  by  which  nature  perfe<'ts  a  cure.  In  a  large  number 
of  cases  in  from  four  to  ten  weeks  there  is  nothing  to  indicate  that  tlioro 
has  been  a  tunjor  or  a  growth  of  any  character. 

Diagnosis. — The  diagnosis  is  a  very  important  question,  and  one  not  easily 
made  out  by  many  physicians.  Not  many  years  ago  the  writer  was  called  to 
see  what  was  supposed  to  be  a  hernia  cerebri,  which  proved  to  be  a  cephalhe- 
matoma. The  principal  affections  with  which  a  cephalhematoma  may  be  con- 
founded are  caput  succedaneum,  hernia  cerebri,  erectile  tumors  or  angioinata 
of  the  scalp,  and  the  different  forms  of  soft  tumor  that  have  been  enunuTatwl 
in  the  consideration  of  caput  succedaneum,  to  which  should  be  added,  in  the 
writer's  judgment,  the  condition  known  as  eraniotabes.  The  means  of  diflor- 
entiation  may  briefly  be  stated.  Caput  succedaneum  is  an  edematous  condition 
of  the  tissue  of  the  scalp  that  is  present  at  birth,  and  it  disappears  nipidly 
without  any  accompanying  symptoms.  It  has  a  boggy  feel,  while  in  ccplial- 
hematoma  there  is  always  some  fluid.     The  position,  process  of  repair,  and 


PATHOLOGY   OF    THE  NEW-BORN  INFANT. 


821 


\\ 


ater  should  lie 
derccl  luuUr  a 
ice  in  the  cliii- 
The  first   is 
rove  fatal. 
!y  than  wiitors 
,  at  the  end  of 
rst  1000  lal.uis 
•ed.      Heuniiig 
371  in  5y,«S5 
;r's  cases.     I'lio 

iscribed  to  pres- 
)t  a  great  niajoi'- 
ihalliematoiuata 
II  every  case  the 
appeared  to  the 
ielding  os  or  hv 
ssels  to  rupture ; 
kely  to  occur, 
ally  at  the  birth 
ition  is  called  to 
e.ss  enlargement, 
tint  to  that  of  ail 
ire  cranial  bone, 
■oloration  of  the 
r  the  circulation 
disease  or  coni- 
at  the  end  of  u 
)egins  the  subsi- 
a  large  number 
licate  that  there 


duration  are  also  quite  different.  It  should  be  remarked  here  that  caput  suc- 
ecdaneum  may  hide  a  cephalhematoma  for  three  or  lour  days.  From  hernia 
cerebri  the  differentiation  should  not  be  difficult.  The  hernia  occurs  along 
Hie  line  of  a  suture  or  in  the  vicinity  of  a  fontanelle;  there  is  no  fluctuation, 
hut  usually  there  is  a  pulsation  which  is  synchronous  with  the  heart-beat. 
( 'ries  and  agitation  of  the  child  cause  a  hernia  cerebri  to  enlarge ;  not  .so  with 
a  cephalhematoma.  A  vascular  tumor  on  the  scalp  has  the  .same  boggy  feel 
noticed  in  caput  succedaneum,  but  it  never  fluctuates,  and  usually  there  is  a 
discoloration  of  the  skin  that  is  not  pi-esent  in  a  cephalhematoma. 

By  craniotabes  is  meant  the  soft  places  found  upon  the  cranial  bones  in 
rickety  children.  It  has  appeared  to  the  writer  that  a  layer  of  bone  in  .some 
rickety  children  can  be  so  thin  that  a  softness  and  fluctuation  could  almost  be 
made  out,  thus  giving  rise  to  the  suspicion  that  a  blood-tumor  of  the  scalp 
existed  at  that  point.  Such  a  case  as  this  has  never  occurred  in  the  writer's 
jiraetice,  but  it  always  appeared  po.ssible,  and  in  his  teachings  he  has  cautioned 
his  students  in  this  respect. 

Tiie  enlargements  on  the  scalp  causal  by  protrusion  of  the  meninges  alone, 
or  those  containing  fluid  or  brain-substance,  will  need  no  further  consideration 
than  that  given  on  pages  304  and  818. 

Complications, — When  the  hemorrhage  is  ex  "ual  complications  are  very 
rare.  In  a  very  few  cases  suppuration  has  taken  i)lace,  or  there  has  been 
such  tension  with  i)ain  as  to  interfere  with  the  nutrition  of  the  child.  Of 
course,  if  pus  is  formed  next  to  the  brain,  necrosis  may  take  ])lace  or  a  menin- 
gitis might  be  effected.  The  danger  is  reduced  almost  to  nil  if  maltreatment 
is  not  inaugurated  by  some  surgical  process.  A  cephalhematoma  caused  by 
forceps  delivery  may  make  a  fracture  obscure,  and  is  a  dangerous  complication. 

Process  of  Repair. — At  the  end  of  four  or  five  days  (it  is  stated  by  one 
author  after  a  single  day)  where  the  swelling  joins  the  cranial  bone  a  very 
small,  hard  ridge  will  be  felt.  This  ridge  is  the  beginning  of  a  hyperostosis, 
or  a  tlirowing  out  of  bony  material  by  which  the  bone  and  periosteum  are 


Fl(    44».— I.onRitiuUniil  soction  through  n  oopliallii'iiintdmn  :  n,  (liirn  mntcr ;  I',  criiiiimn ; 
c,  ptTiorniiiuiii ;  rV,  iK'KinninK  hyporustosis ;  r,  scalp  (l)iivis). 

re|)aired,  a  resorption  of  blood  having  now  begun  to  take  ])lace.  There  is 
not  only  a  ridge  of  bony  material,  but  there  are  also  Ibriuiiig  forward,  toward 
the  central  jiart  of  the  tumor,  little  projections,  so  that  after  a  time  a  thin  crust 
or  shell  of  bone  is  absolutely  formed  over  the  swelling.     This  crust  will  some- 


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822 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


times  crackle  like  parchment.  During  this  time  the  blootl  and  sernm  arc  hcinc 
resorbed,  and  while  this  course  of  repair  is  slow,  in  all  cases  to  which  the  writci'-s 
attention  has  been  called  a  complete  restoration  has  taken  place  witiiont  aiiv 
induration  or  thickening.  It  has  been  stated  that  sometimes  a  hyperostosis 
remains  at  the  seat  of  swelling,  bnt  this  has  not  been  true  in  the  writer's  oases. 

Pathology. — A  section  through  the  blood-turaor  (Fig.  443)  reveals  tlio  i'act 
that  an  extravasation  of  blood  has  taken  place  between  the  bone  and  the  |i(ii. 
cranium.  The  bone-surface  is  roughened,  and  the  ])ericranium  is  attaclicd 
only  to  the  margin  of  the  bone,  wiiere  inflammatory  irritation  produas  a 
perceptible  thickening. 

Prognom. — If,  as  remarketl  above,  a  cephalhematoma  is  left  alono,  the 
prognosis,  almost  without  exception,  is  excellent.  If  there  is  ])rcsent  a  geniTal 
systemic  disease,  the  probability  of  resolution  is  not  so  good. 

Treatment. — Interference,  except  in  cases  which  will  be  mentioned,  with  tiie 
pretence  that  something  is  necessary  deserves  censure.  Any  deviation  from 
this  course,  in  the  writer's  judgment,  is  always  fraught  with  danger.  In 
regard  to  the  advisability  of  surgical  interference,  there  is  in  this  oj)erativo  era 
a  difference  of  opinion.  Winckel  and  Olshausen  advise  opening  the  tumor 
at  about  the  sixth  or  eighth  day,  yet  a  case  was  lost  by  one  of  these  gentle- 
men following  this  procedure.  Among  those  who  advise  against  operation 
are  Henoch,  Baginsky,  Zweifel,  Biedert,  and  especially  the  surgeon  F.  Koenig. 
The  weight  of  authority  is  certainly  against  operative  measiu'cs  so  long  as 
there  are  no  signs  of  inflammatory  reaction  or  of  suppurution. 

Apoplexy  of  the  New-born. — The  ctiologi/  of  cerebral  hemorrhasie  of 
early  life  differs  from  that  in  the  adult.  While  in  the  latter  it  usual iv 
results  from  a  diseased  condition  of  the  arteries,  rendering  them  liable  to 
rupture,  or  from  hypertrophy  of  the  heart,  in  the  infant  it  is  often  dn(>  to 
venous  congestion,  the  hemorrhage  occiu'ring  in  the  capillary  vessels  of  tlie 
pia  mater  or  in  the  choroid  i)lexus.  The  pia  mater  in  early  iufaney  is 
very  delicate.  Apoplexy  may  also  occur  as  a  complication  of  cephalliema- 
toma  ;  it  may  be  due  to  compression  of  the  umbilical  coi'd,  producing  asphyxia ; 
it  may  be  associated  with  atelectasis.  There  is  usually  a  history  of  diffieiilt 
labor,  impaired  circulation,  perhaps  convulsions,  but  it  also  occiu's  without  the 
existence  of  other  injuries  where  labor  has  been  of  long  diu'ation.  C.  Kim<re 
has  found  collections  of  bloixl  the  s^ize  of  a  pigeon's  egg  in  the  dtn'a  mater. 
These  collections  have  been  observed  in  normal  labors. 

Laceration  of  the  sinuses  may  produce  very  extensive  hemorrhage  wliieli 
will  prove  fatal.  Interference  with  the  circidation  during  labor,  or  pressm-e 
produced  l)v  the  cord  about  the  neck  of  the  fetus,  or  the  jiresencc  of  stiinna, 
is  sometimes  followed  by  cerebral  hemorrhage.  These  cases  are  usually  asjiliyx- 
iated.  If  respiration  can  be  established,  paralysis  is  likely  to  follow.  Paraly- 
sis is  not  always  marked  at  first,  but  may  be  noticed  in  the  course  of  nioiitlis; 
it  may  be  followed  by  contractures.  Sj)eech  is  generally  impaired,  and  intel- 
ligence is  usually  somewhat  affected. 

Congenital  Atelectasis. — By  atelectasis  is  meant  a  condition  in  wliicli  the 


PATHOLOGY   OF    THE   NEW-BORN  INFANT. 


82;j 


"i' 

f? 

n 

1 

\i 

;riiin  are  I)('iii<; 
ich  the  writer's 
e  without  any 
a  hyperostosis 
!  writer's  ca.-cs, 
eveals  the  tact 
e  and  tlie  |t('ii- 
iim  is  attached 
ion  proehices  a 

left  alone,  tlie 
resent  a  general 

itioncd,  with  the 
deviation  from 
th  danj;er.  In 
his  operative  era 
minf?  the  tnmor 
of  these  irentle- 
igainst  operation 
rceon  F.  Kncniu. 
■jiires  so  long  as 

heniorrhasie  of 
latter  it  usnih  y 
them  liahle  to 
is  often  due  to 
V  vessels  of  tlie 
early  infancy  is 
of  cephalhenia- 
;lncing  asphyxia; 
listory  of  diihcnlt 
■curs  without  tiie 
tion.     C.  KiMiire 
the  dura  mater. 

lemorrhage  which 
labor,  or  pressure 
:>sence  of  strnma, 
usually  asi>hyx- 
foUow.     Tmi-iIv- 
)ursc  of  months ; 
{paired,  and  intel- 


Ition  in  which 


the 


lung-tissue  remains  nnexpanded,  or,  having  heen  tilled  with  air,  collapses  and 
returns  to  its  condition  before  birth.  Thus  atelectasis  may  be  either  con- 
genital or  acquired.  In  the  congenital  variety  the  ciiild  evinces  some  difHculty 
in  breathing  at  birth.  Sotnetimes  it  is  asphyxiatetl,  and  at  other  times  the 
trouble  is  made  manifest  by  rapid  breathing  and  the  want  of  expansion  of  one 
or  both  sides  of  the  chest. 

Etioloyy. — Atelectasis  does  not  seem  to  be  luc  c  ngenital  difficidties  with 
the  respiratory  apparatus,  for  in  many  cases  t.r  ungs  can  be  expanded  post- 
mortem without  difficulty,  nor  is  it  due  to  an  enlarged  thymus  gland.  The 
majority  of  those  who  have  investigate<l  the  cause  of  this  difficulty  believe  that 
it  is  due  to  natural  weakness  of  the  infant  or  to  some  debilitated  condition  of 
tiic  mother,  premature  birth,  etc.,  rendering  the  respiratory  muscles  too  feeble 
to  elevate  the  thorax  during  respiration.  Asphyxia  and  pressure  on  the  brain 
from  any  cause,  producing  paralysis  of  the  respiratory  centre,  is  also  considered 
a  cause. 

Frctjuency. — Congenital  atelectasis  is  not  fre(iuent.  The  writer  has  seen 
hut  three  or  four  cases  of  this  condition — that  is  to  say,  where  the  condition 
lasted  long  enough  to  become  very  apparent. 

Symj)toms. — There  is  usually  a  cyanotic  condition  of  the  body  of  the  child 
in  congenital  atelectasis ;  very  soon  the  infant  commences  to  cry,  but  respira- 
tion is  exceedingly  rapid  and  short.  If  a  small  portion  of  the  lung  is  affected, 
tiie  difficulty  will  be  so  temporary  as  hardly  to  be  notic-eable.  It'  a  consider- 
ahle  portion  of  the  lung  is  congenitally  collapsed,  the  difficulty  in  breathing 
will  be  more  marked.     Occasionally  convulsions  precede  death. 

Didf/noHis. — The  diagnosis,  which  is  usually  difficult,  (»ften  not  made  during 
life,  must  be  founded  upon  the  rapid  and  irregidar  breathing,  upon  the  cyano- 
sis, and  upon  physical  examination.  The  walls  of  the  chest  upon  the  affected 
side  do  not  expand,  and  there  is  dulness  on  percussion. 

Proynofiifs. — The  prognosis  depends  on  the  extent  and  cause  of  the  difficulty. 
If  a  large  area  is  involved  and  the  condition  is  accompanied  by  cerebral  lesions, 
the  prognosis  will  be  unfavorable;  if  the  area  involved  is  small  and  unattended 
by  cerebral  lesions,  the  prognosis  will  be  good. 

Treatment. — The  first  object  in  treating  congenital  atelectasis  must  be  to 
induce  a  deep  inspiration.  For  this  purpose  an  effort  may  be  made  to  stimu- 
late the  respiratory  muscles.  Usually  the  only  effective  treatment  is  very 
gentle  inflation  of  the  lung  through  a  sofl  catheter  introduced  into  the  larynx. 
Diffusible  stimulants  shotdd  be  administered,  the  child  must  be  surrounded 
by  artificial  heat,  and  everything  must  be  clone  to  support  nutrition. 

2.  Traumatic  Injuries  of  the  New-born. 

The  principal  factors  in  the  production  of  injuries  of  the  new-born  are 
anomalies  of  the  pelvis,  deviations  from  the  normal  mechanism  of  labor,  and 
tlie  necessity  for  instrumental  delivery ;  in  addition,  wounds  of  the  presenting 
part  arc  sometimes  produced  by  the  attendants  either  through  ignorance  or  by 
rough  handling. 


I     I 


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824 


AMintlCAN   TKXT-nOOK    OF   OliSTETRJCS. 


m 


A.  Ir^juries  to  the  Scalp,  Pace,  Neck,  Limbs,  Trunk,  and  Bowels.— 
Wouiuls  of  tlio  Hcalp  and  J( ice  are  froqiicntly  produced  when  artificial  deliv- 
ery is  found  neces.sary.  Pressure  by  tin  blades  of  the  forceps  may  prodihc, 
lacerations  of  the  scalp  and  forehead,  contusions  of  the  face,  and  injury  to  t In- 
facial  plexus  of  nerves.  These  wounds  are  fretpiently  bilateral,  correspond ii,.; 
with  the  points  where  the  i'oreeps  was  applied,  and  where  there  is  unusual  re.>i>i- 
ance  either  from  the  parturient  canal  of  tin;  mother  or  from  the  Ixxvs  of  tin. 
skull  of  the  child.  Injuries  to  the  presenting  part  are  sometimes  also  piu- 
duced  even  in  normal  labor.  Thus  the  scalp  has  been  injured  in  the  atteiii|.t 
to  rupture  what  was  supposed  to  be  the  bag  of  M-aters.  Caput  sueeedam  nm 
has  likewise  been  thus  mistaken  and  punctured,  and  even  eyes  and  evrJiiU 
have  thus  been  injured. 

Injuries  to  the  head  are  frequently  indicative  of  pelvic  deformities  in  ilic 
mother;  especially  is  this  true  of  the  contracted  pelvis.  If  the  eonjnjrntc 
diameter  is  diminished,  the  promontory  of  the  sacrum  usually  produces  pres- 
sure  on  a  limited  spot  or  on  two  or  three  spots  near  each  other.  A  spiiim- 
8ha])ed  depression  of  the  ))!irietal  bone  may  thus  be  produced.  The  neck  ot' 
the  fetus  sometimes  shows  the  effects  of  traction  produced  by  long-contiiiiicd 
extension.  These  effects  are  usually  manifested  by  transverse  stria)  at  the 
point  where  the  strain  of  the  integument  was  the  greatest  (Miiller.)  Sonii'. 
times  subcutaneous  lacerations  occur,  giving  rise  to  more  or  less  extensive 
extravasations  of  blood. 

In  the  attempt  to  assist  the  after-coming  head,  especially  if  this  is  done  In- 
unskilful  hands,  a  blood-tumor  may  form  from  a  hemorrhage  into  the  slieatli 
of  one  of  the  sterno-eleido-mastoid  nuiscles.  This  condition  is  known  ns 
hematoma  of  the  sterno-madoid.  There  is  usually  some  laceration  of  tlic 
fibres  of  the  muscles  as  well  as  injury  to  the  vessels.  This  accident  is  more 
common  in  breech  jiresentations,  but  it  also  occurs  in  head  presentations,  and 
has  been  observed  after  spontaneous  delivery  ;  in  the  latter  case,  however,  the 
tumor  is  very  small.  The  swelling  is  not  always  observed  immediately  aiier 
birth  ;  it  is  generally  irregular,  somewhat  elongated,  situated  usually  in  tlic 
upper  i)art  of  the  right  stei-no-cleido-mastoid,  becoming  harder,  and  disappear- 
ing in  the  course?  of  from  four  to  eight  weeks.  The  profjnosis  is  favorable  as 
to  the  life  of  the  child.  Paralysis  of  the  arm  corresponding  with  the  side  on 
which  the  injury  existed  sometimes  occtu's,  but  this  usually  disappears  with 
the  tumor.     This  injury  sometimes  causes  torticollis. 

Fracture  of  the  clavicle,  in  extracting  the  after-coming  head,  may  result  in 
puncture  of  the  lung  by  the  broken  end  of  the  bone. 

In  transverse  presentations  the  upper  extremities  of  the  child  arc  sometimes 
injured,  the  presenting  arm  being  covered  with  excoriations,  or  the  meinltcr 
may  be  considerably  swollen.  The  large  bowel  may  rupture  from  jire-exi-^t- 
ing  ulceration,  which  is  usually  at  the  sigmoid  flexure.  Effusions  of  blood  in 
the  i)leural  and  peritoneal  cavities  have  been  observed  after  difllicult  lahur, 
and  extraction  of  the  feet  or  the  breech  is  sometimes  followed  by  iiijinios 
and  lacerations  of  the  abdominal  viscera  of  the  fetus. 


■li- 


i  Bowels. -- 
tificial  (Icliv- 
may  pniiluici 
injury  to  llic 
correspond  i  1 114 
musual  r('.>i-i- 
I  Uoi'.oH  of  tin- 
linos  also  pio- 
n  the  attcinjit 
t  succodancuiii 
L'S  and  cydids 

)rniities  in  the 

the   conjiij;:!!!' 

produces  pres- 

icr.     A  spooii- 

Tlio  neck  of 

long-eontiiiiicd 

iQ  stria)  at  liie 

Liiller.)     Sdiiu'- 

less  extensive 

this  is  done  hy 
into  the  slieiitli 
u  is  known  as 
ceration  of  tlie 
ccident  is  more 
jcsentations,  and 
e,  however,  the 
mediately  afler 
usually  in  the 
and  disappear- 
is  favoral)le  as 
Ivith  the  side  nii 
disappears  with 

ll,  may  result  ii> 

id  arc  sometimes 
lor  the  memlicr 

from  pre-exist- 
lons  of  blood  in 

difficult  hilM'i', 
Ived  by  injuries 


PATHOLOGY   OF    THE   NFAV-hORN   INFANT. 


825 


B.  Irxjuries  to  the  Skull  and  Other  Bones. — 'I'he  head  of  the  now-born 
infant  is  eoniinoidy  distorted  by  the  pressure  of  liie  iM'lvic  walls  in  norn)al 
labors,  each  |)re.sentation  and  position  eausinj;  its  cliarai^teristit!  chanjre  in  the 
shape  of  tho  infant's  head,  the  distortion  di.sappearinfjj  a  few  iiours  after  deliv- 
iry.  Injiu'ios  of  tiie  fetus  ail'eetinj;  tiie  bones  of  the  head  and  extremities  may 
iiecur  from  tlie  pressure  of  instruments,  from  tho  hand  of  tho  obstetrician,  and 
also  spontan('(»usly  f»«  a  result  of  very  rapid  labor,  especially  if  i)irth  takes 
place  while  the  mother  is  .standing'.  Fractures  and  lacerations  of  the  sutures 
are  likely  to  result  from  a  contracted  pelvis. 

Injuries  to  the  cranial  bones  may  be  complete  or  incomplete  fractin-os  or 
simjdy  doj)re.xsions ;  any  of  them  are  fro(pi(iitly  a.ss(K'iated  with  cephalhem- 
atoimi  and  intcrcranial  hemorrhaj>;e.  ('ranial  fractures  when  at  all  nuirked 
are  usually  accompanied  by  an  extracranial  or  intracranial  hematoma.  Pe- 
ripheral fractures  may  sometimes  be  extensive,  and  yet  not  be  followed  by 
serious  consequences.  Injuries  of  tho  occipital  bone  sometimes  prove  very 
serious,  on  account  of  compression  of  the  occipital  foramen.  Occasionally 
injury  to  the  medulla  results. 

Injuries  to  the  .spinal  column  sometimes  result  from  traction  on  tho  child's 
feet  or  the  breech  in  difficult  labors.  The  injury  consists  usiudly  in  the  separa- 
tion of  one  or  more  of  the  epiphyses  ;  tho  ligaments  are  usiujlly  unimpaired. 
Hemorrhages  into  the  membranes  nuiy  occur.  Fractures  of  the  clavicle  and 
the  hiuuerus  are  likely  to  occur  in  bre<'eh  presentations  during  the  delivery 
of  an  arm.  Separation  of  the  epiphyses  of  the  humerus  may  also  occur,  and 
it  is  liable  to  be  mistaken  for  fracture  of  the  neck  of  the  scapula  or  for 
luxation  of  the  humerus.  This  injury  is  always  accomi)aniod  by  an  inward 
rotation  of  the  humerus. 

The  treatment  of  these  traumatic  injuries,  both  of  the  soft  parts  and  of  the 
bones,  will  consist  in  observing  the  .same  rules  as  for  corresptrnding  injuries  in 
older  patientKj. 

V.  Iiy'uries  to  the  Brain  and  the  Peripheral  Nerves :  Obstetrical 
Paralysis. — In  some  labors  which  have  been  terminated  by  the  use  of  for- 
ceps, as  well  as  some  where  maniutl  interference  is  necessary,  either  from  pres- 
siu'c  by  the  forceps  or  by  twisting  or  stretching  or  direct  press\u'e  of  the  hand, 
there  is  simietimes  noticed  slight  paralysis  either  upon  one  side  of  tho  face  or 
ill  one  of  the  oxtreuiities.  The.se  lesions  may  be  of  peripheral  or  of  central 
origin,  the  latter  being  usually  the  result  of  cerebral  or  of  sj)inal  hemorrhage. 
These  hemorrhages  have  already  been  de.seribed  (p.  822).  Injuries  to  the 
nerves  are  usually  an  aeeompaniment  of  severe  injuries  of  the  bones,  the  frac- 
tured ends  pressing  upon  the  peripheral  nerves  or  on  some  plexus.  One  ft)rin 
of  paralysis  is  frequently  produced  in  the  attom])t  at  delivering  the  arm  :  this 
form  is  known  as  Duchenno's  obstetrical  paralysis. 

Sometimes  there  will  be  slight  bruises  or  ecchymosos  of  the  face,  and, 
where  manual  interference  has  taken  place,  of  the  arms  and  legs.  The  first 
sym])tom  noticed  is  generally  the  want  of  jiropor  action  of  the  nuiscles  of  the 
face.     In  some  cases  there  will  be  retraction  of  the  eveball  and  contraction  of 


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AMKlilCAN   TEXT- nan K   OF   OIlSTKTItU'S. 


tlio  pupil,  n  slipht  droopiiifj;  of  tlic  cyolid,  tiHiially  some  irrojjiilaritv  (if  tli.^ 
mouth,  iiiul  want  of  expression  of  the  side  of  the  faee  involved.  Wiiore  the 
paralysis  involves  an  arm  or  a  limb  (Dnehenne's  paralysis)  the  muscles  will 
api>oar  8ofl  and  Hahby  and  the  usual  motions  will  !>(>  absent. 

The  (lidf/noKix  of  obstetrioal  paralysis  can  be  made  without  diffieultv,  us  it 
is  hardly  possible  that  anything  else  could  pntduce  the  Hymptoms  in  a  new- 
born infant. 

J'rdf/noniH, — Paralysis  of  the  faee,  the  result  (»f  injury,  usually  disappears  in 
the  course  of  a  few  weeks.  Paralysis  involving  larger  trunks  of  nerves,  :ni(i 
in  eases  where  the  injury  has  been  considerable,  will  be  longer  in  disappcir- 
ing,  and  in  (piite  a  percentage  of  these  cases  some  permanent  deformity  will 
remain. 

Tirdliiicnf. — In  paralysis  of  the  faee  little  more  is  necessary  than  to  pnittri 
the  parts  which  are  bruised  and  ecchymosed  by  an  antiseptic  dressing,  !iih| 
after  a  time  to  tise  massage  and  electricity.  Where  the  injury  is  to  one  of  the 
extremities,  the  lind)  should  be  very  carefully  protected  by  wool  or  ciittdn, 
proper  support  being  made  so  that  no  dragging  shall  take  place,  and  at  the 
end  of  two  or  three  weeks  the  use  of  oleetricity  and  massage,  with  the  admin- 
istration of  such  internal  remedies  as  are  usually  employed  in  such  injiu'ios, 
such  as  small  doses  of  nux  vomica  with  general  tonics  to  improve  nutrition. 
When  all  acute  symptoms  disappear  and  contractions  begin  to  be  noticed, 
special  attention  should  be  given  to  the  preventicm  of  detbrmities. 

o.  Deviations  from  Some  of  the  Physiological  Processes  which 
Characterize  the  Early  Life  of  the  Infant. 

Thrrk  arc  a  number  of  conditions  and  processes  peculiar  to  the  earlv  life 
of  the  infant  that  are  especially  liable  to  produce  pathological  conditions. 

Exfoliation  of  the  Epidermis. — It  is  a  fact  that  nearly  all  the  organs 
and  mucous  membrauos  of  the  new-born  are  predisposed  to  congestion  and  to  a 
catarrhal  condition  which  is  accompanied  by  exfoliation  of  the  superficial  layer 
of  cells.  The  great  delicacy  of  the  skin  and  nuicous  membranes  at  this  period 
is  a  decided  predisposing  cause  to  hemorrhage,  and  the  great  tendency  to 
exfoliation  readily  affords  entrance  to  the  various  forms  of  niicro-organisiiis 
which  ])roduce  (b'sease.  Epstein  pointed  out  that  during  the  first  days  of  life, 
as  a  rule,  considerable  exfoliation  of  epithelium  takes  place  in  the  mucous  mem- 
brane of  the  oral  cavity.  In  this  cavity  there  are  t'vo  points  on  either  side  of 
the  posterior  angle  of  the  hard  jialate  that  in  a  great  number  of  chiklreii  pre- 
sent e|)itlielial  defects  during  the  first  days  of  life.  Here  the  mucous  niein- 
brane  is  very  thin  and  anemic  from  the  stretching  of  the  pterygoid  ligament  in 
sucking  and  in  opening  the  mouth.  In  these  parts  the  superficial  and  deeper 
loss  of  epithelium  occurs,  especially  if  on  attem|>ting  to  Avash  the  mouth  of  tlio 
new-born  it  is  roughly  handled.  This  shedding  of  epithelium  is  also  particu- 
larly marked  in  the  epithelium  of  the  genital  tract  of  female  children. 

Icterus  Neonatorum. — Icterus  of  the  new-born  can  hardly  be  s|)()k<ii  of 
as  a  disease,  but  rather  as  a  phenomenon  depending  in  many  cases  on  natural 


I'ATJIOLOaY   OF    THE   NHW-liOlty    INFANT. 


827 


|troco.s.st's  of  th«  first  tlays  of  life  It  occurs  in  from  79  to  84  per  coiit.  of  all 
infants  (I'orak,  Cruse),  anil  is  most  likely  to  m-cur  in  children  prematurely 
l)orn  or  when  lij^ation  of  the  conl  has  been  delayed.  The  yellow  skin-diseol- 
uration  occurs  usually  several  days  after  hirtli,  hut  occasionally  it  exists  in  the 
pre-natal  state.  The  discolorati<»n  of  the  skin  is  usually  not  accompanied  hy 
liny  symptoms  of  disease,  and  is  not  very  markinl,  appearing  first  on  the  face, 
later  on  the  trunk.  In  mild  cases  the  sclerotics  remain  unatlected.  This  usual 
form  of  icterus  neonatorum  is  physioloj^ical  and  is  without  serious  symptoms; 
it  usually  disappears  spontaneously  within  a  week.  If  the  howels  arc  slu>;^ish, 
small  doses  of  rhubarb  or  hydrarfjjyrum  cum  ereta  may  be  ^iven.  The  "  symp- 
tomatic" form  is  more  serious,  on  account  of  the  patholo>rical  conditions  with 
which  it  is  associated,  and  from  which  it  must  be  ditferentiated.  It  is  consid- 
ered on  another  l>age. 

There  have  Ik-cu  many  hypotheses  as  to  the  cause  t>f  the  usual  (the  pliysio- 
loijical)  form  of  jaundice,  but  no  explanation  has  been  oll'ercd  that  is  entirely 
sntisfa(!tory.  The  two  theories  more  jjenerally  considered  are — first,  that  of 
IhiiKitoi/cnic  oritjin  (Virchow's  and  others) — that  is,  the  bil('-pi<iment  is  sup- 
|M).sed  to  oriffinatc  in  a  rapid  destruction  of  blotxl-corpnscles — and,  second,  the 
li<lt(ito(/etiie  orijijin,  in  which  the  small  common  biliary  duct  liiils  to  carrv  off 
excess  of  bile  :  these  theories  are  fully  described  in  the  recent  text-books  on 
diseases  of  children. 

Mastitis. — The  mammary  <:;lands  of  infants,  both  male  and  female,  often 
assume  during  the  first  two  weeks  a  fun<'tion  similar  to  lactation  in  the  adult 
woman.  The  milky  fluid  secreted  closely  resend)les  colostrum.  This  func- 
tional activity,  being  accompanied  by  con<^estion,  is  very  likely  to  assume  the 
form  of  inflammation,  producinjf  swelling:;,  redness,  and  pain. 

External  irritation,  such  as  pressure,  attempts  on  the  part  of  the  atten<linfj 
midwife  or  nurse  to  sepieczi!  out  the  milk,  etc.,  increase  the  tendency  toward 
iiillammation.  If  ])roperly  cared  for,  this  physiolo<rical  swellinjij  will  soon 
subside ;  if  irritated  and  perhaps  sul))cctcd  to  much  handlinix,  producinj; 
abrasions  of  the  epithelial  covering,  suppuration  may  occur.  Infection  of  this 
gland  is  described  on  another  page. 

P)'0(jnoHis  and  Tvcdtincnt. — The  prognosis  is  generally  good.  Prophy- 
laxis occupies  the  first  place  in  treatment.  In  cases  accompanied  by  much 
swelling  of  the  gland  the  latter  may  be  dressed  with  vaseiin  anil  boratcd  cot- 
ton. If  swelling  and  redness  of  the  skin  occur,  then  the  gland  should  be 
covered  with  an  antiseptic  wet  dressing. 

Diseases  of  the  Navel. — Under  this  head  we  may  consider — (1)  Anatom- 
ical and  physiological  considerations,  and  dressing  of  the  navel ;  (2)  umbil- 
ical hemorrhage  ;  (3)  slight  disturbances  of  healing  of  navel  wounds ;  ulcera- 
tions and  umbilical  fungus;  (4)  umbilical  hernia;  umbilical  fecal  fistula; 
(•'))  diseases  of  the  umbilical  vessels;  (6)  omphalitis;  (7)  gangrene  of  the 
navel. 

1.    AnATOMICAT.  and    PtlYSIOLOaiCAT.   CoNSrOKRATinXS,  AND    DUKSSIXf} 

OF  THE  Navel. — Under   normal   conditions   the   umbilical   cord  desiccates 


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828 


A3fEIiI('A.\    TEXT-BOOK   OF   OBSTETRICS. 


and  drops  off  i'roin  about  the  fourth  to  the  i^'xtli  day  after  the  birth  ol"  the 
cliild.  The  cieatrix  should  then  look  clean,  but  it  will  remain  moist  ;iiii! 
rather  soft  until  the  tenth  or  the  twelfth  day.  The  dressing  of  the  ei.iil 
should  be  such  as  to  assist  this  normal  process  and  to  j)rcvent  the  formatinn 
of  moist  putrel'action. 

As  will  appear  in  this  discussion,  the  umbilical  wound  is  the  eomnioiK-t 
atrium  for  infection  which  befalls  the  new-born,  often  with  most  disnstidi^ 
results.  To  prevent  this  accident  the  most  explicit  tlirections  in  regard  in 
the  antiseptic  treatment  of  the  umbilicus  should  be  given  to  the  attendant-. 
It  is  not  sufficient  to  give  the  nurse  verbal  instructions  simjjly  to  dress  ihc 
cord  as  she  thinks  best,  but  it  is  the  duty  of  the  obstetrician  to  see  not  onlv 
that  the  cord  is  dressed  in  an  antiseptic  manner,  but  that  it  is  also  kept  ])('i-- 
fectiy  clean  until  the  atrium  for  infection  at  this  place  is  closed. 

Some  such  method  as  the  following  for  treating  the  stump  should  he 
adopted :  After  cleansing  the  child,  the  abdomen  and  the  cord  should  lie 
washed  with  an  antiseptic  Huid — bichlorid  solution  (1  :  10(H)) — and  the  cdid 
should  be  tied  with  a  ligature  that  has  previously  been  sterilized.  The  ((nd 
is  now  thoroughly  washed  with  the  same  antiseptic  liquid,  and  turned  up  a 
little  to  the  left  upon  a  ]>iece  of  sterilized  gauze.  Both  the  gauze  and  the  cdid 
should  be  dusted  over  with  boric  acid,  and  then  be  covered  by  a  compi(>ss  nl' 
borated  cotton.  The  cord  should  be  thoroughly  washed  each  day  with  steiil- 
ized  water,  and  be  dressed  in  the  same  manner  each  time.  Particular  atten- 
tion should  be  paid  to  the  stump  after  the  cord  has  fallen  off;  it  should  he 
dressed  with  .some  antiseptic  lotion,  and  the  room  in  which  the  child  is  placed 
should  carefully  be  guarded  against  all  septic  influences.  kShould  decomposi- 
tion of  the  cord  take  jilace  jirevious  to  its  .'separation,  Kross  advises  a  dressuig 
of  bichlorid  of  mercury  (1  :  1000). 

2.  O.MPHAi.ORKn.\<ii.v  (UMnii.iCAi.  IIkmouuhaok). — ITmbilical  heinor- 
rhage  is  no  disease,  but  ralher  is  a  symptom  of  one  of  various  pathological 
conditions.  We  distinguish  two  classes  of  omjihalorrhagia  :  First,  hemoriliaiio 
from  the  vessels  of  the  und)ili('al  cord;  second,  hemorrhage  from  the  iinihil- 
ical   wound. 

Hemorrhage  from  the  Umbilical  Vessels. — Of  this  class  there  an> 
two  varieties — one  occurring  before,  and  one  after,  the  sei)aration  of  tin' 
cord. 

A.  Jlemorrhagc  before  the  sepantfion  of  the  mnbUleal  cord  may  occur  if  the 
ligature  is  not  properly  tied.  The  ligature  may  be  loo  loo^' ,  or  it  may  have 
cut  into  the  tissue  of  the  cord,  thus  opening  a  blood-vessel,  whereujioii  liie 
hemorrhage  takes  jdace.  I?ut  it  does  not  follow  that  in  every  ease  of  iiii|iei- 
fect  ligattu'o  of  the  cord  a  hemorrhage  occurs.  That  this  statement  is  true 
we  know  from  numerous  cases  where,  although  no  ligaliu'c  had  been  used,  im 
hemorrhage  followed.  At  the  birth  of  a  living  child,  if  it  has  cried  lii>tily, 
a  small  amount  of  blood  flows  from  the  fetid  end  of  the  divided  cord  ten  "V 
fifteen  minutes  after  the  cord  is  cut  through.  This  blood  is  never  tiie  bliiilit 
red  oxygenated  blood.     After  a  short  time  this  slight  hemorrhage  stops. 


'" 'fnH'if 


I* 


PATHOLOGY   OF    THE   XEW-BOUN  INFANT. 


829 


isosi  :i  (Irossiii'j; 


The  anatomical  and  patliolcigical  investi}:;ations  made  by  B,  F.  Schultze 
will  assist  to  understand  fully  tlio  above  faots,  as  well  as  others  relatinif  to 
diseases  of  the  unibilieal  eord.  With  the  lirst  respiration  of  the  new-born 
( hild  the  expansion  of  the  lungs  leads  to  distention  of  the  blood-vessels  of 
the  thorax  ;  thus  the  blood-pressure  sinks  in  all  the  large  vessels  of  the  bodv. 
'I "he  greatest  fall  of  the  pressm-e  occurs  in  the  pulmonary  artery,  then  in  the 
aorta,  then  in  the  other  large  vessels,  including  the  uml)ilieal  artery.  Thus 
the  jiulse  in  the  umbilical  cord  after  a  deep  respiration  is  weakened  and  the 
arteries  contain  little  blood.  At  the  time  the  arterial  pressure  falls  one 
(ihserves  in  the  umbilical  vessels  an  exceedingly  niarke<l  nuiscular  contraction, 
and  notices  that  the  lumen  of  I'u  vessels  is  rapidly  reduced. 

Strawinski,  who  studied  tiif  peculiar  arrangement  of  the  muscles  of  the 
umbilical  arteries,  found  in  them  an  internal  longitudinal  and  an  external 
circular  layer  of  the  vessels,  lie  and  Von  Hasch  also  demonstrated,  by 
measurement  made  in  the  lower  animals,  the  actual  reduction  in  l)lood-pressiu'e. 
'i'he  umbilical  cord  no  longer  receives  blood  from  the  ])lacenta ;  the  blood  it 
already  held  has  been  aspirated  into  the  thorax,  so  that  the  vein  becomes  empty 
and  its  walls  contracted,  although  less  energetically  than  the  walls  of  the  arterv. 
Kxpansion  of  the  lungs  and  contraction  of  the  inuscidar  coat  of  the  umbil- 
ical vessels  are  the  two  important  factors  which  usually  make  severe  hemor- 
rhages from  the  umbilical  cord  of  the  new-born  child  impossible.  It  nuist  be 
stated,  also,  that  in  many  of  the  lower  animals  the  tendency  to  hemorrhage  is 
lessened  by  various  conditions,  such  as  traction  i»f  ihe  cord  and  by  its  being 
bitten  off.  But  even  in  the  human  ott'spring  a  great  tendency  to  hemorrhage 
(Iocs  not  exist,  even  though  the  (Ujature  be  not  applied.  This  tiict  has  abun- 
dantly been  corroborated  by  medico-legal  experience,  since  in  eases  of  illegiti- 
mate birth  the  cord  is  often  cut  by  scissors  and  left  untied,  yet  death  by 
licmorrhai.  >  rarely  occurs,  if,  however,  in  the  new-bo':i  child  the  respiration 
is  imperfect,  causing  oidy  partial  expansion  of  the  lungs,  then  the  und)ilical 
Vi  -iseis  remain  tilled  with  blood  and  pulsate  strongly. 

Ji'  asphyxia  of  the  first  degree  bo  the  cause  of  imperfect  respiration,  the  blood- 
pressure  rises  and  the  pulse  becomes  strong.  In  such  a  case,  should  the  eord  be 
severed  and  not  ligated,  ])rofuse  hemorrhage  would  usually  follow.  This  fact 
explains  most  hemorrhages  following  imperfect  ligation  of  the  cord.  When, 
hipwever,  such  hemorrhages  occur  in  matin-e  and  well-developed  children,  they 
must  be  due  to  insufficiency  of  the  muscidaris.  Hoffman  fbinid  that  after 
iiirth  the  umbilical  arteries  do  not  contract  evcidy  tliroiighdut  their  extra-  and 
intia-abdominal  extent,  but  that  the  contraction  takes  place  in  a  centripetal 
direction.  The  pulsation  is  first  weakened  in  the  portion  nearest  (he  placenta, 
this  weakening  taking  place  progressively  toward  the  umbilicns.  For  several 
niiiMites  after  the  first  respiration  of  the  child  there  is  still  a  full  pulse-wave 
felt  near  the  abdominal  entrance,  while  the  peripheral  portion  is  i)Ioo(llc>s  and 
eontracted. 

Ft  caiuiot  yet  be  decided  what  causes  the  iin|)crfect  or  only  temporary  con- 
traction of  the  blood-vessels.      It  is  jnissible  that  increase  of  arterial  pressure — 


f 


mm- 1 ' 


'  I 


'  I 


830 


AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 


as,  for  instance,  in  asphyxia — dinunishcs  tlic  rosistanoc  of  the  musciilaii.; 
some  authors  believe  that  ])rotrac'tcd  warm  baths  may  produce  rohixatimi 
of  the  niuscularis. 

For  tlie  prevention  of  hemorrhage  a  few  ihiijs  after  birth  desiccation  of  iho 
umbilical  stump  plays  an  important  part.  If  the  cord  dries  up  noriimllv. 
then  the  dry,  hard  portions  eifect  a  positive  protection  against  the  eveiiinal 
occurrence  of  hemorrhage;  if,  however,  the  cord  should  become  gan<''i('ii(iii.- 
its  vessels  will  become  distended  and  may  again  become  pervious.  SdiiH' 
authors  think  that  any  obstruction  to  the  return  of  venous  blood  to  the  licait 
may  ])r()duce  hemorrhage.  Inasmuch  as  various  conditions  mav  arise  that 
would  ])revent  a  physiologically  bloodless  condition  of  the  umbiliciil  cord  and 
the  obliteration  of  the  tnnbilical  vessels,  it  is  to  be  urged  in  everv  case  that  the 
cord  be  carefidly  ligated. 

ProplniUuvix  and  Treatment:  LUjatlon  of  the  i'orit. — The  ligature  sliuuld 
be  placed  about  two  or  three  fingers'  width  from  the  navel.  Particular  caie 
must  be  taken  with  asphyxiated  or  premature  children  that  the  ligatuic  is 
firm  and  that  it  does  not  cut  into  the  tissues;  for  this  reason  a  moist  tape 
increases  the  security.  If  the  cord  is  very  thick,  a  second  ligature  may  he 
applied  after  the  cord  is  somewhat  collapsed.  The  tape  should  be  from  lo  to 
2  centimeters  (|  inch)  wide  ;  in  case  of  hemorrhage  a  second  ligature  wuM  K- 
a])plied.  If  the  und)ilical  end  is  too  short  or  has  been  thrown  off,  a  c()iii|in  - 
sion  bandage  must  be  applied  or  the  individual  vessels  nuist  be  secured  hv 
encircling  stitches.  If  the  infant  is  anemic,  stimulants  must  be  administered 
and  artificial  heat  must  be  applied  to  prevent  collapse.  For  very  gelatiiKnis 
cords  Hudin  advises  the  use  of  the  elastic  ligature:  he  found  that  in  these 
cases  a  slight  blood-pressure  may  suffice  to  j)roduce  hemorrhage,  even  thuuuh 
the  cord  be  ligated  with  a  linen  tape.  Rough  handling  of  the  stump  dniiiiir 
desiccation  must  of  course  be  avoided. 

J}.  JLinorrhaf/efrnm  the  Vnibi/ieal  Wonnd. — (Omphalorrhagia  ;  also  ealh'd 
"  Idio])atliic"  or  "Spontaneous  Hemorrhage.") — The  appearance  of  a  lew- 
drops  of  blood  on  the  dressing  immediately  after  the  separation  of  the  ediii, 
even  though  this  occur  for  several  days,  is  not  uncommon,  and  generallv  is 
of  no  importance.  The  ])atliol()gical  condition  to  be  here  described  is  the 
one  usually  associated  with  grave  constitutional  disturbance,  generally  termi- 
nating in  death.  Fortunately,  this  form  of  hemorrhage  is  very  rare;  Wiiiekel 
found  one  ease  in  oOOO  births,  male  children  being  attacked  more  fre(|ueiitlv 
than  females,  and  strong,  healthy  children  more  fnupKMitly  than  the  t'eelile. 
It  is  of  interest  to  note  the  great  numbei-  of  cases  of  und)ili('al  liemcinliai;(' 
that  have  l)een  re|)orted  in  America  in  contrast  with  thos(;  in  Europe.  The 
condition  occurs  in  the  negro  and  the  nudatto  as  well  as  in  the  white  race. 
(iraudidier,  to  whom  the  writer  is  indebted  for  uuich  information,  colleeted 
a  siunmary  of  220  cases. 

T/ie  etiolor/if  of  umbilical  hemorrhage  is  still  imperfectly  understood.  Imt  it 
is  evident  that  hemojdiilia  is  not  the  oidy  cause.  In  "bleeders"  uini)ilieMl 
hemorrhage  is  very  rare;  among  185  liunilies  of  bleeders,  with  576  individiiMl.-- 


&  ■ 


musculari   . 
c    rt'laxutimi 

catiim  (if  tile 
i|>  nonutdly. 
tho  cvoiilnul 

I  gangn'iiiiii>, 
^•ious.  S(iint> 
,  to  tho  lu'iiit 
ay  arise  lliat 
Ileal  eortl  ninl 
•  ease  that  iln' 

gatiire  slmiild 
'artieular  eaie 
the  ligature  is 

II  a  moist  tape 
mature  may  lie 
bo  IVoiii  1  h  til 
raturc  iri!st  \h 
off,  a  ooiii|iii-.>- 
be  seetireil  hy 
le  administi'ml 
v'crv  gelatinous 
I  that  in  thesi' 

even  though 
sttimp  (luriiiiT 

la  ;  also  ealled 
iiiee  ol'  a  few 
)n  of  th<'  eonl, 
11(1  generally  is 
cperibed  is  the 
piicrally  teriui- 
rare  ;  Winekel 
tro  fre(iueiitly 
Kin   the  feelile. 
nl   heinnriliagc 
Europe.     Tlie 
the  white  race, 
ation,  eoUeeted 

(h'fstood.  I  nit  it 
(M-s  "  umiiilieiil 
575  individual 


PATHOLOGY   OF    THE  NEW-BORN  INFANT. 


831 


who  wci*e  bleeilers,  spontaneoii.s  umbilioal  hemorrhage  occurred  only  in  nine 
laniilies  iu  twelve  individuals,  and  in  the  latter  it  i.s  a  question  wiiether  in  all 
uf  thera  it  occurred  without  the  bleeding  of  large  blood-vessels.  Moreover,  in 
the  cases  of  spontaneous  hemorrhage  that  have  reooven'd  it  has  not  been 
(il)served  that  there  was  a  tendency  to  bleeding  in  later  life,  while  in  hemo- 
iiliilia  the  disposition  to  hemorrhage  usually  remains  through  life. 

Grandidier  offers  the  explanation  of  "transitory  hemorrhagic  diathesis" 
which  has  developed  on  account  of  changes  in  the  respiration  of  the  iiew- 
liorn  ;  but  this  is  only  a  suggestion  as  to  a  cause.  The  (juestion  is  of  inter- 
est whether  the  health  of  the  parents,  especially  the  mother,  bears  any  rela- 
tion to  the  disease.  In  Grandidier's  cases  syphilitic  disease  was  present  six 
times  in  the  mother  and  twice  in  the  father.  American  physicians  .state  that 
the  excessive  use  of  alkaline  remedi(\s  during  pregnancy  is  the  cause  of 
this  difficulty.  Others  consider  the  depressing  iiiHueiices,  severe  vomiting, 
and  excessive  thirst  during  ])regnancy  as  possible  causes.  If  the  results  of 
post-mortem  examination  are  examined,  it  will  be  found  that  the  idiopathic 
umbilical  hemorrhage  is  usually  associated  with  one  of  the  following  con- 
ditions: (1)  congenital  syphilis;  (2)  sepsis;  (3)  acute  fatty  degeneration; 
(1)  hemophilia. 

Si/p/ii(i.s  is  a  cause  of  umbilical  hemorrhage.  Not  alone  (irandidier,  but 
other  authors  liave  found  syphilis  of  the  parents  present  in  many  cases  of 
umbilical  hemorrhage  in  children.  The  description  of  the  syphilitic  changes 
which  the  child  showed  during  life,  and  which  were  found  post-mortem,  is 
siillicicnt  to  establish  syphilis  as  an  etiological  factor.  This  oiiiuion  is  ren- 
dered .still  more  certain  by  the  general  t(.'iuleiicy  to  liemorrliag(>  iu  cinigenital 
syphilis.  In  cases  of  marked  hemorrhagic  diathesis  it  may  happen  that  the 
lieinorrhage  takes  jilacc  from  the  umbilical  wound  as  well  as  from  other 
organs. 

(SV'yw/,s'. — The  observations  of  Weber,  Hitter,  and  I^pstein  leave  little 
doubt  that  sepsis  of  the  new-born  may  give  rise  to  idiojiathic  umbilical 
liemorrhage.  It  is  known  that  capillary  hemorrhages  are  of  iVecpieiit  oeeiir- 
ri'iiee  in  sepsis,  but  severe  hemorrhages  in  various  organs  are  also  observed. 
Most  of  these  cases  were  observed  in  orphan  asylums.  Epstein  found  among 
51  children  with  this  form  of  hemorrhage  that  24  were  suH'ering  iVom  acute 
.-rpticemia.  Extensive  gangnme  of  various  parts  of  the  surtiiee  of  the  body 
i;    frequently  associated   with   this   form   of  hemorrhage. 

KIcbs  and  his  follower,  Eppinger,  attribiit'-  the  heinori-hages  to  the  inva- 
sion of  a  micrococeiis,  the  motinK  li(riiiorrli(i(/ici(iii.  Often  the  blood-vessels 
ill  the  iiei<>;lil)oi|iood  of  the  hemorrhajre  were  filled  with  the>e  mierocoeei, 
which  were  also  found  constantly  in  th(  blood.  According  to  Colin  and 
Wcigert,  many  cases  of  hemorrhage  have  been  observed  in  which  bacterial 
thrombus  and   emboli^::'   are  the  cause  of  the  extravasations. 

Th(>  occurrence  of  umbilical  heiuorrhage  in  (ifntij'iittt/  ili'i/ciicr/iflon  will  !»• 
tninid  fully  considere(l  on  another  |»age. 


f 


'  i^  I 


Siiinj)t()m.'<  (iiiil  P/ij/sicdl    Si(/iis   of  <iU  llii'Kc   I' 


(ll'll\X    tl 


f  If, 


fiiiorr/im/ 


'i-.lt 


832 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


l.ji 


'm. 


hemorrhage  generally  manifests  itself  about  the  fifth  day,  usually  just  aii.i- 
occasionally  before,  the  separation  of  the  cord.  According  to  Minot  it  inav 
occur  as  late  as  the  second  or  the  third  week ;  the  subject  mav  be  vx  il 
developed  and  apparently  healthy.  The  hemorrhage  does  not  arise  fr-jiii  one 
or  two  distinct  vessels,  but  oozes  freely,  like  a  fluid  from  a  sponge.  'Ciie 
bleeding  may  at  first  be  so  slight  as  to  be  mistaken  for  the  phvsiol()'ri(aI 
process  above  referred  to,  but  its  real  signiticance  will  be  manifested  by  tli(. 
persistent  oozing  or  in  a  hemorrhage  so  severe  at  first  as  rai)iil]v  to  cxliaii-r 
the  strength  of  the  little  patient.  There  is  often  slight  icterus,  sonictinus 
vomiting  and  colic,  clay-colored  stools,  sometimes  bloody  discharge  from  tlic 
stomach  and  bowels ;  in  severe  cases  cyanosis  and  somnolence  are  pri  .-(ni, 
showing  that  there  is  a  marked  and  grave  constitutional  disturbance,  in 
the  neighborhood  of  the  umbilicus  occur  spots  of  ecchymosis,  that  also  uniMar 
in  other  parts  of  the  body,  so  that  the  whole  child  appears  mottled  with  bhii>li- 
red  spots.  Edema  of  the  ankles  and  the  hands  frequently  occurs,  and  it  iii;i\ 
extend  to  other  parts  of  the  subcutaneous  connective  tissue.  Death  may  f  )llu\v 
in  several  hours,  but  the  patient  may  live  for  two  or  three  weeks.  Graiididicr's 
statistics  show  a  mortality  of  8;'>  per  cent.  Death  is  preceded  by  symptoms  of 
collapse,  coma,  and  occasionally  convulsions. 

Differential  Diagnosis. — The  diagnosis  of  this  form  of  umbilical  hemor- 
rhage from  the  more  common  form  first  described  is  based  on  the  grave 
constitutional  disturbance  which  soon  follows,  and  on  the  great  difficiiUv, 
usually  the  impossibility,  of  checking  the  hemorrhage. 

TJierapeutics. — Since  omphalorrhagia  is  a  symptom  of  a  number  of  con- 
stitutional diseases  marked  by  a  tendency  to  hemorrhage,  the  treatnuiit 
directed  solely  toward  the  arrest  of  hemorrhage  will  scarcely  suffice.  Usually 
all  attempts  at  arresting  the  hemorrhage  are  futile.  The  employment  of  a 
styptic  is  only  a  temporary  measure;  it  may  be  combined  with  firm  pressure 
upon  the  wound.  The  most  successful  treatment  consists  in  ligature  ol"  tlio 
navel  according  to  Dubois'  method.  A  hare-lip  pin  is  passed  along  the  (HJtro 
of  the  umbilical  wound  from  ]:^t  to  right  in  such  a  way  that  the  skin,  l)iit 
not  the  whole  thickness  of  the  abdominal  wall,  is  included.  By  means  of 
a  thread  passed  beneath  the  pin  the  navel  is  now  raised,  and  a  second  pin  is 
passed  under  the  first  pin,  and  at  right  angles  to  it,  through  the  abdoiiiiiial 
wall.  A  figure-of-8  ligature  is  passed  around  the  second  pin,  and,  finally,  cir- 
cularly around  the  base  of  the  navel.  This  method  is  said  to  have  arrotcd 
the  hemorrhage  in  a  few  cases.  A  plaster-of-Paris  bandage  has  been  advised. 
The  attempt  to  search  for  tlu^  vessels  with  a  view  to  ligating  them  is  almost 
never  successfid.  Hemorrhages  occurring  in  other  parts  of  the  body  are  to  he 
treated  in  a  similar  maimer.  The  internal  treatment  should  be  directeil  (u  the 
cause,  but  thus  far  promises  very  little. 

3.  Stjoht  Disturhance  in  Hkalino  of  Navim,  Woinds. — Occasion- 
ally when  the  process  of  desiccation  of  the  cord  has  been  incomplete,  or  wlicn 
there  has  been  some  irritation  of  (he  navel  by  friction,  espe(!ially  wluii  n(jt 
kept    pcrtei'tly  clean,  excoriation    and  even   ulceration   may   occur.     In  tlii> 


pf^-TUl'ilJ 


PATHOLOGY    OF    THE   NEW-BORX  IXFAXT. 


833 


jus-t  Uil.'l', 
lot,  it  ni:iy 
ay  1)0  \v(  il 
se  tr'jm  (jiic 
oiige.     '["he 
liysiolo^ical 
*itcd  by  tlic 
V  to  oxhiuist 
;,  sonu'tiint's 
ge  tVmn  the 

arc  |)r(\-('nt, 
U'baiK'o.  I II 
t  also  apiifiir 

with  bhiisli- 
s,  and  it  iivay 
h  may  toltnw 

Graiulidicr's 

symptoms  of 

jilical  hcMimr- 

oii  the  ^nivc 

■eat   difficulty, 

.unbcr  of  vm- 
the   tiviitiiuiit 
ffice.     Usually 
pluymcnt  of  a 
firm  pressure 
ligature  of  the 
[long  the  otljie 
the  skin,  hut 
By  means  of 
second  pin  is 
I  the  abdominal 
lul,  finally,  cir- 


havc  arre 


-ted 


been  ai 
hem  is 


Ivised. 
almost 


body  are  to  be 
Idireoted  to  the 

ll)S. — (Krasi'in- 
Iplete,  or  when 
vlly  when  lint 
r.     Ill  thi- 


leen 


event  the  treatment  consists  in  cleansing  the  wound  with  an  antiseptic;  solution 
(;>  per  cent,  boric  acid)  and  in  apjdying  a  mild  astringent.  Ilunge  advises  sali- 
(vlic  acid  and  starch  (1  :  o  to  1  : 3).  The  stump  in  those  cases  should  be 
dressed  twice  a  day. 

Umbilical  Fungus. — If  the  woimd  heals  slowly  and  secretes  for  a  lonsr 
time  sero-purulent  fluid,  there  sometimes  then  develops  a  red  granular  growth 
which  bleeds  readily,  and  from  which  there  is  more  or  less  oozing  of  serous  or 
soro-jiurulent  fluid.  This  growth  in  some  cases  has  a  broad  base;  in  other 
cases  one  or  more  of  the  growths  ar(>  pedunculated,  soft,  and  not  sensitive.  In 
the  early  weeks  these  growths  may  be  visible  only  on  retracting  the  surround- 
ing integument,  but  later,  if  not  arrested,  they  may  form  an  elevation  of  con- 
siderable extent  surrounded  by  excoriatious.  Usiudly  the  health  of  the  child 
d(ies  not  suffer.  The  fuutjus  itself  is  not  sensitive,  but  the  surroundinsr  exco- 
riation  may  become  painful.  Histologically,  this  fungus  is  a  granulation 
tumor.  The  wound  in  the  navel,  as  a  rule,  cannot  heal  while  the  fungus 
exists,  although  in  very  exceptional  cases  the  growth  may  become  covered 
with  epidermis.  This  disease  must  be  difl'erentiated  from  the  adenoma  de- 
scribed by  Kustner. 

Tlie  trcdtment  consists  in  cauterizing  the  growth  with  nitrate  of  silver  and 
applying  a  salicylic-acid  bandage.  Removal  by  scissors  is  likely  to  produce 
considerable  hemorrhage. 

Diseases  of  the  umbilical  vessels,  omphalitis,  and  gangrene  of  the  cord  are 
considered  on  other  pages  of  this  work. 

4.  Umbilicaf.-cokd  IlKHXt.K  (lleruito  Funiculi  Uiid)ilicalis). — Und)ilical- 
coi'd  hernia  depends  upon  the  arrest  of  developmiMit  of  the  abdominal  wall 
in  the  first  stages  of  fetal  life.  Frequently  other  malformations  are  present, 
st'.eh  as  hare-lip,  club-foot,  hydrocephalus,  and  spina  Itifida.  Lange  found 
from  a  study  of  21  cases  collected  in  literature  that  in  seventeen  of  them  other 
malformations  were  also  present.  There  will  be  considered  in  this  discussion 
only  such  cases  of  umbilical-cord  hernia  as  are  not  associatcfl  with  other  mal- 
forniations  which  interfere  with  life. 

Anatomi/. — The  umbilical-oord  hernia  is  a  round  or  an  oval  swelling  in  the 
uinhilical  region,  varying  in  size  from  a  nut  to  that  of  an  orange;  occasiou- 
;illv  larger.  The  tumor  may  occupy  the  greater  part  of  the  abdominal  wall. 
The  hernial  sac  consists  of  peritoneum,  covered  by  the  amnion  which  originates 
fi'oiu  the  umbilical  cord  and  reaches  the  base  of  the  swelling.  The  base  of 
the  swelling  is  continuous  with  defi'ctive  integiunent.  Sometimes  a  small  part 
iif  the  skin  reaches  a  little  over  the  tunmr.  Between  the  external  covering 
;i!i(l  the  iHMMtoneunt  is  a  thin  layer  of  Wharton's  jelly,  'fln^  amnion  and  peri- 
toneum may  be  firmly  united.  The  sac  usually  contains  some  intestine,  at 
times  also  the  liver,  stomach,  spleen,  and  other  viscera,  such  as  the  kidneys 
anil  |)ane-eas.  Two  or  more  of  these  viscera  may  be  ixmnd  together  by  adhe- 
MoiH.  The  implantation  of  the  umbilical  coi'd  is  sometimes  on  the  summit  of 
the  swelling,  more  often  somewhat  deeper.  The  umbilical  vessels  jiass  from 
the  e(inl    between    the    amnion    and    the    pei'itoneiim    over    the    swelling    to 


'ii  Hi! 


I':'Hi 


834 


AMEniCAN    TEXT- BOOK   OF    OBSTETRICS. 


'mm 


it, 


tlie  alxlominal  defect,  the  veins  ])as.sing  to  the  liver  and  the  arteries  towaid 
the  bladder. 

CUnkal  Appearance. — Immediately  after  birth  the  thin  amniotic  eovcrini^r 
of  the  und)ilical-eord  hernia  presents  a  grayi.sh-wliite,  translucent  appearance; 
the  presence  of  meconium  in  the  intestines  gives  the  swelling  a  dark  green  colur. 
On  palpation  one  may  detect  peristaltic  motion  of  the  intestine;  the  presence 
of  a  part  or  of  the  entire  liver  renders  the  contents  of  tlie  tumor  fniiK  r. 
During  the  process  of  desiccation  in  the  innbilical  cord  in  the  next  I'vw  dnvs 
the  appearance  of  the  hernia  is  nuich  clianged.  The  circular  edge  of  skin  at 
the  base  is  reddened,  and  suppuration  often  takes  place.  After  separation  df 
the  amnion  active  granuhition  may  build  up  tlie  edge  of  the  nk-cr.  The 
wound-surface  grows  less,  the  edges  contract,  and  finally  the  hernia  may  cinse 
by  cicatricial  contraction.  Death  often  I'csults.  By  rough  handling  tlie  hernia 
may  become  gangrenous ;  in  this  case  the  gangrene  is  liable  to  extend  into  the 
contents  of  the  sac,  and  the  child  dies  of  sepsis.  In  other  cases  suppuraiion 
extends  along  the  umbilical  arteries  or  directly  to  the  peritoneum,  and  death  is 
due  to  arteritis  umbilicalis  or  to  peritonitis. 

Diarpiotiis, — A  case  of  large  und)ilical-cord  hernia  can  scarcely  be  niistakeii 
for  anything  else.  Small  hernite  of  cylindrical  form  are  more  a])t  to  lead  to 
error  in  diagnosis.  In  all  cases  of  marked  swelling  of  the  umbilical  cunl  at 
its  fetal  insertion  one  should  thiidc  of  the  possibility  of  hernia  of  the  cord. 

Pi'ofptosis. — Formerly  the  prognosis  was  considered  always  bad.  In  1S.S4, 
liindfors  taught  that  healing  without  operative  measures  might  be  procured  hv 
suitable  retention.  Previous  to  his  time  cases  of  healing  by  j)rotection  and 
compression  had  been  reported.  More  recently  the  jjrognosis  has  become  some- 
what more  favorable,  but  the  mortality  still  remains  high. 

Treatment. — The  treatment  has  already  been  indicaied.  It  consists  of  two 
methods:  first,  favoring  natural  tendency  to  obliteration;  and,  second,  the 
radical  operation.  The  first  method  consists  in  favoring  desiccation  by  applv- 
ing  careful  antiseptic  dressing  of  iodoform,  aristol,  zinc,  or  bisnnitli.  The 
hernia  shoidd  be  protected  by  a  cotton  compress,  and  when  the  cord  and  anmieii 
have  dropped  off  granulation  of  the  edges  must  be  favored  by  the  application 
of  solutions  of  nitrate  of  silver.  As  soon  as  reduction  .seems  )H)ssible  it  nuisl 
very  carefully  be  performed,  and  a  compression  pad  be  apj)lied  and  held  in 
place  by  adhesive  sti'Mps. 

Riidical  Operation. — If  this  method  is  clutscn,  the  operation  should  be  per- 
formed soon  after  birth.  In  this  case  all  efl'orts  at  reposition  are  omitted. 
Twenty-four  hours  previous  vo  the  operation  iodoform  dressings  are  applied. 
The  o})eration  consists  in  u'.aking  a  circular  incision  into  the  skin  at  the  ha«i 
of  the  swelling,  .2  to  .5  centimeter  {\  inch)  outside  of  the  sac,  cutting  down 
close  to  the  peritoneum.  After  examination  ttf  the  contents  and  separation  el' 
adhesions  the  abdominal  wall  is  closed  by  interrupted  sutures,  taking  care  to 
bring  the  e<lges  of  the  skin  into  ])crfcct  ap|)osition. 

In  liS8,'i  to  188J),  Lindfors  in  his  collection  of  10  oi)erative  cases  had  seven 
recoveries.     Hiiicc  iheii  he  has  added  to  the  number.     MacDonald  in  1S"J0  had 


I    M' 


I'ATIIOLOdY    OF    Tin:    XKW'-JiORX  JXFAXT. 


8:5") 


;t  consists  of  two 

and,  sLH'ona,  the 

-cation  by  iipply- 

bisniuth.     TIk- 

[.(ird  and  amnion 

V  the  appli^'ation 


Ition  arc  oniiltfil. 

Isings  arc  applifi. 
f^kin  at  tlio  l)!i-' 
sac,  cnttinii-  '1"^^" 
and  separation  ot 


]i)  cases  with  seventeen  recoveries.     Since  then  other  operators  liave  met  with 
hai)py  results. 

4.  Infectious  Diseases  of  the  New-born. 

It  has  long  hoon  observed  that  occasionally  a  child  born  in  ap])arentlv  por- 
f'trt  health,  with  good  family  history  and  with  excellent  hygienic  snrronnd- 
iiigs,  has  developed  during  the  lirst  days  of  its  life  a  disease  characterized  bv 
high  temperature,  exhaustion,  collapse,  and  death.  Sometimes  there  has  been 
found  a  local  trouble  which  explained  the  cause  of  these  phenomena,  but  fre- 
(|ii(ntly  nothing  could  be  noticed. 

FrctjKcnci/. — The  occurrence  of  infection  of  the  new-born  is  probably 
ijivater  in  private  practice  than  is  generally  recognized.  It  is  tiiir  to  suj)pose 
that  in  many  infants  attacked  with  fever  and  i)rostration,  accompanied  possibly 
witli  some  jaundice  and  continued  exhaustion,  a  fatal  result  takes  place  from 
septic  infection.  In  hospitals  a  high  percentage  has  always  been  acknowledged. 
Miller  found  that  700  or  800  deaths  occurred  yearly  from  diilerent  foiiiis 
of  sepsis  of  the  new-born. 

FJioliHjy. — In  considering  the  etiology  of  sepsis  of  the  new-born  we  cannot 
iivoid  some  reference  to  the  subject  of  sepsis  in  ntcro.  After  an  extensive 
.-wirch  through  medical  literature  Von  Holtz  positively  asserted  that  although 
septicemia  tn  iitero  was  rare,  it  undoubtedly  occurred.  For  this  earlv  l()rm 
of  sepsis  the  two  modes  of  genesis  which  have  been  assumed,  and  which  have 
given  rise  to  consid'M'able  debate  and  experimental  research,  are  iihiwnldl 
infection  and  infection  f :/  <tsj)ii'(ition  of  the  (imniotic,  Jinid.  Although  the  jila- 
cental  transmission  of  se])tic  micr»j-organisms  from  the  mother  to  the  fetus 
lias  not  i'ully  been  demonstrated,  either  clinically  or  experimentally,  this  pos- 
sibility can  hardly  be  denied.  Several  cases  accurately  described  bv  A\'eber, 
Biild,  and  Orth  leave  little  doubt  as  to  this  mode  of  infection.  The  theory 
of  fetal  sepsis  produced  by  the  aspiration  of  either  jMitrid  anniiotic  fluid  or 
iftMiital  secretions  seems  probable  from  a  case  described  by  Kiistner;  experi- 
ments made  by  Hohenhausen  and  (tcyl  are  cited  in  sujjport  of  this  theorv, 
hut  the  evidences  are  not  conclusive. 

Many  other  theories  have  been  advanced  on  the  means  by  which  tiie  oi-gan- 
ism  of  the  new-born  may  be  invaded  by  intectious  matter.  P.  Miillcr 
iiiade  exper'ments  to  prove  that  disease-germs  are  transmitted  from  mother  to 
child  by  means  of  the  mother's  milk.  There  has  be(>n  demonstrated,  on  the 
one  hand,  the  i)resence  of  sta]>hylococci  in  the  milk  of  septic  pu(>rperal 
women,  but,  on  the  other  hand,  since  staphylococci  have  lu'cn  tliund  in  the 
milk  of  healthy  w(mien,  and  since  such  nn'lk  has  not  been  injurious  to  the 
ehililren  who  were  nourished  by  it,  since  also  children  inu'sing  fron;  Wdinen 
with  septic  diseases  hav<^  remained  healthv,  the  (piestiou  of  sepsis  being  trans- 
mitted throuixh  mother's  milk  nuist  still  be  considered  unsolved. 

Air-infection  is  another  theory,  according  to  which  tlic  fetus  th.nt  has 
aspinitcd  amniotic  fluid  will  contain  a  favorable  culture-medium  in  its  lungs 
tor  pathogenic  germs  that  may  exist  in  the  sick-room. 


t 


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|iF 

&  > 


I  n 


•*; 


836 


AMERIVAN    TEXT-BOOK    OF    OliSTETIiH'S. 


Pdthohxjii. — I'atliolojfit'al  coiulitioiis  will  diifcr  accord iii<^  to  the  cause  ul'ilu. 
infoctiuii.  Ill  sonic  cases  tlic  iiifcctioii-atriiiin  cannot  be  tbuiul :  if  it  i.«,  ||„, 
navel,  diseases  ol'  hlood-vcssels  will  be  tbiiiid,  with  evidences  of  stiitic  uvy]. 
tonitis  and  iiiHaniiiiation  of  other  abdoiniiial  orpins.  If  the  infectidn  i,;,^ 
taken  place  through  the  mucous  nietnbranes,  we  find  the  patholoijieal  <'<)niii- 
tioiis  present  in  the  month,  the  larynx,  and  the  upper  aii>passaj;-es,  as  well  ;i< 
in  the  intestinal  mucous  meiiibraiie.  Evidences  of  septic  piieiinKniia  \\li|i 
bloody  exudate  into  the  pleura  and  pericardium  have  been  found.  SdnieliuK •< 
hemorrha<!;e.s  have  taken  place  into  the  brain,  the  lunu;s,  and  the  kidiu  \^ 
This  result  is  due  partly  to  diseases  of  the  liver  and  partly  to  intlaniniatinn 
of  the  veins  of  the  umbilicus. 

Sipnptoins. — The  manifestations  of  infection  of  the  new-born  nec(»aiilv 
vary  as  different  organs  are  inv(jlved  or  as  the  entire  system  is  invadcij. 
ISIaiiy  of  these  cases  of  infectious  disease  are  characterized  by  a  rapitl  Iiks  di' 
weight  and  by  restlessness  and  insomnia.  There  is  usually  a  rapiil  and  shal- 
low respiration,  attended  with  vomiting  and  diarrhea.  The  temperatinc  is  frc- 
(piently  105°  F.,  l)Ut  in  some  cases  where  the  infection  is  profound  coilanx' 
will  early  occur.  Some  of  these  attacks,  with  symptoms  that  are  exceedinolv 
severe  for  a  short  time,  are  aborted.  In  other  cases  nothing  is  observed  until 
about  the  fifth  or  the  seventh  day,  when  usually  there  will  be  found  in  tlif 
region  of  the  umbilicus  some  evidences  of  suppuration,  or  at  least  some  redness, 
with  possibly  a  bad  odor.  These  symptoms  are  st)metimes  followed  bv  (li|)li- 
theritic  exudates  in  different  parts  of  the  body.  The  child  is  fretful,  its  tem- 
})eraturc  rises  to  102°  F.  or  higher,  very  frequently  the  abdomen  is  hard  and 
tender,  and  septic  peritonitis  and  death  iiillow. 

Other  symptoms,  such  as  icterus  and  melena,  may  be  associated  with  sepsis. 
They  are  not  invariably  present,  and  are  sometimes  described  as  special  dis- 
eases. Icterus,  in  its  general  application,  is  considered  on  another  page,  lait  its 
special  relation  to  sepsis  will  be  considered  under  Icterus  Si/niptomaliciix,  also 
under  (iddro-intentinal  Ilemorrfiaf/e. 

In  other  cases  the  symptoms  are  those  which  would  come  under  one  of  the  ((ni- 
ditions  presently  to  be  described — infection  of  the  umbilicus,  erysipelas,  mastitis. 

Wound-infection. — The  atrium  for  infection  in  the  great  majority  ot' 
cases  is  doubtless  through  some  wound,  such  as  traumatic  injuries  due  to 
delivery,  or  lesions  of  the  mucous  membranes  due  to  physiological  i)riK('sses 
of  desquamation,  but,  most  frequently  of  all,  through  the  umbilical  woniul. 
Prof.  J.  licwis  iSmith  makes  the  following  classification:  1.  Uinbiliial 
phlegmon,  or  local  sepsis;  2.  Sepsis  following  the  introduction  o\'  poison 
through  the  umbilical  s'cin  ;  and  3.  Sepsis  received  in  other  ways  or  tliroiigh 
channels  other  than  the  umbilicus. 

A.  iNKKrrrox  tmuough  the  Umhilict'S. — This  condition  includes  many 
of  the  abnormal  conditions  of  the  navel.  The  milder  forms  of  infection  inter- 
fering slightly  with  a  normal  healing  process  or  producing  ulceration  arc  con- 
sidered on  page  832.  The  graver  forms  of  infection  of  the  umbilicus  aro 
diseases  of  the  umbilical  vessels,  omphalitis,  and  gangrene. 


jr^vf  1111. 


PATiioLoav  or  the  nfav-houx  ixfaxt. 


h;j7 


if  il   i.-  tin' 

septic  iHii- 
nl'fi'tiiin  !i;i- 
[yArA  ('(inili- 
s,  as  wfll  iis 
iimonia  \mi1i 

tlu'  Ividiii  V-. 
iiillammatiiiu 

n\  nct't'-^arily 
111  is  iuvailnl. 
,  vi\])'\(\  1^>-^^  "' 
lipid  and  shal- 
pcraturc  is  tVc- 
ifouiul  collapse 
ivo  oxcocdiii>j;ly 
observed  until 
)e  ibimd  in  the 
ii  some  redness, 
llowed  by  diph- 
IVctful,  its  teia- 
uen  is  hard  anil 

,\ted  with  ^epsis. 
d  as  special  dis- 
l)iit  its 


ler  pa;j;e, 


aticH!<,  alstj 


iiptoni 


evoneoftheeon- 
'sipelas,  mastitis, 
rcat  majority  ol 
inpiries  due  to 
Uogical  processes 
(imbilieal  wound. 
1.    rnibilical 
Letion  of  itoisoit 
ways  orihrou'^di 

|,n  includes  many 
If  infection  intev- 
llceration  arc  coii- 
Ihe  umbilieii-  are 


Diseases  of  the  Umbilical  Vessels — Arteritis  and  Phlebitis. — A<'eor(l- 
iiifr  to  lliiiigo,  arteritis  and  phlebitis  of  the  umbilious  are  of  septic  orit^in,  the 
iormer  occurring  more  frequently  than  the  latter.  The  infection  first  attacks 
the  perivascular  connective  tissue,  extends  t(i  the  advontitia,  and  ])rodnces  dila- 
tation and  thronibo.sis,  after  which  the  disintegration  of  the  thrombus  may 
induce  general  .sepsis,  the  infection  being  conveyed  through  the  lymphatics. 
( )ceasi()nally  localized  disea.se  of  the  vessels  may  produce  death. 

S]imptoin.s. — There  are  no  sym])toms  which  would  indicate  with  certainty 
the  existence  of  arteritis  or  of  phlebitis  of  the  navel,  but  w(!  can  infer  that  these 
condition.s  exist  where  local  ulcerative  or  su])])nrativc  jirocesses  are  associated 
with  much  constitutional  disturbance.  The  course  of  the  diseases  is  often 
acute.  A  child  who  is  ap])arently  well  may  suddenly  manifest  restlessness, 
followed  by  collapse  and  death.  At  other  times  there  arc  the  usual  symptoms 
of  general  sepsis. 

I)i(i(/nosis,  Pro(/no,^is,  and  Treat iiwiif. — The  diagnosis  usually  cannot  be 
made  definitely  until  after  death.  Cases  of  the  milder  form,  occurring  in 
children  who  are  well  develo])ed,  usually  recover.  For  children  ])rematurely 
horn  the  prognosis  is  grave.  The  treatment  consists  in  the  use  of  antisej)tic 
dressings,  and  in  adopting  all  jwssible  means  to  support  the  strength  by 
nourishment  and  alcoholic  stimulants. 

Omphalitis, — This  aifetttion  is  an  infiammation  of  the  navel  with  phleg- 
mon of  the  surrounding  tissues.  In  the  region  of  the  navel  there  is  a  red 
swelling,  at  the  apex  of  which  the  navel  may  be  observed.  Usually  the 
healing  of  the  wound  is  incomplete.  The  redness  and  inflammation  extend 
in  a  circle  around  the  .stump,  the  skin  is  tense,  without  wrinkles,  and  glisten- 
ing, and  the  abdominal  wall  is  hard,  infiltrated,  and  very  sensitive.  This 
infiltration  may  involve  the  greater  part  of  the  abdominal  wall,  and  may  even 
extend  to  the  deeper  tissues  down  to  the  peritoneum.  The  child  is  restless, 
has  fever,  pain  upon  every  motion,  even  on  respiration,  and  consequently 
assumes  a  fixed  attitude  ;  respiration  becomes  costal,  the  lower  extremities  are 
drawn  up  toward  the  abdomen  and  are  held  immovably  in  that  position.  On 
the  siu'face  of  the  abdomen  dilated  veins  may  be  seen.  The  (lisea.se  may  last 
(lavs  or  weeks.  It  nsuallv  begins  in  the  second  or  the  third  week.  The  ter- 
inination  is  favorable  if  the  disease  is  not  too  extensive,  but  if  inflammation 
involves  the  abdominal  wall,  peritonitis  is  likely  to  follow,  li'  the  navel  ves- 
sels become  diseased,  gangrene  may  result. 

Prognosis  and  Treatment. — The  younger  the  child  the  more  favorable  is 
the  prognosis.  The  treatment  consi.sts  in  the  use  of  antisejitic  dressings,  of 
which  salicylic  acid  and  iodoform  are  the  best.  If  suppiu'ation  takes  pla(.'e, 
the  pus  nmst  be  evacuated  early.  The  constitutional  treatment  is  the  same  a.s 
thiit  for  arteritis  and  phlebitis. 

Gangrene  of  the  Navel. — Gangrene  arises  from  idcers  of  the  umbilicus, 
from  general  inflammation  due  to  sepsis,  and  from  cholera  infantum.  As  a 
local  infection  of  the  navel  it  is  not  infrequent,  especially  when  the  patient  is 
iieirlected. 


t 


838 


A.VKh'fCAX    TEXT- HOOK    OF    OIISTETRIVS. 


Si/iitj)h)iiiK. — The  iiiarjjin  ot"  tlio  wuund  of  the  navel  hocnmcs  discolnnMl  aiiil 
there  is  mure  or  less  ooziii*^  (if  a  muddy  fluid,  or,  in  oin|)lialitis,  a  vesicK'  nmv 
form  eontainiiijf  tiirl)id  fluid.  When  this  vesicle  hursts  it  leaves  a  raw 
surface.  The  spreading;  of  the  moist  «i:aiif;rene  may  he  rapid,  may  larjrelv  he 
on  the  surface  of  or  deep  in  the  navel  ;  the  latter  condition  is  the  most  (lanucr- 
ous.  There  is  always  fetid  odor.  If  the  child  is  stron<i,  tlien  the  process  niav 
become  arrested  and  the  defect  may  heal  hy  gramdation,  hut  usuallv  there  is 
rapid  loss  of  streiij^th,  terminating^  the  second  or  the  thinl  dav  in  deatli. 
Gan«frene  follo\vin<i:  cholera  infantum  usually  terminates  rapidlv  in  <;eii(ral 
sepsis  and  death,  hut  this  fatal  termination  has  occurred  as  late  as  the  twcutv- 
third  day.  Peritonitis  sometimes  occurs  in  which  perforation  of  the  intotiiics 
may  take  j)lace,  leaving  a  fecal  fistida.  Profuse  hemorrhage  is  one  of  tlic 
probable  complications. 

Treatment. — A  3  per  cent,  solution  of  acetum  aluminum,  applied  wiili  a 
compress  covered  with  rubber  cloth,  acts  antb^eptically  and  hastens  the  separa- 
tion of  the  slough  ;  after  that  the  indications  for  treatment  are  to  su))port  tlie 
strength  by  nourishment  and  alcoholic  stimulants. 

B.  In'I'Kctiox  of  Otiikii  WoI'XDs. — Various  injuries  upon  the  bodv  of 
the  child  may  lead  to  wound-infection  tiie  same  as  occurs  in  the  navel  wound. 
In  i)re-antiseptic  times  frcfpiently  small,  insignificant  injuries  of  the  skin  of 
the  child  from  pressure  of  the  forceps  were  followed  by  phlegmonous  iiitl;iiii- 
mation  about  the  injury,  and  sometimes  by  general  sepsis.  The  infection  in 
such  eases  was  transmitted  by  unclean  instruments  or  hands  (hiring  lalxu'  or 
after  the  birth  of  the  child.  In  a  similar  manner  various  infections  iiiav 
follow  if  operations  are  done  upon  the  child  and  asepsis  and  antisepsis  arc  iidt 
observed,  as  in  opening  a  ce])haliu'matoma,  in  operating  for  umbilical  in  rnia 
or  spina  bifida,  in  opening  a  mammary  abscess,  etc.  It  may  occur  in  tlut 
cutting  of  the  band  in  a  tongue-tied  child  or  through  the  ritual  of  circum- 
cision. The  most  fretpient  entrance  of  infection  is  through  the  defects  in  the 
epidermis  and  mucosa  pnxlueed  by  the  tendency  to  exfoliation  referred  to  on 
page  826. 

The  infection  may  also  take  place  about  the  buttocks  if  the  bed  or  tlio 
clothing  be  impregnated  with  septic  material.  Infections  about  the  inoiitli 
and  the  buttocks  may  lead  to  severe  intestinal  inflammation.  Through  the 
mucous  mend)rane  of  the  genital  tract  of  the  female  child  infection  may  alsd 
take  ])lace  on  account  of  the  shedding  of  epithelium,  and  the  infection  may 
take  on  a  di]ihtheritic  nature  and  lead  to  gangrene  of  the  external  genital 
organs,  terminating  in  the  deatli  of  the  child.  Gonorrheal  infection  from  the 
parturient  canal  of  the  mother  is  doubtless  often  transmitted  to  the  giiiital 
tract  of  the  female  child,  leading  to  obstinate  leiicorrheal  discharges  which 
occur  in   early  life. 

Erysipelas. — Upon  taking  up  a  work  on  Diseases  of  CJiildren,  written 
in  1800  by  Mi(>liael  Underwood,  the  writer  found  under  the  head  of  "  Infan- 
tile Erysipelas"  a  description  of  unquestionably  septic  processes  which  to-day 
would  be  charged  to  bacterial  infection.    The  writer  is  tempted  to  (juotc  freely 


II      i 


rATllOLOUY   OF    THE    XEW-llonX   IXFAXT. 


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f 

colorcil  ;nul 
vcsicU'  may 
avcs   ;i  raw 

V  l:ir;i'<'ly  lie 
iKist  ilimi^cr- 
nmccss  uuiv 
lally  tlnMc  i- 
ay  ill  tlcatli. 

V  in  p'licval 
■;  tlic  twcnty- 
the  intestines 
s  one  (il    the 

)plieil  witli  a 
ns  the  separa- 
to  suitp"!'*  the 

\  the  bo'ly  *'t" 
tiavol  woiiinl. 
;)t'  the  skin  of 
iionous  iiitlam- 
"he  infection  in 
nrinpj  lnhor  tn- 
infections  may 
itisepsis  are  not 
[nhilieal  hernia 
y  occur  in  the 
tual  of  cirenm- 
iC  defects  in  the 
vcforrecl  to  en 

I  the  bed  or  tlio 
Unit  the  month 
Throniih  tlie 
Ifection  may  also 
|e  infection  may 
external  livnital 
fection  from  tlio 
h   to  the  iienital 
lischaro'cs  wliieh 

\mh-cn,  wi'i'"'" 

Ics  which  tn-(1ay 
h  to  (luote  freely 


from  this  old  work,  hotli  from  tlio  fijciieral  interest  in  a  voice  from  the  past  and 
from  its  particular  aptness  and  historical  value.  Tiio  author  says:  "This 
ilispase  does  not  appear  to  ho  distinctly  noticed  by  any  j)reeedinjr  \vrit('r.  The 
i'ronoh  have,  indeed,  spoken  lately  of  a  somewhat  simihir  alfection,  combined 
with  other  con>j)hiints  infesting  crowded  hospitals,  but  the  disease  does  not 
appear  to  have  been  anywhere  noticed  in  its  simple  and  ifemnne  form.  I 
think  it  may  with  propriety  be  termed  the  Intimtile  Erysipelas.  It  is  a  very 
dangerous  species  of  that  spurious  inHammation,  and  it  is  not  very  often  met 
with  outside  of  lying-in  hospitals.  The  ordinary  time  of  its  attacks  is  a  ll.'w 
(lays  after  birth,  but  it  is  sometimes  mot  with  much  later.  It  seizes  upon  the 
most  robust  as  well  as  delicate  children,  and  in  an  instantaneous  manner;  the 
progress  is  rapid  ;  the  skin  turns  of  a  purj)lish  hue,  and  soon  becomes  exceed- 
ingly hard. 

'*  The  milder  species  of  it  appears  often  on  the  fingers  and  hands  or  the  feet 
and  ankles,  and  sometimes  upon  or  near  the  joints,  forming  matter  in  a  very 
short  time.  The  more  violent  kind  is  generally  seated  about  the  share-l)one 
(or  pelvis),  and  extends  upward  on  tiie  belly  and  down  the  tlilghs  and  legs, 
though  sometimes  it  begins  in  the  neck,  and  is  ctpially  fatal."  (The  author 
i)elieved  it  more  dangerous  as  it  atl'ects  the  central  part  of  the  body.)  "  In  a 
few  instances  the  disease  has  been  attended  by  some  varieties.  Infants  have 
not  only  come  into  the  world  with  several  hard  and  inflammatory  patches  and 
ichorous  blisters  about  the  belly  and  thighs,  but  with  other  spots  already 
actually  in  a  state  of  mortification." 

Since  the  time  of  Underwood  it  has  been  noticed  that  epidemics  of  puer- 
peral infection  have  been  followed  by  deaths  of  a  considerable  ninnber  of  chil- 
dren from  erysipelas  or  local  phlegmon  or  from  diseases  of  the  internal  organs 
not  so  easily  differentiated.  It  has  remained,  however,  for  the  new  pathology 
of  the  present  generation  to  give  a  fair  explanation  of  its  etiology. 

It  has  been  found,  on  the  one  hand,  that  no  micro-organisms  are  present 
in  vessels  of  the  stump  of  the  navel  cord  which  has  been  removed  under  the 
strictest  antiseptic  precautions;  on  the  other  hand,  it  has  been  demonstrated 
that  germs  of  various  diseases  exist  in  the  cord  and  blood-vessels  of  eiiildren 
wlio  suffer  from  symptoms  which  have  been  named  al)ove. 

The  following  is  the  history  of  a  case  of  erysipelas  vulva? :  C.  B.,  age  three 
months,  twin,  female.  Four  days  after  the  boy  twin  was  circmncised  hy  a 
iabl)i  the  baby  girl  was  taken  sick.  The  preputial  wound  of  the  boy  healed 
nicely  after  iiaving  a  slight  )>nrident  secretion  for  a  fi'w  days.  Diajx-rs  were 
used  in  common  for  botii  babies.  Tiio  temperattu'o  of  the  female  twin  was 
sod)  105°  F.,  pulse  140,  and  there  were  swelling  and  redness  of  the  lai)ia,  in 
a  '  ,v  hours  extending  to  the  thighs  and  lower  ]>art  of  the  i>aek.  Tiie  redness 
'.IS  shiny,  and  clearly  defined  with  slightly  raised  margin.  On  the  second  day 
tice  process  had  extended  over  the  entire  bat'k.  On  the  evening  of  the  second 
(lay  the  temperature  was  10")°  and  the  )>ulse  1(50,  and  the  ciiild  was  restless. 
There  was  typical  Cheyne-Stokes  respiration.  During  the  next  tliree  days  the 
procx'ss  abated  over  the  back,  but  extended  downward,  involving  thighs,  legs, 


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a!id  feot.  At  the  end  of  twelve  days  the  swelling  and  ralness  had  all  !is- 
appeared.  As  soon  as  the  process  began  to  lessen  on  the  trunk  and  extend  to 
the  lower  extremities  the  condition  of  the  patient  began  to  iniprov*.-. 

Peritonitis. — Acute  peritonitis  in  the  new-bi.rn  is  always  septic,  ami  it 
usually  results  from  the  absorption  of  septic  material  at  the  und)ilical  woiind 
or  from  umbilical  phlebitis  or  arteritis.  It  is  almost  unknown  in  niivatc 
practice.  Runge  found  only  four  cases  of  peritonitis  among  55  post-iiior- 
tenis  in  infants  dying  of  umbilical  arteritis  and  of  septicemia  the  result 
of  puerperal  infection.  In  puerperal  peritonitis  death  most  commonly  occins 
within  a  week.  Pleuro-pneumonia  occasionally  exists  in  these  cases  of  septic 
infection. 

Syiuptomi*  and  Treaiment. — The  early  symptoms  are  usually  those  of  crv- 
sijielas  around  the  base  of  the  cord.  There  may  be  vomiting,  diarrhea,  jaun- 
dice, distention  of  the  abdomen,  fever,  and  wasting.  The  treabnenf  of  Ixitli 
pritonitis  and  pleuro-pneumonia  at  this  early  period  of  life  consists  oliicHy 
of  prophylactic  measures.  When  the  diseases  have  appeared,  notwithstanding 
prophylaxis,  the  main  reliance  is  free  stimulation. 

Phlegrmasia. — This  disease,  which  takes  place  in  a  considerable  iiunil)or 
of  infants,  is  analogous  to  phlegmasia  in  adults,  except  in  certjiin  moditiciitions 
with  respect  to  the  special  anatomy  of  the  first  days  after  birth.  It  is  un- 
doubtedly a  septic  infection,  usually  associated  with  septic  disease  of  the  blood- 
vessels of  the  cord. 

Parotitis. — A  case  of  suppurative  parotitis  with  a  fatal  result,  and  septic 
infection  through  the  umbilicus,  producing  endocarditis,  and  resulting  talallv 
at  the  eighth  week,  has  been  placed  on  record. 

Mastitis. — The  milder  form  of  mastitis  has  been  described  on  page  S'27. 
The  mammary  gland  often  gives  entrance  to  infwtion,  either  by  way  (jf  the 
milk-duets  or  through  slight  injuries  to  the  nipple,  owing  to  improper  manipu- 
lation or  from  pressure  or  bruising  of  the  gland.  If,  in  case  of  slight  inlec- 
tion,  the  little  gland  is  carefully  guarded  against  new  invasions,  and  is  dressed 
with  boric  acid  or  with  a  solution  of  the  bichlorid  of  mercury,  the  hardness 
and  pain  usually  disa])pear,  and  the  restdt  will  be  all  that  one  could  desire. 
If,  however,  the  breast  is  mechanically  irritatetl,  and  thus  made  more  vulnei- 
able,  and  if  attention  to  cleanliness  be  neglected,  pus  in  all  probability  w  ill 
form. 

Symptoms. — The  infection  begins  usually  in  the  second  week  of  life,  with 
marked  redness  of  the  overlying  skin  and  increased  tenderness  upon  pres- 
sure. If  at  this  point  the  disease  is  not  averted,  then  there  is  an  increase  in 
the  swelling,  I'cdness,  and  tenderness.  The  diseased  gland  becomes  inereased 
in  size,  tisually  in  circumscribetl  portions.  With  the  developing  redness  of  the 
skin  there  arc  formed  in  the  gland  absceases  which  finally  rupture  and  dis- 
charge one  or  two  teaspoonfuls  of  pus.  During  the  abscess-formation  the 
child  is  restless  and  its  temperature  high.  After  the  discharge  of  the  pus  eou- 
valescence  is  usually  uninterrupted  and  the  cavity  ra])idly  heals.  Socondaiy 
abscesses  are   seldom  formed;   the  disease  usually  involves   but  one  of  the 


i 


It. 


PATHOLOGY    OF    THE   XFAi-JiOnX   jyFAXT. 


841 


ii;laiuls.  Ill  other  cases  the  disease  does  not  roniaiii  liinite<l  to  the  gland,  hnt 
extends  to  the  surrounding  tissne  ;  it  then  hwomos  pcniiKtutllis.  In  tiiis  ease 
tlio  extension  of  the  infiltration  may  he  very  great,  reaching  to  the  axillary 
space.  Then  the  temperature  rises  very  high  and  there  is  rapid  loss  of  weight. 
As  soon  as  the  ahscess  is  opentxl  the  symptoms  ahate.  The  contents  of  these 
al)scesses  may  be  very  fetid  and  contain  sloughs  of  tissue.  In  such  cases  death 
from  sepsis  has  been  recorded. 

Dr.  Bush  narrates  the  following  extremely  interesting  case  of  sepsis  of  the 
now-born :  A  healthy  child,  born  at  full  term,  weighing  nine  poiuids.  In 
soven  days  the  cord  fell  off,  leaving  a  granulating  surface.  On  the  fifth  day 
of  life  the  mammary  glands  were  swollen  and  some  fluid  exuded.  In  two  days 
tiiere  was  greater  swelling  in  the  left,  but  not  in  the  right,  side.  Five  days: 
later  (twelfth  day)  the  entire  right  side,  half  of  the  thorax  from  the  middle  of 
the  sternum  to  the  axillary  line,  were  hot,  swollen,  hard,  dusky-retl  in  color, 
with  fluctuation  about  the  breast.  Green  stools  and  fever  were  present.  Open- 
ing of  the  abscess  evacuated  30  cubic  centimetei's  (1  ounce)  of  sero-sanguinolent 
fliiid  with  some  tissue.  There  was  a  constant  discharge  of  bloody,  foui-smell- 
iiig  matter,  but  for  the  time  the  child  improved.  Two  days  later  there  was  a 
second  opening,  and  ultimately  large  ulcers  formed,  which  extended  to  the  ribs, 
so  that  the  pleura  lay  naked  at  the  bottom  of  the  wound,  death  taking  place  at 
tlio  end  of  ten  weeks. 

lite  prognosis  is  generally  good,  but  in  the  development  of  the  glandular 
function  at  a  later  period  of  life  atrophy  of  the  diseased  gland  may  follow.  In 
female  children  this  atrophy  may  interfere  with  the  function  of  lactation  later 
in  life ;  it  may  also  lead  to  retraction  of  the  nipples. 

Treatment. — The  prophylactic  treatment  for  mild  forms  of  mastitis  has 
been  indicated  on  page  827.  If  swelling  and  redness  of  the  skin  occur,  then 
tlio  gland  should  be  covered  with  a  wet  antiseptic  dressing.  If  suppuration 
occurs,  the  abscess  should  be  opened  early.  The  incision  is  made  in  the  direc- 
tion radiating  from  the  nipple ;  the  after-treatment  is  according  to  general 
surgical  principles.  If  the  tissues  outside  the  gland  are  involved,  then  early 
incision  is  indicated.  Carbolic  preparations  in  the  treatment  of  these  wounds 
sliould  be  avoided.  The  little  patient's  strength  must  be  supportetl  by  appro- 
priate food  and  stimulants. 

Tetanus  Neonatorum. — This  disease  consists  of  tonic  spasms  of  the 
niasseters,  extending  rapidly  to  the  voluntary  muscles.  The  disease  usually 
begins  at  the  time  of  the  separation  of  the  stump  of  the  cord — that  is,  from 
tin-  fifth  to  the  ninth  day  after  birth.  It  is  now  much  loss  frofpicnt  than  in 
former  years.  An  examination  of  early  literature  on  ])o«liatrics  shows  that  in 
oldon  times  death  from  this  disease  very  frequently  occurred. 

Etiology. — Formerly  the  cause  of  this  disease  was  assigne<l  to  various  con- 
ditions; dense  population  was  thought  to  be  a  predisposing  cause,  locality 
another  (Keating).  It  is  particularly  common  in  tlio  tropics.  In  East  India 
and  in  Africa  the  disease  is  ])articnlarly  fatal  ;  in  Jamaica  25  per  cent,  of  the 
iio<;ro  children  die  each  vear.    In  New  Orleans  and  in  IJaltimore  the  mortality 


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AMERIVAN    TEXT-HOOK    OF   OBHTETRICS. 


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from  this  source  was  formerly  very  j^rcat.  Pressure  upon  tl>o  brain  and 
neglect  of  ordinary  care  of  the  infimt  were  also  considered  special  caii^o  • 
npon  closer  study,  however,  it  seems  that  one  cause,  common  to  all,  !< 
filth. 

According  to  the  recent  teachings  of  Pathology,  tetanus  is  a  wound-in Icc- 
tion  (Briegcr)  produceil  by  the  tetanus  bacilli,  inoculating,  as  a  rule,  the  navel 
wound  and  there  producing  ptomai'ns  (described  by  Bricger),  of  which  tifmiia 
is  the  most  characteristic.  Any  wound  of  the  new-born  may  thus  be  inncii- 
latcd.  It  has  been  proven  that  these  bacilli  occur  upon  the  surface  oi"  tli" 
earth,  particularly  in  the  dust  that  accumulates  upon  the  floors  of  houses,  it 
is  easily  understood  how  in  this  way  the  bacilli  may  l)e  introduced  into  a 
wound,  especially  under  conditions  unfavorable  to  asepsis.  It  is  also  appan  nr 
why  in  tropical  regions,  in  crowded  cities,  and  among  the  p(Kir  this  disease  lias 
been  of  such  frightful  prevalence.  Hartigan  and  Hirsch  describe  the  disease 
as  occurring  very  frequently  among  the  negroes,  with  whom  it  is  a  practice  to 
apply  to  the  navel  the  roots  of  certain  plants. 

Pathological  Anatomy. — Autopsies  have  thus  far  shown  nothing  character- 
istic of  the  disease.  There  are  usually  exudates  of  bloody  serimi  in  tli(!  spinal 
meninges,  and  some  extravasations  of  blood  which  may  be  the  result  of  flic 
violent  spasms.  Similar  changes  are  found  in  strychnin  tetanus.  Tiie  other 
organs  show  nothing  characteristic  or  constant.  The  navel  wound  niav  seem 
perfectly  normal ;  occasionally  there  is  suppuration  of  the  wound  and  some 
disease  of  the  vessels. 

Symptoms, — The  most  marketl  symptoms  are  those  pertaining  to  the  mus- 
cular system.  Premonitory  symptoms  are  usually  present  for  many  hours, 
and  sometimes  days :  restlessness,  sudden  cries  during  sleep,  ditticiilty  in 
nursing,  rigidity  of  the  muscles  of  masticaticm,  these  muscles  being  as  hard  as 
wood.  The  mouth  cainiot  be  opened,  the  lips  are  pressed  togeth.er,  sometimes 
protruding;  the  brow  is  corrugatetl ;  at  times  there  is  an  extreme  sensitive- 
ness of  the  entire  surface  of  the  body.  Later  there  is  ditficulty  in  swallow- 
ing, which  frcfiuently  becomes  impossible.  Pidse  and  respiration  are  fre(juent, 
and  there  are  sometimes  diarrhea  and  urinary  disturbances.  When  the  mnseles 
of  mastication  are  involved,  this  condition  is  called  "  trismus ;"  when  there  is 
general  rigidity  of  all  the  muscles,  we  speak  of  it  as  "  tetanus."  The  opis- 
thotonos by  this  time  is  particularly  noticeable,  and  the  abdomen  is  alsd 
hard  ;  the  arms  and  hands  are  flexed.  As  a  general  thing,  however,  tlie 
uuiscles  of  the  body  are  less  involved  than  those  of  mastication  ;  the  eoM- 
vulsions  are  at  first  clonic,  becoming  after  awliile  contiimous.  The  respi- 
rat(»ry  nuiscles  are  only  slightly  att'ected.  Spasms  of  the  laryngeal  muscles 
may  cause  sudden  death.  Laceration  of  muscles  and  fracture  of  bones  have 
occurred  as  complications  of  the  disease ;  paralysis  of  grotips  of  muscles  may 
remain. 

DlagnoxiH  and  Prognoi^iH. — The  diagnosis  is  based  on  spasm  of  the  masseter 
muscles,  followed  by  opisthotonos  and  general  hyperesthesia.  Unless  treatment 
is  commenced  early  the  outlook  is  unfavorable.    The  attacks  become  more  tVe- 


f.Ml: 


f! 


PATIIOLOaY   OF    THE   XKW'-BORX  IXFAXT. 


843 


(|iient  and  more  intcnso,  tlic  pntiont  loses  flesh,  liyporestliosia  of  llic  skin  jicconi- 
panios  rigidity  of  the  tnnseidar  system,  and  finally  death  takes  plaw. 

The  proplii/fnctic  trcatinrnt  coufi'xHtfi  in  observing  ahsohiti;  <'leanliness  on  the 
part  of  the  attenihuits.  The  antiseptie  treatment  of  the  nmhilieal  woinul  mnst 
lie  insiste<l  npon.  Long  befon;  the  nature  of  tetanus  was  understood  cauter- 
i/ation  of  the  nmhilieal  wound  was  employed.  When  the  disease  is  fully 
(Icveloptnl,  its  management  eonsists  in  making  the  symptoms  as  light  as  pos- 
sible and  in  supporting  the  strength  of  the  ehild.  The  little  patient  shoidd 
he  isolated.  The  first  indieation  is  usually  met  by  means  of  narcotics,  among 
which  chloral  is  useful :  1^  grains  may  be  given  by  the  mouth,  and  twice  that 
amount  by  the  rectum  ;  15  to  30  grains  may  be  given  per  diem.  Opium  does 
iKit  meet  with  nnieh  favor.  C'ldoroform  inhalations  are  also  useful.  The 
action  of  the  narcotics  is  increased  by  the  use  of  hot  baths  every  one  to  three 
jninrs.  A  great  many  other  narcotics  have  been  recommended,  such  as  the 
hromids,  extract  of  Calabar  bean,  atropin,  etc. 

Icterus  Symptomaticus. — The  icterus  which  is  often  associated  with 
infections  disease  is  designated  the  "symptomatic  form  of  icterus."  It  occurs 
ill  septicemia,  in  syphilis,  in  Winckel's  disease,  and  in  Buhl's  disease.  It  is 
tiiis  association  with  grave  constitutional  disturbances  that  distinguishes  it 
from  the  mild  form  described  on  pag(!  826.  In  this  grave  form  the  dis- 
coloration is  more  marked,  the  sclerotic  is  usually  deeply  tinte«l,  and  there  is 
rapid  loss  of  body-weight.  Tliere  is  also  marked  increase  of  urea  and  uric 
acid  in  the  urine. 

Tlir  jKilhohf/ical  cnndidnni*  at  this  time  of  life  that  are  most  commoidy  met 
with  in  icterus  are — obliteration  of  the  hepati'-  duct,  due  either  to  congenital 
stricture  or  to  syphilitic  perihepatitis,  stipticemia,  Buhl's  disease,  and 
Winckel's  disease. 

Treat  incut. — The  treatment  for  icterus  is  indicated  by  the  condition  on 
which  it  depends. 

Buhl's  Disease  (Acute  Patty  Degeneration). — Pathof/cnmH  and  Eti- 
oln(/tj. —  In  18(50,  Buhl  described  a  disease  whose  anatomical  characteristics 
were  parenchymatous  inflammation  and  fatty  degeneration  and  hemorrhages  in 
the  heart,  the  liver,  and  the  kidneys.  The  cause  of  this  disease  is  not  yet 
known.  Some  authors  deny,  while  others  accept,  a  septic  infection  (Miiller). 
l>igclow  found  micro-organisms  in  the  organs  in  cases  of  acute  fatty  degen- 
eration. 

J'atholof/ical  Anatomif. — The  body  is  cyanotic,  and  it  usually  shows  icterus 
and  edema  ;  not  seldom  ecchymosis  is  foinid  in  the  skin.  The  undjilical  wound 
and  vessels  are  normal.  In  almost  all  the  internal  organs  hemorrhages  the  si/e 
iif  a  pin-head  or  larger  arc  found  ;  they  are  also  found  in  the  meninges,  the 
pli'iu'a,  pericardium,  peritoneum,  thymus  gland,  and  muscles.  In  the  lungs 
ii('ii\orrhagi(!  infarcts  occur,  and  bloody  mucus  or  clear  blood  is  found  in  the 
bronchi.  In  the  heart-muscle,  the  liver,  and  the  kidneys  fatty  degeneration  is 
present.  In  the  stomach  and  intestines  much  blood  is  found  ;  the  kidney 
parenchyma  presents  many  hemorrhagic  foci ;   the  spleen-pulp  is  very  soft. 


!l--|  ]\ 


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AMEHTCAN   TEXT-BOOK    OF   OBS f ETHICS. 


IK'!  ' 


■:v,  i 


Spnpfomn. — Most  of  tlio  cliildron  with  Biihrs  disoaso  arc  Im>i'h  asphyxintiii. 
altlioiifrh  tho  labor  is  easy  and  rapid.  Tlio  asphyxia  is  hut  partially,  or  nut  at 
all,  overcome.  Deep  inspiration  and  lusty  <'ryin}f  do  not  (xx'ur,  and  soon  :,■- 
vore  cyanosis  supervenes,  at  which  time  many  ot'tliese  chihlren  die.  IfMcith 
d(M\s  not  (KHJur,  there  follows  up<»n  the  evacuation  of  the  meconium  a  diarrlirn, 
with  some  blood,  and  later  entirely  l)loo<ly  stools  and  the  vomitinj^  of  liloiui. 
With  the  separation  of  the  cord  there  fre<]uently  ensues  parenchymatous  Ik m- 
orrhajje  from  the  umbilical  wound.  At  the  same  time  hemorrlia<je  fnuii  ilii> 
nuicous  membrane  of  the  mouth,  the  lutse,  the  conjunctivic,  and  from  the  cxli  r- 
nal  ear  and  skin,  takes  place,  whereupon  icterus  develops,  >\liich  in  Innt'-cnii- 
tintied  cases  becomes  extreme.  Tiater,  tnlema  of  the  skin  (H'curs,  and  dcalli 
from  collapse  follows,  without  any  marked  elevation  of  temperature,  usnallv 
about  the  end  of  the  swond  week.  Death  may  be  preceded  by  only  one  uf 
the  al)ove  symptoms,  such  as  cyanosis  or  heniorrhafje.  Buhl's  disease  is  rare. 
and  has  only  l)een  seen  in  lying-in  hospitals. 

Diof/noxis,  Prof/noxix,  and  Treatment. — The  diar/nosin  has  rarely  been  made 
during  life,  and  only  positively  post-mortem  after  microscopic  examinalidii  ot' 
the  fatty  organs.  The  prof/nosin  in  this  affwtion  is  always  fatal.  Tlic  as- 
phyxia is  treattHJ  on  general  principles,  and  every  et!'ort  inust  be  made  to 
support  the  strength  of  the  patient. 

Winckel's  Disease. — Sifinptonus. — In  1879,  Winckel  described  a  disease, 
observed  in  the  Dresden  lying-in  h  )spital,  that  was  characterized  by  cyanosis, 
icterus,  hemoglobinuria,  somnolence,  and  rapid  collapse  without  fever.  Twcntv- 
four  cases  were  observed,  only  one  of  which  ended  in  recovery.  The  sickness 
began  with  restlessness  and  cyanotic  discolorations,  atler  which  there  occurred 
icterus,  vomiting,  and  diarrhea,  and  later  convtdsions,  collapse,  and  death.  The 
urine  was  pale  brown,  oNving  to  the  prest>nce  of  hemoglobin.  The  lu'ine  con- 
tained also  renal  epithelium,  graiudar  casts  with  blood-corpuscles,  mi»!roeoeei, 
detritus,  and  some*  albumin.  The  urine  was  of  a  syrupy  consistence^  dark- 
brown,  and  coidd  be  expresse<l  on  the  cut  surface  of  the  kidney  only  on  (iini 
pressure.     The  mothers  of  the  sick  children  all  remaincxl  well. 

I'athn/nf/ica/  Anatomi/. — The  condition  of  the  kidneys  was  characteristit.'. 
The  cortex  was  of  a  brown  color  and  was  l)osct  with  hemorrhagic  spots.  The 
pyramids  were  cli.rk  red,  with  infarcts  of  hemctgloblin  in  the  apices.  In  the 
bladder  there  was  dark  urine.  In  almost  all  the  organs  and  in  the  serous 
njembranes  pnnctiform  hemorrhages  were  found.  Moreover,  there  was,  as  a 
rule,  swelling  of  Peyer's  patches  and  of  the  mesenteric  lymph-glands.  In 
the  blotxl  the  white  corpuscles  were  increased  and  the  retl  ones  enlarged,  and 
fine  granular  bodies  in  rapid  motion  were  seen  in  the  plasma.  The  liver, 
and  at  times  the  heart,  showe<l  fiitty  degeneration.s.  The  liver  and  the  kiihuys 
in  some  cases  jiresentetl  collections  of  bacteria.  Cyanosis  and  jaundice  ol'  the 
external  skin  and  internal  organs  were  observetl. 

Two  similar  cases  were  previously  observetl  by  Parrot  (1873);  fnitlier, 
Bigelow  saw  ten  epidemic  cases,  and  several  sporadic  cases  were  noted  l»y 
Epstein  in  the  foundling   hospital   of  Prague.     Two  such  cases  have  been 


[dv- 


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PATiioLoav  or  the  NKW-iionx  infant. 


81.) 


(k'ScrilxHl  by  Horz.  In  all  the  cases  licinoglubiiiiiria  was  absont  or  not  looked 
lor. 

Ktiolof/;/. — Tli(i  last-named  two  authors  elaini  a  septit;  (»ri{i;iii  of  the  disease. 
Winekel  eoiild  not  discover  the  exact  canseot'the  disease.  Poisoning  by  plios- 
plionis,  potassium  chlorate,  carbolic  acid,  and  arsenii;  could  surely  be  cxchidcHl. 

Helena  Neonatorum. — Meleiia  means,  literally,  "  black  disease,"  on 
iurount  of  the  black  (bloody)  masses  which  arc  vomited  or  passed  in  the 
stools.  According  to  our  present  knowknlge,  it  is  ditficnlt  to  elassily  this  con- 
(liti(tn,  inasmuch  as  it  must  be  regarded  as  a  symptom  of  one  of  several  dis- 
cMses.  It  (K'curs  in  general  sepsis,  in  syphilis,  and  in  liuhl's  disease.  Some 
authors  speak  of  it  in  connection  with  hemophilia.  The  condition  is  fully 
(l('scribe<l  under  (lasfro-iiidxiinnl  Hcmorrhaye  (p.  Ho.'J). 

Pemphigus. — Pemphigus  neonatorum,  apart  from  syphilis,  is  rare  in 
infants,  and  is  characterized  by  tlu^  ajjpearance  up<tu  the  skin  of  numerous 
vesicles,  which  develop  rapidly,  then  rupture,  and  soon  dry  up.  There  then 
remains  a  moist  surface,  which  heals  after  a  few  «lays  without  the  formation 
of  a  cicatrix.  Vaw\\  V(!sicle  is  placed  upon  a  reddened  base.  The  vesicles 
(Minsist  of  a  raised  superficial  portion  of  the  epidermis  with  exudates  beneath. 
Tlie  vesicles  are  round  or  oval,  and  vary  in  size  from  that  of  a  pea  to  that  (»f 
u  pigeon's  or  a  hen's  egg,  and  have  considerable  rescnd>Iance  to  !)urn-blisters. 
Tlieir  nund)er  is  variable;  there  may  be  a  single  vesicle  or  a  gn^at  part  of  the 
l)u(ly  may  l)c  eoverwl  with  them.  The  vesicles  contain  a  yellowish  serum, 
which  may  later  become  more  turbid  and  of  a  ])<n'ul<!nt  appearance.  The 
vesicles  appear  by  preference  on  the  abdon)en,  around  the  navel,  or  on  any 
part  of  the  trunk,  or  the  head,  and  less  fre(piently  on  the  extremities,  rarely 
oil  the  palms  of  the  hands  and  soles  of  tii(!  feet,  a  fact  of  considerable  value 
ill  tlifferentiating  syphilit'c  ju'inphigus.  The  eruption  on  the  extremities  is 
usually  not  marked.  The  vesicles  generally  develop  suddenly,  occasionally 
overnight;  previous  to  the  eruption  the  child  may,  but  ordinarily  does  not, 
manifest  irritability  and  disturbance  of  health;  the  eruption  is  prone  to  occur 
in  successive  attacks.  The  disease  begins  from  the  fourth  to  the  ninth  day  of 
life;  after  the  fourteenth  day  up  to  the  third  week  its  course,  as  a  rule,  is 
ended.  Usually  fever  is  absent.  In  very  severe  cases  high  tempcratun.'  may 
occur,  followe<l  by  exhaustion  and  death.  As  complications  and  se(|iiel!e  there 
may  occur  furunctdosis  and  other  ulcerative  processes  leaving  scars.  IJmbil- 
ii'iil  suppuration  and  disease  of  the  umbilical  vessels  are  described  as  compli- 
cations in  fatal  cases. 

AV/o/of/y. — There  seenis  to  be  no  doubt  that  pemphigus  rtf  the  new-born  is 
an  infectious  disease.  It  occurs  in  well-dcscril)c<l  epidemics  and  endemics, 
partly  in  cities  and  partly  in  asylums,  sometimes  in  the  practice  of  a  single 
iiiiilwife.  Many  epidemics  have  been  observed  since  l.S;U  in  maternities  in 
cities  and  in  the  practice  of  midwives.  The  first  cause  of  such  epidemics  still 
remains  undecided.  Often  these  epidemics  may  be  tra«v<l  to  a  single  pci'son. 
The  disease  has  been  transmitted  from  the  nursing  infant  to  the  mother  or  the 
wet-nurse,  manifesting  itself  on  the  mammary  gland,  but,  as  a  rule,  the  infco 


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tion  <»f  ndiilts  is  raro.  It  is  probably  of  l)act('ri()logical  «)ngin,  but  the  sporiiir 
genu  has  not  Ix't'ii  tlcnioiistratctl.  This  cniptioii  imist  not  be  confoiiiKK'd  with 
that  of  eongonital  syphilis,  although  there  is  s(nne  resoniblaiK-e  between  tliem. 

Tlie  treatment  of  pemphigus  consists  in  protwting  the  blisters  from  iujiiiics; 
in  case  of  rupture  of  the  vesicles  starcii  or  pulverized  salicylic  acid  and  simvli 
shoidd  be  applie<l.  Where  the  eruption  is  excessive  warm  baths  give  hiik  li 
comfort.  After  the  bath  the  patient  is  wrapj)ed  up  in  cotton.  In  cax' of 
ulceration  this  shoidd  be  treated  on  general  principles. 

Syphilis. — Syphilis  in  early  infancy  naturally  conjes  under  two  heads,  the 
acquired  and  the  here<litary  form.  The  hereditary  form  is  considered  imdcr 
DificdSffi  of  the  FitHH  In  Vtero  (p.  297). 

J'Jti()/o(/j/. — According  to  Fournicr,  children  acquire  syphilis  more  uftoii 
than  is  usually  supposed.  The  causes  for  contagion  after  birth  are  usuallv 
the  following : 

1.  Nursing,  by  which  a  syphilitic  nui-se  infects  the  child,  or  in  whicii  tlic 
niu'se,  being  herself  uninfwtiHl,  nurses  at  the  same  time  a  second  child  wliidi 
is  syphilitic.  Infants  not  only  contract  syphilis  from  mend)ers  of  the  Caniilv 
and  the  nurses,  but,  as  Keating  says,  "syphilitic  infants  are  sources  of  dainrcr 
to  non-syphilitic  nuanbers  of  the  family,  and  numerous  cases  are  seen  in  wliicli 
the  baby  has  infected  its  grandparents,  nurses,  and  other  infants."  In  these 
cases  the  infection  is  transmittctl  by  means  of  patches  dcvelopwl  about  or  in 
the  infant's  mouth  ;  sometimes  papules  are  the  medium  of  contagion. 

2.  Infection  may  take  place  through  the  mother  subsetiuently  infirtwl 
or  through  attendants,  especially  by  kissing. 

3.  The  poison  may  be  inoculateil  by  the  midwife's  or  the  physieiim's 
instruments  or  by  the  hands. 

The  question  whether  syphilis  is  ever  transmitted  through  the  milk  of  the 
mother  or  that  of  the  wet-nurse  is  important.  We  have  no  cvideni-e  to  show 
that  this  is  done.  Discharges  from  i)rimary  sores  are  liable  to  inoculate ; 
also  discharges  from  various  secondary  lesions,  whether  these  are  ac(|uired  (ir 
are  hereditary.  Infants  suffering  from  sy])hilitic  coryza  or  specific  ulceration 
may  inoculate  the  breast  of  a  wet-nurse,  but  probably  never  that  of  tlic 
mother.  Vaccination  has  been  the  means  of  introducing  syphilis.  \"a('('ina 
syphilis  manifests  itself  not  earlier  than  a  month  or  six  weeks  after  vac- 
cination ;  it  does  so  by  the  formation  of  a  chancre  at  the  seat  of  the  vaccination 
(Hutchinson). 

The  t<i/mjjto»!s  of  syphilis  in  early  infancy  will  be  found  on  page  208. 

Treatment. — The  treatment  of  infantile  syphilis,  like  that  of  the  adult,  con- 
sists chiefly  in  the  use  of  mercurials.  Mucous  patches  may  bo  dusteil  w  itii 
calomel.  For  syphilitic  coryza  J.  Lewis  Smith  advises  Squibb's  oleatc  of 
mercury,  2  per  cent.  For  the  general  treatment  the  use  of  mercury  by  inunc- 
tion has  always  given  satisfactory  results  in  the  writer's  experience.  I'^t 
iininction  the  oleate  of  mercury  or  the  mercurial  ointment  should  be  used,  tlic 
oleate  in  the  strength  of  2  per  cent. ;  of  the  ointment,  gr.  v-x  may  be  ap- 
plied to  a  healthy  part  of  the  skin  and  be  covered  with  a  flannel  binder.     For 


\'^ 


t: 


b  vaccnitituiu 


PATHOLOGY   OF    THE  yi:W-IlOItX   IXFAXT. 


H['i 


iiitornal  medication  caloniol  may  be  given  in  doses  of  gr.  -^--^fj  two  or  three 
times  a  day.  When  these  mercurials  pr<Mluee  diarrhea  they  may  Ik?  comhinetl 
witii  opium  and  aromatic  powder  or  Iw  omittcil  for  a  short  peri<Ml  and  again  Ik* 
resorted  to.  Tiie  chihl  should,  if  possible,  ix'  nursed  by  its  mother;  if  this 
caunot  be  carried  out,  it  should  be  fed  on  artificial  foinl.  A  wet-nurse  should 
pot  be  engaged. 

Tuberculosis. — Aequiretl  tuberculosis  at  the  ])eri{xl  of  early  infanev  is  verv 
rare.  Most  authors,  however,  admit  the  jK)ssibility  of  transmission  of  the 
disease  at  this  period  of  life.  As  producing  causes  arc  mentioned  all  those 
wliicli  lower  vitality,  especially  syphilis  and  tulx'rculosis  in  the  parent.  Dinxit 
transmission  from  parent  to  child  is  possible,  though  perhaps  not  fre«pieiit. 
A  tuberculous  mother  should  not  nurse  her  infant,  kissing  shoidd  be  pro- 
hibited, and  the  child  should  sleep  in  a  separate  room  (Jacobi).  Exj)eriments 
on  the  lower  animals  have  demonstratefl  that  tuberculosis  may  be  traiismitte<l 
by  the  ingestion  of  milk  from  tuberculous  cows ;  this  applies  also  to  the  use 
for  the  fee<ling  of  infants  of  milk  thus  afUx^ted  that  has  not  l)een  boiled.  Ca- 
tarrhal conditions  of  the  air-passages  doubtless  favor  the  invasion  of  the  bacillus. 

77ie  diofpiosis  of  tuberculosis  in  the  very  young  eaimot  readily  be  made:  if 
the  disease  is  limited  to  the  lungs,  there  is  evidence  of  brontthial  trouble.  In 
these  cases  Epstein  recommends  passing  a  catheter  into  the  larynx  ;  this  will 
produce  a  cough,  during  which  suHicient  mucus  nuiy  adhere  to  the  instrument 
for  microscopical  examination. 

The  treatment  is  chiefly  pro]»hylaetic,  as  indicate<l  above.  When  the  disease 
is  established  in  early  infancy  the  same  methods  of  treatment  should  be  applied 
as  those  for  older  children. 

Ophthalmia  Neonatorum. — Ophthalmia  of  the  new-born  is  a  local  affec- 
tion contractetl  during  birth,  liefbre  prophylactic  measures  were  adojited 
tiiis  disease  occurred  in  lying-in  hospitals  with  alarming  frequency.  During 
1SG8-69  in  the  lying-in  hospital  of  the  University  of  Herlin  bleiuiorrhea 
(R'ourred  in  5.6  per  cent,  of  the  births.  In  the  Charit6  at  Berlin  from  12  to 
14  per  cent,  were  noted.  Kilian  gives  the  percentage  at  the  maternity  hospi- 
tal of  Berlin  from  1820  to  1834  as  being  nearly  50  per  cent.  Since  the  intro- 
(liu'tion  of  Cred6's  prophylactic  measures  the  percentage  has  been  reduced 
almost  to  nil. 

Etiohf/y, — Some  authorities  assign  different  causes,  stich  as  irritating  dis- 
charges of  the  i)artiu'ient  canal,  wiiether  s]>ecific  or  non-specifie,  exposure  to 
bright  light,  cold,  etc. — others  (Unger,  Bumm)  pronounce  all  cases  of 
opiithalmia  neonatorum  to  be  due  to  gonorrheal  infection,  the  gonococcus  of 
Noisser  being  alone  the  exciting  cause.  There  is  no  doubt  that  the  secretions 
of  the  parturient  canal  of  the  mother  are  usually  the  medium  of  conveying 
]n'ogenic  frerms.  These  secretions,  coming  in  contact  with  the  cornea  of  the 
iiitint,  remain  fixed  tor  some  time,  giving  rise  to  a  purulent  conjunctivitis  which 
manifests  itself  on  the  third  or  the  fifth  day  afler  birth.  The  eye  may  become 
infected  previous  to  birth  by  the  amniotic  fluid,  or  later  through  the  infectious 
material   on  the  hands  of  attendants,  etc.  (Runge).     Frecpiently  the  cornea 


'^U  n 


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848 


AMKIilCAN   TEXT- BOOK   OF   OliSTETIilClS. 


i 

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Im 


If!      .   i\ 


becomes  iiivolvcnl  in  tliis  process,  in  which  case  extensive  ulcerution  inav  octnir 
resulting  in  loss  of  siglit.  Indirectly  the  disease  may  be  transmitted  ln»in  tlic 
eyes  of  one  child  thns  alfi-cttHl  to  those  of  another;  it  may  also  be  transmitti  i| 
through  unclean  hands  of  attendants,  unclean  sponges,  towels,  and  tluoiiuli 
water  used  for  the  bath. 

l'<itliolo(/ic(il  Aiiatoini/. — The  changes  produce  excessive  liypereiniu  and 
swelling  of  the  palpebral  nuicosa,  rendering  it  thick  and  uneven.  Later  (Ik  iv 
is  proliferation  of  the  epithelium,  and  beneath  it  is  a  diffuse  iiiHitratioii  df 
lymphoid  cells.  According  to  Hunnn,  the  gonococci  contained  in  tlic  secre- 
tions invade  the  upper  epithelial  layer  and  find  their  way  down  to  the  paiiil- 
lary  bodies,  where  this  invasion  excites  marked  hyperemia,  producing  later 
the  profuse  discharge.  Tlu;  cornea  may  remain  clear,  but  it  is  liai»lc  tu 
become  invaded,  showing  points  (»f  ulceration  ;  or  a  general  infiltration  iiiav 
take  place,  resulting  in  an  extensive  destructive  process. 

Si/mptoniK — The  first  numifestations  of  this  disease  ocjcur  on  the  third  or 
the  fifth  day  after  birth,  ami  consist  of  rwlness  and  swelling  of  the  palpelnal 
and  ocular  conjunctiva.  One  or  lK)tli  eyes  may  be  affectetl ;  sometimes  the 
lids  are  glued  together.  The  secretion  is  at  first  watery,  containing  flakes  d' 
fibrin  ;  later  it  is  purulent  and  very  profuse.  In  the  course  of  several  davs 
the  swretion  diminishes  in  quantity,  and  after  six  or  eight  weeks  the  disease 
assumes  the  form  of  chronic  conjunctivitis. 

The  protpimiH  becomes  unfavorable  in  cases  in  which  the  cornea  is  in- 
volved ;  20  or  30  per  cent,  of  the  cases  of  blindness  in  children  is  due  to 
corneal  ulceration  thus  induced.  Great  care  must  be  given  to  the  cleansiii),^ 
(tf  the  vaginal  canal  in  suspected  cases  of  gonorrhea  by  the  use  of  antiseptie 
douches  previous  to  birth. 

The  treatment  consists  chiefly  in  ])rophylaxis.  The  duty  of  preventing  tiie 
occurrence  of  this  serious  disease  devolves  upon  every  obstetrician.  Iiiinie- 
diately  after  birth,  before  the  child  has  opened  its  eyes,  all  secretions  u])on  and 
about  the  lids  shoidd  carefully  be  washed  away  with  sterilize<l  water  or  with  a 
1  or  2  per  cent,  solution  of  boric  acid. 

In  many  hospitals  Credo's  method  is  that  usually  adopted — that  is,  after 
cleansing  the  eyes  with  water  1  drop  of  a  2  per  cent,  solution  of  nitrate  of" 
silver  is  dropped  into  each  eye.  At  the  first  manifestation  of  the  «liseas(! 
active  measures  should  be  adopted.  Usually  but  one  eye  is  alfecte<l ;  in  that 
case  the  other  eye  should  be  protected  by  placing  over  it  absorbent  cottoii, 
covering  the  cotton  with  a  watch-crystal,  and  sealing  this  with  collodion  or 
with  adhesive  plaster ;  but  the  eye  should  be  examined  daily  to  be  assured  of 
its  healthy  state. 

When  the  disease  has  been  developed  two  forms  are  distinguished,  the  mild 
and  the  severe,  each  having  two  stages,  the  congestive  and  the  purulent.  In 
the  mild  form  the  treatment  in  the  first  stage  consists  of  the  application 
of  cold  compresses.  In  the  second  stage  the  eye  is  cleansetl  every  two  lionrs 
with  a  saturated  solution  of  boric  acid,  and  a  \  per  cent,  solution  of  nitrate 
of  silver  is  applietl  to  the  cul-de-sac. 


1 


VATlIOLOay    OF    THE   XFAV-noltX   IXFAXT. 


849 


In  the  .severe  form  cold  coin  presses  are  applii-d  ;  the  eye  is  cleansed  by  a 
solution  of  bichlorid  of  ntercnry  (1  ;8()0())  and  a  saturated  horic-acid  solution 
ii-cd  alternately  every  hour.  As  soon  as  suppuration  is  established  the  solu- 
tion of  nitrate  of  silver  is  applied  to  the  cnl-<le-sac  of  the  cornea.  While 
iiiiikin^j  these  applications  to  the  upper  everted  lid  the  cornea  nuist  be  pro- 
tcded  by  the  lower  lid,  and  vice  vvrnd  (Mettnian).  It  is  best  to  la-gin  with  a 
'1  per  cent,  solution,  but  shonhl  this  fail  to  control  the  suppurative  priK-ess  a 
\  percent,  solution  may  Imj  employed,  and  should  immediately  be  neutralizetl 
l)y  a  solution  of  salt.  Should  un  ulcer  of  the  cornea  f(»rm,  it  is  the  practice 
dl'  ophthalmologists  to  employ  cautiously  weak  solutions  of  eserin  (|  to  \ 
irniiu  to  the  ounce).  When  iritis  or  a  central  ulceration  of  the  cornea  is  pres- 
I'lit  atropin  (gr.  ij-iv  to  the  ounce)  is  preferred.  The  first  signs  ol'  poisoning 
bv  this  drug  shoidd  carefidly  be  observed.  When  the  swelling  subsides  and 
the  discharge  decreases,  and  espwially  when  there  is  corneal  haze,  hot  applica- 
tidiis  may  be  made.  For  the  treatment  of  further  complications  the  reader  is 
ictlrred  to  works  on  ophthalmology. 

La  Grippe.* — The  testimony  that  very  yoinig  infants  may  be  sid/jcct  ti> 
tliis  disease  is  increasing.  Dr.  Townsend  of  Hoston  has  place<l  on  record  a 
(•as(>  where  the  mother  had  an  attack  of  intluenzu  either  before  or  shortly  after 
luT  confinement,  anil  the  child  very  soon  after  its  birth  began  to  sneeze,  had 
riipitl  respiration,  followed  by  a  tentpcratnre  of  104°,  and  passed  through  an 
attiick  of  la  (ji'lppe.  It  is  fair  to  presume  that  this  child  was  infected  before 
(ir  within  a  short  time  after  its  birth.  The  liritisk  Joiinutl  narrates  another 
case  in  which  the  infant  died  on  the  third  day,  having  had  a  high  temperature, 
iai)id  respiration,  and  pulmonary  catarrh.  The  mother  of  this  child  had  influ- 
t'liza  four  days  after  her  delivery. 

The  following  casef  was  observetl  in  1890:  A  healthy  woman  was  delivered 
of  a  healthy  child  ;  both  mother  and  chikl  appeannl  perfectly  well  during  the 
tii'st  week,  after  which  the  husband  was  taken  with  in  i/i'ipjie  of  the  gastro- 
intestinal form.  Two  days  later  the  wife  was  taken,  and  on  the  following  day 
tlic  infant  manifestwl  characteristic.'  symptoms  of  the  disease — restlessness,  rise 
of  temperature,  icterus,  loss  of  appetite,  and  diarrhea.  The  stools  were  fre- 
(|ii(iit  and  of  a  putrescent  odor.  In  all  three  njend)ers  of  the  family  the  in- 
testinal catarrh  was  accompanied  by  catarrh  of  the  respiratory  tract.  In  the 
moflier  this  attack  was  followed  by  prolonged  and  great  nervous  exhaustion, 
for  which  no  other  cause  could  be  assigned. 

I >i(upio.si'<  and  Treatment. — It  is  difficult  to  diagnosticate  la.  f/rippe  in  very 
young  patients,  but  when  the  infection  is  present  in  the  house  and  the  parents 
or  the  nurse  arc  nnder  its  infinence,  if  an  infant  within  a  very  few  hours  after 
biitli  presents  the  usual  symptoms  of  fever,  exhaustion,  and  great  prostration 
associated  with  the  involvement  of  one  of  the  three  systems  that  is  usually 
selected  by  this  infection,  the  disease  is  most  probably  due  to  the  poison  of 

*  Most  of  the  material  for  this  subject  is  talieu  from  Dr.  Karle's  article,  '•  Manifestations  of 
LaOriiipe  in  Children,"  Areluven  nf  Pediatric^!,  1892. — M.  .J.  Merp;ler. 

t'l'lie  case  described  occurred  in  my  own  practice,  but  has  nes'cr  been  reported.— M.  J.  M. 
54 


^H 


p 


«')(» 


AMHJilCAy    Ti:XT-I\()(iK    O/'    OIlSTE'rUlVS. 


I     f 


If- 


kj 


It 


iiifliicii/a.  Ill  trcatiii;:  tlicse  chscs  wv  slioiild  he  M;ni,l,.(l  l)y  tlic  siimc  priiicii.lr- 
as  for  adults — that  is,  disiiift't'tiiij;  tlio  intestinal  tract,  su|HM)rtiiifr  the  strfii;:ili. 
and  nioctin^  complications. 

('.  Ixi'Kc HON  OK  iiii-:  ni(ii;sTivi:  AM)  I{i;si'ii{.\T».uv  TitAcis. — Septic 
Oastro-intestinal  Catarrh. — Infection  thron<ih  the  inncons  nu'iiii)iinie  of  tiir 
month  is  characterized  hy  a  catarrhal  state  involvinj;  the  intestinal  tract.  |;|,- 
stein  descril)e<l  the  difl'ereiit  decrees  of  invasion  as  septic  catarrh,  seplic  cidui.. 
and  sc|»lie  diphtiieritis.  This  form  of  catarrh  <litlers  from  the  ordinary  dv-- 
jM'ptic  form  in  that  it  occurs  in  nursinjj  children,  and  that  it  is  more  linlilc 
to  occur  in  winter  than  in  summer.  This  ditrerence  is  ascribed  to  the  fact  iliai 
durinj;  the  winter  ventilation  is  not  so  j;ood  as  durinji  warm  weather. 

Thrush  (s^itre  ov  noor)  is  a  local  disease  of  the  nnicons  memhrane  ul'  tin 
mouth  due  to  the  jirowth  of  a  vcfretablc  jtarasite,  (»ften  desijrnated  (iiiliinii 
<i//tit'(inn.  Althoujrh  the  parasitic  character  of  the  disease  has  ion;;  Ih^-h  |<,|,,u  u^ 
no  definite  hotanical  place  has  been  assiiiiu vl  t»»  the  fuiiiruv.  The  pn-vcncc  ^4' 
.soor  is  very  common  amonj;  infants,  and  it  occasionally  oi^iirs  in  the  virv 
yoinifj.  It  is  of  frequent  occurrence  in  foundlinji  homes.  Artilicial  tuod  iind 
inipaire<l  nutrition  favor  its  develo|mient.  The  disease  manifests  itself  in  ilii' 
formation  of  white  points  resembling;  curdled  milk  ;  these  patches  eoalesiv  :iii<l 
adhere  to  the  mucosa,  which  becomes  very  tender.  Xursinj;  becomes  dilHiiilt. 
and  diarrhea  often  residts  from  the  disonleriHl  .state  of  nutrition. 

DuKpumii  and  Treulnuut. — The  diai^nosis  is  based  on  the  occurrence  of  the 
white  patches  above  described.  In  donbtfid  cases  a  microscopical  cxanniiiitiun 
will  reveal  the  nature  of  the  disease.  The  treatment  consists  in  removal  of 
the  patches,  cleansin«>:  the  imico.sa,  and  supporting;  the  stren<;th  of  the  patient. 
After  each  mirsin<;  the  little  patient's  mouth  should  be  washed  carcftdly  with 
a  mild  antiseptic  fluid — boric  acid,  5  per  cent.,  or  chlorate  of  potash,  2  yw 
cent.  The  a|)plieation  should  be  made  very  <;ently  to  prevent  nmiecessiirv 
desfiuamation  of  the  nuicosa.  If  the  child  mu'ses  from  the  breast,  the  nip|il(s 
slu)nld  be  washed  off  carefully  with  a  sin.     r  solution  before  and  after  nur-inti, 

Gonorrheal  infection  will  also  produce  an  acute  catarrhal  inflammatii)n  ol' 
the  mouth.     The  treatment  is  similar  to  that  of  thrush. 

Stomatitis  Aphthosa. — We  are  indebted  to  Holm  for  jiivinj;  this  term  ;i 
definite  meanini^,  as  there  have  been  a  number  of  varied  i)athological  (cmli- 
tions  of  the  mouth  that  were  termed  "  ajdithie."  Bolin  limits  the  term  t<i  :i 
patholoij;ical  lesion  of  the  mucous  mend)rane  of  the  month,  whicli  lesion  i- 
characterized  by  the  formation  of  distinct  discolored  spots  from  which  tiic 
epithelium  denudes,  leavinj^  shallow  nlcers.  As  to  the  anatomical  nature  nf 
these  spots,  there  is  still  considerable  discussion,  some  holding  that  it  is  a  true 
vesicidar  eruption,  others  that  it  is  due  to  a  solid  exudation  between  the  ciiti? 
and  the  epithelium. 

The  etinlofjy  is  not  settled.  Although  the  disease  is  more  likely  to  oc<  nr 
after  the  tenth  month,  it  may  occur  in  the  yoJing.  Aphthse  are  found  in  the 
mouths  of  many  children  in  asylums,  maternity  hospitals,  etc.  Sometimes  tlmv 
seem  to  be  conveyed  from  child  to  child  by  wet-nurses  whom  the  childirii 


W 


\\ 


j'ATi/()Lf)(,'y  OF  Tin:  st:\\-noii\  /.wrAxr. 


Sol 


stvciiuili. 
— Septic 

me  of    lilr 

act.  l.|>- 
)tic  <'r(iii|i. 
ii\iiry  ilv-- 
lorc  li;il>lc 
10  fuel  tlial 
r. 

nnc  «il   till' 
itrd  (iiiliiiiii 

)n'M'iicc  "I 
n  tlic  vi'iv 
ul  I>mh1  iind 
itself  ill  ilic 
malt'si  c  iiiid 
ncs  tlitliciih. 

•rcnco  (if  till' 

oxaiuiiiatinii 

renu)val  of 

tlio  ]>aticiit. 

ircfiilly  with 

Ix.tasli,  2  1><T 

tuuicccssarv 

,  the  iiiliplcs 

lifter  mirsin;!'. 

nmiatioii  of 

!«•  this  term  a 
ogical  cciiili- 
Ihe  term  to  a 
liieh  lesion  i- 
|m  which  till' 
pal  nature  of 
Itit  it  is  a  true 
}en  the  ciiti.- 

[koly  to  occur 
Ibnml  in  the 

Inictinu's  they 
the  child I'cii 


I 


|i;iv(>  ill  coiiiiiioii,  Itiit  the  l)a<'terial  ori^riii  of  the  disease  has  not  hcon  deiiion- 
^i rated.     This  eruption  rrei|iieiitly  nceiirs  in  |t(M»riv-»>',.".irished  children. 

77/c  trcdiiiiciif  consists  of  antiseptic  iiieasiii'es  as  rej;ards  iuiisin<;-l)ottles.  care 
(il  liie  hreast  of  tlie  wet-nurses,  etc.  The  child's  nioiith  should  he  washed 
fiv(|uciitly  with  a  solution  of  Itctrie  acid,  .'}  per  cent.;  the  ulcerated  portions 
iiiiv  he  touched  with  a  solution  of  nitrate  of  silver. 

Diphtheria. —  Lit<i'atur<!  «loes  not  cite  iiiaiy  cases  of  di))htheria  in  the  iiew- 
iioni  ;  characteristic!  cases,  however,  have  Iteeii  observed.  J.  Lewis  Smith 
iiclieves  the  new-horn  to  be  siisceptil)le  to  this  infection,  and  he  reports  several 
ca-cs.  In  two  of  these  cases  umbilical  phlegmon  was  also  prcM-nt.  Diphtheria 
ill  th(!  mother  does  not,  as  a  rule,  greatly  endaiiirer  the  chihl  (Miillcr),  althoiijrh 
casts  ar(!  on  record  in  which  the  disease  was  tran-mittcd  directly  from  mother 
to  child.     The  treat iiwnt  is  the  same  as  that  in  older  t  liildreii. 

Rhinitis. — TIh;  oeciirrence  of  persistent  coryza  in  very  yoniitr  infants  is  fre- 
(|iiriitly  due  to  hereditary  syphilis.  This  sympttsni  usually  docs  imt  manif<'st 
itself  before  the  second  month,  but  it  may  (M;cr  arlier.  Xoii  yphilitio  siip- 
pniiitive  rhinitis  may  t)c(nir  dnrin>^  the  first  few  days  oi  lile,  and  may  be  due 
to  iiif'   '•  ••;  from  the  discliarjfcs  in  the  parturient  canal. 

T/n'  treatment  of  the  simple  eatanlial  and  suppiinuive  rhinitis  consists  in 
ieansin^  the  nasal  passaj^e  with  mild  disinfectiii<;  solut'.iiis,  as  in  older  chil- 
dren ;  a  small  syrinjie  or  medicine-dropper  may  be  used  for  this  piapose. 

5.  General  and  Unclassified  Diseases. 

Sclerema  neonatorum  is  a  disease  consistinji;  of  an  induration  of  the  skin 
mid  the  subcutaneous  cellular  tissues,  associated  with  rapid  lowering  of  the 
biiily-temperatiire.  The  disease  is  hardly  known  outside  of  foundling  homes 
anil  Miaternity  hospitals. 

Kflohf/i/. — The  etiology  is  imperfectly  understood.  Haginsky  suggests 
infectious  agents.  It  has  also  been  asserted  that  the  disease  is  due  to  an 
(XK'ss  in  the  tissues  of  the  infant  of  palmytic  acid,  which  solidities  at  the 
low  temperature  accompanying  the  <lisease.  There  seems  to  be  some  rc- 
liitiiin  between  imjierfect  develo])ineiit  of  the  fetal  heart  and  sclerema 
(Di'inme),  It  occurs  in  eases  of  premature  birth  and  in  infants  who  are 
piiorly  nourished, 

Si/mptom.s. — The  premonitory  symjUoms  are  slight :  the  skin  is  first  red 
anil  then  has  a  mottled  appearance;  these  changes  manifest  themselves  first 
U|iiin  the  calves  of  the  legs,  on  the  dorsum  of  the  feet,  then  upward,  involving 
the  thighs,  the  abdomen,  the  upper  extremities,  the  face,  and  the  head.  The 
roital  temperature  f d|,s  from  the  norir.al  to  86°  or  even  83°  F. ;  the  pulse  is 
\voak,the  excretions  and  secretions  sluggish,  and  the  edema  which  now  forms 
iviiilers  the  skin  pale  and  hard  ;  gradually  the  whole  body  becomes  cold  and 
risrid,  and  eventnally  sensibility  is  lost.  Death  occurs  without  convulsions. 
Occasionally  the  patient  recovers ;  in  these  cases  the  infiltration  subsides,  the 
ilorsiim  and  soles  of  the  feet  ])eing  longest  affectiHl, 

I'dthologkal  Anntomy. — The  portions  of  the  skin  affected  are  either  yel- 


i 


I 


f 


rii  i 


^52 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


!> 


i:  i 


li'n 


lowisli-whitc  or  prcsont  a  mottled,  bluish  appearance.  Incision  throiii'-li  tlic 
infiltrated  skin  is  Ibllowetl  by  discharge  of"  a  yellowish  or  a  reddish  Huid  iVdii; 
the  cellular  tissue.  This  fluid  usually  coagulates  upon  exposure  to  the  air. 
The  brain  is  edematous,  rarely  showing  hemorrhagic  spots.  In  the  lun-Ts  tlicic 
is  usually  atelectasis,  occasionally  eviilence  of  lobar  pneumonia.  In  sonic  u[' 
the  other  organs  there  frequently  are  ecchymoses.  This  disease  mav  bo  lum- 
plicated  by  pneiunonia,  septic  disease  of  the  umbilicus,  pemphigus,  and  synliili^. 

Diofpwsis  ami  Prof/nonifs. — The  diagnosis  is  based  chiefly  on  the  infiitnitinn 
of  the  skin  and  the  falling  of  temj)erature.  This  edematous  form  of  sclcicniu 
must  be  diflerentiated  from  the  adipose  form  in  older  children;  also  from  the 
usual  forms  of  edema  that  are  characterized  by  "pitting"  on  pressure.  Tlic 
prognosis  is  unfavorable. 

Treatment. — The  treatment  consists  chiefly  in  the  api)lication  of  artili(i;il 
heat  and  massage  and  the  administration  of  stimulants.  Artificial  heat  is  siiii- 
plied  both  dry  and  by  means  of  the  bath.  An  incubator  will  be  of  service  to 
maintain  the  temperature.  Massage  is  given  with  the  view  to  improving  tlic 
circulation  and  favoring  the  absorption  of  the  serum. 

A.  jMoney  reports  a  case  of  sclerema  neonatorum  successfully  treated  l»v 
friction  over  the  indurated  areas  with  sweet  oil,  together  with  daily  inniictiim 
of  blue  ointment  into  the  skin  of  the  abdomen.  This  autiior  excludes  anv 
evidence  of  syphilis  in  this  case.  Alfred  liarrs  also  reports  a  case  in  wliieli 
tlic  induration  entirely  disappeared  in  two  months  on  mercurial  treatment. 
One-half  grain  of  gray  powder  was  administered  night  and  morning.  Stiimi- 
lants  must  be  administered  frequently — whiskey,  il  to  5  drops  every  hali'lnnir. 
Aqua  camphor  and  tincture  of  digitalis  may  be  added  with  ailvantagc.  In 
all  cases  special  care  must  bo  given  to  favor  the  nutrition  of  the  cliild.  tur 
which  purpose  ^arar/r  will  be  of  service. 

Hemorrhagic  Diathesis. — It  will  be  noticed  in  a  few  cases  that  an  infant 
exhibits  within  a  short  time  after  birth  a  tendency  to  bleed,  at  first  perliaps 
from  the  umbilical  region,  then  from  mucous  mend)ranes  of  the  difleieiit  open- 
ings of  the  body,  from  the  conjunctiva?,  and  finally  from  the  integinnent.  In 
other  cases  this  tendency  will  be  noticed  upon  a  slight  local  injury  wliieli 
under  ordinary  circumstances  would  be  insignificant. 

Etiolof/y. — Our  knowledge  in  regird  to  the  cause  of  the  disease  is  i;itliei' 
indefinite,  but  in  a  majority  of  cases  it  may  be  traced  to  some  constitutional  nr 
septic  influence.  The  symptoms  have  already  been  stated,  above.  Anemia 
naturally  results. 

7>/V«7»io«/,s'. — If  there  is  a  family  history  of  a  tendency  to  heinorrli;iuc.  if 
the  hemorrhage  is  persistent,  producing  prostration,  anemia,  and  collapse,  ilie 
diaurnosis  is  easilv  made. 

Prof/unsiK. — Except  in  very  young  infants  the  patient  rarely  dies  dnrinu 
the  first  hemorrhage.  The  longer  a  "bleeder"  suivives,  the  greater  is  liis 
chance  of  outliving  the  tendency  to  bleed.  In  the  very  young  when  tlieiv  are 
symptoms  which  suggest  continuous  bleeding,  anemia,  and  a  tendency  to  col- 
lapse, the  prognosis  is  very  bad. 


t,, 
% 


^iuiiji 


PATHOLOGY   OF   THE  NEW-BORN  INFANT. 


853 


M> 


iroiiiili  tlif 
fluid  iVdui 
to  the  air. 
lungs  tllrlC 
in  SOUK'  (if 
lay  1)0  c'uiii- 
inl  sypliill-. 
i  inliltnitiiiM 
ot"  sclfrfiiia 
Iso  from  till' 
ssure.     '11 10 

of  ai'tilicial 

boat  is  siip- 

of  sorvioo  to 

aprovinji'  tlio 

V  troatotl  l»y 
ilv  inunction 
cxclndos  any 
*asc  in  which 
111  ti'oatincnt. 
inij.  Stimu- 
'i-y  half  hour, 
vantaoo.  In 
tho  ohild.  tnr 

hat  an  infant 
first  iicriiaps 
ill'oront  i^yvw- 
'iXiiinont.  In 
injury  wliich 

'aso  is  lather 
stitntinnal  it 
)V(.'.     AiuMiia 

oinorrhauc  i' 
collaiisc,  tlio 

,-  dies  dnviiiiT' 
rroator  is  his 
shon  thciv  arc 
idonov  t«i  <'(il- 


I 


Patholoyy. — Nothing  except  tho  anemic  condition  is  found  in  the  viscera 
upon  post-mortem  examination.  An  unusual  thinness  of  the  blooil-vessels 
lias  been  noticetl. 

Trealmcnt. — The  principal  indications  are  to  check  the  hemorrhage  and  to 
support  the  strength  of  the  child :  to  this  end  the  extremities  of  the  child  should 
1(0  kept  warm,  and  if  ice  is  used  as  a  local  hemostatic,  it  should  cover  but  a 
sn:all  surface,  for  the  tendency  to  reduced  temperature  and  collapse  is  very 
gioat.  Among  the  remedies  which  promise  the  best  results  are  ergot,  prepa- 
rations of  iron,  gallic  acid,  and  aromatic  sulj)liuric  acid. 

Hemorrhage  from  the  Female  Genital  Organs. — It  happens,  veiy 
rarely,  that  there  is  a  slight  oozing  of  blood  from  the  vagina  during  the  first 
low  days  of  the  infant's  life. 

Ktioloyi/. — In  all  probability  this  slight  hemorrhage  is  due  to  the  congested 
condition  of  the  pelvic  organs.  The  sudden  cessation  of  the  How  of  bloo<l 
tlirough  the  umbilical  arteries  may  also  contribute  to  this  result.  It  is  claimed 
by  some  authors  that  menstruation  may  occur  in  the  new-born.  CuUingworth 
ciillocted  32  cases  of  menstruation  in  young  infants. 

Symptoms  and  Treatment. — The  symptoms  are  simply  a  slight  oozing  of 
blood,  which  can  be  ditferentiated  by  an  examination  of  the  parts.  A  rwl  stain, 
often  produced  during  the  first  days  of  infancy  by  the  escape  of  uric  acid  or 
urates,  must  not  be  mistaken  for  this  form  of  hemorrhage.  If  the  hemor- 
rhage is  slight  and  unassociated  with  the  hemorrhagic  diathesis,  no  treatment 
will  1)0  required. 

Gastro-intestinal  Hemorrhage  (Helena). — IJy  this  term  is  meant  an 
osoape  of  a  variable  amount  of  blood,  usually  from  the  bowels,  but  occasion- 
ally vomited,  during  the  first  few  days  of  infant  life.  The  amount  of  blood 
lost  and  the  symptoms  that  follow  in  this  disease  range  all  tho  way  from  a 
slight  and  harmless  hemorrhage  with  no  general  symptoms  to  a  loss  of  blood 
so  great  that  the  death  of  the  child  is  imniineut.  This  form  has  been  spoken 
of  by  some  authorities  as  tho  "  black  disease,"  and  by  others  as  "  niolona.'' 
Wo  recoixnize  thi'oe  classes  or  varieties  of  {jastro-intostinal  homorrhaijo : 

First,  tho  unimportant  class  duo  to  very  slight  congestion  or  abrasion  in 
tli(>  integrity  of  the  lower  bowel.  Thrombosis  of  the  umbilical  blood-vessels 
has  been  thought  to  increase  the  congested  and  hyjioroinic  condition  of  the 
iiastro-intostinal  canal,  which  condition  always  exists  immediately  after  birth. 
Asphyxia  Is  another  predisposing  cause.  Rlood  in  considerable  (piantities  may 
flow  from  a  fissured  or  excoriated  nipple  of  tho  mother  and  bo  swallowed  by 
tlio  nursing  child,  and  make  its  appearance  either  as  moderately  l)right,  fresh 
blond  in  the  vomited  niaterial  or  very  much  changed  in  color  and  consistence 
if  it  is  mixwl  with  excreted  matter  from  tho  bowel.  This  discharge  must  not 
1)0  mistaken  for  hemorrhage  coming  from  tho  ohild. 

Tho  second  class  is  somewhat  more  grave :  it  is  caused  by  deep  erosions  or 
iilcoration  in  tho  gastro-intestinal  tract  or  by  the  porfi)rating  round  ulcer  of 
tlio  stomach. 

The  third  variety  is  caused  by  constitutional  iliseases  present  in  the  new- 


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boni,  such  as  lieniorrhagic  diathesis,  syphilis,  various  fonns  of  sepsis,  the  hitn- 
orrhagie  eruptive  diseases,  and  tatty  degenerations. 

The  second  and  third  classes  constitute  inelcna  proper,  which  is  laic 
According  to  Buhl  and  Hecker,  8  cases  occnir  in  4000  births;  accordiiiix  to 
Spiegelberg,  2  in  5000;  according  to  Genrich,  1  in  2800(Ungcr).  The  unim- 
portant or  simple  variety  of  hemorrhage  occurs  somewhat  more  frcqucntlv. 

Symptoms. — The  blood  usually  begins  to  flow  about  the  second  day  ;  sdinc- 
times  it  is  vomited,  at  other  times  it  comes  from  the  bowel.  If  the  blood  i> 
vomited,  its  color  may  not  perceptibly  be  changed,  but  if  it  is  discharged  fiom 
the  bowel,  it  is  usually  dark,  mixed  with  meconium,  which  is  apparentiv  nidiv 
profuse  than  usual.  In  the  course  of  twenty-four  hours,  if  tlie  hemorriiai'-c 
continues,  the  child  begins  to  fail  and  becomes  pale,  cold,  and  indiflercnt  • 
the  pulse  is  small  and  rapid;  respiration  is  very  frequent;  the  child  is  in 
collapse,  and  death  occurs  in  a  few  hours. 

Proynos'iH. — The  prognosis  depends  largely  upon  the  etiology.  In  the  first 
variety  of  gastro-intestinal  vomiting  the  prognosis  is  good ;  in  the  second  and 
third  varieties  it  is  always  grave.  The  mortality  of  true  melena,  as  stated  l)v 
difl^erent  authors,  is  from  30  to  70  per  cent.  The  prognosis  becomes  especiallv 
grave  if  the  hemorrhage  lasts  more  than  forty-eight  hours. 

Diacfnosis. — Look  carefidly  for  local  causes,  and  then  for  some  constitu- 
tional defect.  Slight  hemorrhage  with  trismus  should  cause  one  to  look  Inr 
intussusception.  If  the  blood  is  vomited  and  fresh  and  the  child  has  no  svnip- 
toms  of  depression,  it  may  have  come  from  the  mother's  nipple,  from  the  child's 
tongue,  or  from  some  part  of  the  upj)er  digestive  tract  or  respiratory  ajiparatiis. 
If  it  is  from  the  bowel,  and  evidences  of  cyanosis  or  jaundice  or  de})ressioii 
soon  follow,  in  all  probability  some  general  disease  is  the  cause. 

The  pathohf/j/  varies  with  th.c  cause.  In  true  melena  the  tissues  are  ustialiv 
pale  and  anenjic.  Ecchymoses  upon  the  different  membranes,  and  occasion- 
ally eroded  blood-vessels,  may  be  seen,  or  there  may  be  found  evidences  of  tlio 
severe  general  diseases  referred  to  on  the  previous  page. 

Treatment. — About  the  same  line  of  treatment  is  indicated  here  as  that  for 
the  hemorrhagic  diathesis.  In  the  first  variety  of  hemorrhage  the  treatment 
consists  in  giving  attention  to  the  existing  hx'al  cause.  In  true  melena,  if 
mild,  the  internal  use  of  astringents  may  be  of  value;  in  addition  to  this,  tlic 
treatment  is  directed  to  the  supposed  cause,  while  every  effort  is  made  to  sup- 
port the  strength  of  the  child.  In  severe  cases  all  therapeutic  measures  are 
powerless. 

Colic  and  Diarrhea. — Colic  is  a  very  frequent  cause  of  sufferinir  jn 
infants ;  even  during  the  first  days  of  life  intestinal  colic  will  be  liroiidit 
about  by  an  irritation  of  the  sensory  nerves  of  the  alimentary  canal :  this 
irritation  nuiy  be  due  cither  to  the  abnormal  properties  of  the  digestive 
prfxlucts  or  to  imperfect  processes  of  fermentation,  leading  to  excessive 
formation  of  intestinal  gas;  also  to  the  irritation  produced  by  accumulation 
of  fecal  matter  and  to  the  delayed  expulsion  of  ineconiiun.  In  other  words, 
the  irritation  mav  be  either  chemical  or  mechanical.     In  both  instances  the 


PATHOLOGY   OF    THE   NEW-BORN  INFANT. 


855 


s,  the  licm- 

it'll    is    YWYV. 

iccortliiijj:  to 
The  iiiiiiii- 
quontly. 
day  ;  soiuc- 
lio  hldorl  is 
liargod  iVoiii 
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hc!m(irrlia|j;c 
indill'orciit  ; 
'.  child  is  ill 

In  tho  first 

3  second  and 

as  stated  hy 

les  especially 

irae  constitii- 
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has  no  syniji- 
»in  the  child's 
ry  apparatus, 
jr  de])ressiou 

ss  are  usually 
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ences  of  the 

'c  as  that  for 
le  trcatineiit 

le  inelciia,  if 
to  this,  the 

made  to  siip- 
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sufteriuir  in 
be  hroiiirlit 
canal :   this 

;lie  dii>;e-tive 
to   excessive 

aceunuiliitiim 
other  words, 

instances  the 


first  cause  is  usually  due  to  improper  food.  In  the  young,  reflexes  are  espe- 
lially  easily  excited.  An  infant  nursed  at  the  breast  will  sull'er  from  imperfect 
iligestion  and  from  abnormal  formation  of  gas  if  the  breast-milk  contains  a 
considerable  amount  of  colostrum,  and  also  if  nursetl  by  a  wet-nurse  whose 
milk  is  unsuitable  because  of  disparity  in  age  between  her  own  and  the  child 
she  is  nursing.  All  artificial  foods,  especially  the  amylaceous  group,  predis- 
pose to  flatulence.  Constipation,  whether  due  to  imperfect  diet  or  to  some 
stenosis  in  the  alimentary  tract,  will  give  rise  to  distention  and  irritation,  pro- 
ducing severe  forms  of  colic. 

The  symptoms  of  colic  are  sudden  attacks  of  pain,  manifested  by  the  infant 
refusing  to  nurse,  by  its  restlessness,  and  by  contraction  of  the  limbs  atid  of 
the  abdominal  muscles.  After  the  expulsion  of  gas  the  symi)toms  will  dis- 
appear as  suddenly  as  they  came. 

The  treatment  during  the  attack  consists  of  the  application  of  dry  heat  and 
irentle  friction  in  the  course  of  the  colon.  Should  the  attack  be  severe,  a 
warm  bath  will  afford  the  greatest  relief.  The  introduction  of  a  soft  catheter 
into  the  rectum  will  favor  exj)ulsion  of  the  gas,  and  may  l)e  followed  by  an 
enema  of  oil  or  of  warm  water. 

The  food  must  carefully  be  investigated,  and  if  found  at  fault  it  must  be 
changed  for  one  more  suitable.  In  acidity  of  the  vomited  matter  or  of  the 
stools  small  doses  of  calomel  conibined  with  alkalies  will  be  of  benefit ;  aro- 
matic teas  will  relieve  by  favoring  the  expulsion  of  gas.  Among  medicines 
nsiially  found  efficient  are  grain  doses  of  pepsin,  2  to  5  drops  of  gin  or  whiskey 
ill  hot  water,  drachm  doses  of  hot  so<la-mint,  or  the  milk  of  asafetida  adminis- 
tered by  the  mouth  (10  to  20  drops)  or  by  the  bowel.  The  habitual  use  of 
paregoric  for  this  trouble  is  to  be  condemned. 

Diarrhea. — During  the  first  few  days  after  the  birth  the  stools  of  the  infant 
are  a  dark  brown  or  greenish  mass  called  "  meconium."  This  substance  is 
very  tenacious,  consisting  of  fatty  matters,  epithelial  cells,  biliary  pigments, 
and  cholesterin.  It  is  really  an  accumulation  in  the  small  intestines  of  bile 
which  collected  during  fetal  life.  After  the  third  day  the  meconium  has 
passed,  and  is  substituted  by  yellowish,  semi-liquid  stools.  Tender  normal 
coiiditioiis  the  new-born  infant  has  three  or  four  stools  a  day.  In  infiuits,  on 
tu'count  of  the  pasty  condition  of  the  intestinal  matter,  more  or  less  excremen- 
titioiis  material  will  colle(!t  in  the  rectum,  which  fact  explains  in  some  degree 
the  number  of  daily  evacuations  from  the  bowel  of  infants  in  health.  What, 
then,  constitutes  diarrhea  in  infants^  This  (luestion  can  only  be  decided  by 
(il)serving  the  character  of  the  passages  and  noting  the  growth  of  the  child. 
One  evacuation  each  day  in  some  cases  may  be  suflicient,  but  fre<iuently  where 
this  is  the  habit  some  of  the  deleterious  results  of  constipation  will  be  observed. 
Nevertheless,  we  have  frequently  noted  three  or  four  movements  each  day,  and 
have  found  by  actual  weight  of  the  child  a  normal  increase  from  week  to  week, 
with  every  indication  of  good  development.  From  one  to  four  jiassages  each 
ilay,  then,  would  be  regarded  as  normal.  Deviations  from  the  normal  number 
occur,  such  as  evacuation  every  time  the  napkin  is  changed.     Idio])atliic  diar- 


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AMERICAN   TEXT-BOOK   OF   ODSTETRTCS. 


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rlioa  may  occur  during  tlic  first  week.  It  is  usually  due  to  bad  hygienic  sur- 
roundings, to  foul  air,  and  to  improper  food.  Sudden  changes  of  tLi.ipi'iatiiii' 
are  very  apt  to  produce  diarrhea. 

The  treatment  of  diarrhea,  like  that  of  colic,  i.s  based  on  the  same  princiiilis 
as  that  for  the  same  derangement  in  older  children,  the  selection  of  j)ropcr  I'.mmI 
being  the  principal  element  of  treatment.  Small  doses  of  calomel  (gr.  ^^^  to  tq-.  ' ) 
two  or  three  times  a  day  will  correct  the  fermentation.  If  this  drug  dots  umi 
correct  the  trouble,  from  1  to  3  grains  of  subnitrate  of  bisnnith  and  2  to  4 
drops  ol'  aromatic  sulphuric  acid  may  be  added  to  check  too  frequent  st(iol>. 

Constipation. — Constipation  is  very  common  even  in  the  veiy  yo'ing  ;  it 
may  be  a  symptom  of  various  pathological  conditions.  In  children  the  iiito- 
tine  is  relatively  longer  and  its  calibre  smaller  than  in  adults ;  the  walls  aiv 
thimier  and  weaker.  The  ascending  and  transverse  colon  is  shorter,  and  possibly 
flcxiu'es  are  formed  be<!ause  of  ))ressure  from  above  by  the  liver,  which  is  rela- 
tively larger  in  a  child;  also  by  the  relatively  contracted  condition  of  the 
jielvis.  These  anatomical  peculiarities  give  less  space  to  the  intestinal  tract, 
and  in  some  cases  they  represent  etiological  factors  in  causing  constipation. 
Tlie  peristaltic  movement  in  babies  is  slight  because  of  imperfectly  developed 
nniscular  structure.  As  the  child  develops  peristaltic  action  and  nuiscular  tone 
are  increase<l.  Another  anatomical  peculiarity  in  the  lower  bowel  is  the  deep 
cul-de-sac  which  the  sigmoid  tlexiu'e  »orms  before  it  joins  the  rectum.  This 
pouch  predisposes  to  fecal  accunudations.  Gerhardt  denies  the  existence  of 
so  marked  a  curve  in  the  sigmoid  flexure. 

In  the  healthy  child  the  mother's  milk  is  mostly  absorbed  and  assimilated, 
leaving  but  a  small  amount  of  residue;  the  amount  of  material  evacuated 
has  some  relation  to  the  amount  taken  into  the  system.  The  albiunin  of  the 
milk  is  nearly  all  digested  in  the  stomach  and  bowels  of  the  child,  and  i'lom 
this  very  jirocess  we  have  a  physiological  cause  for  constipation,  fecal  matter 
existing  in  such  small  amount  that  intestinal  peristalsis  is  not  excited. 
Habitual  consti])ation  in  the  mother  may  be  a  predisposing  cause  of  constipa- 
tion in  the  infant.  Other  causes  are  deficient  intestinal  secretion,  excessive 
perspiration,  medicines,  hernic'c,  intestinal  obstruction,  congenital  nialfonna- 
tions,  chronic  peritonitis.  Constipation  occurs  also  in  meningitis,  in  myelitis, 
in  hydrocephalus,  and  in  microcephalic  conditions  and  other  diseases  of  llic 
cerebro-spinal   system. 

What  has  been  said  above  under  the  head  of  Diarrhea  concerninii  the 
number  of  normal  passages  in  an  infant  applies  also  to  constipation,  i'^roiii 
one  to  four  passages  a  day  may  be  considered  normal,  providing  the  child  docs 
not  suffer.  A  steady  increase  in  the  weight  and  the  general  good  condition  of 
nutrition  will  aid  one  to  decide  whether  the  number  of  passages  is  suflii'ieiit. 
Constipation  is  undoubtedly  more  fmjuent  in  adtdts  than  in  children.  In  all 
])rol)ability,  what  are  called  "family  peculiarities"  are  due  more  to  the 
neglect  of  the  ])roper  attention  to  the  wants  and  habits  of  children. 

Treatmevt. — In  the  mn'sling  the  use  of  drtigs  should  usually  be  discaided. 
After  excluding  congenital  defects,  we  shoidd  look  to  the  mother  for  the  canse ; 


!!  n  V 


'ik 


PATHOLOGY   OF   THE  NEW-BORN  INFANT. 


867 


also  to  the  child's  diet.  Artificial  foods,  including  condensed  milk,  in  many 
instances  produce  diarrhea,  but  in  other  cases  they  give  rise  to  constipation ; 
any  food  which  is  absorbed  quickly,  leaving  little  or  no  residue,  will  produce 
tliis  condition.  To  obviate  this  effect,  if  water  has  been  used  as  the  diluent, 
(latmeal-water  should  be  substituted.  The  effect  of  local  stimulants,  such  as 
introducing  soap  or  glycerin  suppositories  into  the  rectum,  should  be  tried. 
Whenever  the  colon  is  blocked  up  it  must  be  cleared  by  tiie  use  of  an  enema, 
(ilycerin  may  be  administered  in  the  form  of  an  enema  (."iO  to  60  drops,  diluted 
w  ith  a  little  water).  Large  injections  of  fluitl  (more  than  2  to  4  ounces)  should 
1)0  avoided  ;  they  produce  ovor-distention  and  paresis. 

Intestinal  Obstruction. — Most  cases  of  intestinal  obstruction  in  the  young 
infant  are  due  to  congenital  malformations,  either  from  arrest  of  development 
or  from  the  effects  of  fetal  j)eritonitis.  Volvulus  or  intussusception  may  cause 
obstruction. 

'The  sipnptovis  of  obstruction  are  constipation,  colic,  intense  pain,  often  dis- 
tention of  the  bowel.  There  is  no  escape  of  flatus ;  sometimes  there  is  a 
discharge  from  the  rectum  of  mucus  and  blood.  In  volvulus  the  symptoms 
usually  occur  suddenly. 

The  diagnosis  is  not  always  easy.  In  cases  of  complete  obstruction  the 
cliild  does  not  pass  meconium.  Soon  after  being  put  to  the  breast  it  begins  to 
vomit,  first  the  contents  of  the  stomach,  then  bile,  later  meconium.  The  ab- 
domen soon  becomes  distended.  Death  occurs  in  a  few  hours  (jr  days.  In 
some  cases  the  anus  is  absent.  If  the  external  opening  is  present,  a  mal- 
formation of  the  rectum  is  apt  to  be  overlooked  and  the  case  diagnosed  as 
simple  constipation.  In  these  cases  purgatives  oidy  increase  the  difficulty. 
The  child  sutlers  much  pain,  cries  almost  constantly,  the  alxlomen  is  greatly 
distended,  vomiting  and  symptoms  of  collapse  appear,  and  death  from  exhaus- 
tion finally  occurs.  If  digital  examination  is  made,  the  finger  will  pass  Init  a 
sliort  distance.  If  there  be  only  a  membranous  septum,  the  bulging  of  the 
jrnt  from  above  can  distinctly  be  felt.  When  the  amis  is  absent  and  the  rec- 
tum ends  just  above  it  (which  is  the  commonest  condition),  bulging  of  the 
lower  entl  of  the  rcctiun  may  be  felt,  but  if  the  rectum  ends  higher  up,  this 
will  not  be  observed. 

Treatment. — Many  infants  with  obstruction  of  the  bowel  are  either  stillborn 
or  they  live  but  a  short  time.  Surgical  measures  must  be  resorted  to  soon  after 
hirth.  When  there  is  only  a  thin  septum  between  the  rectum  and  the  gut,  a 
crucial  incision  and  dilatation  with  the  finger  will  be  all  that  is  recpiired.  The 
mucous  membrane  should  be  stitched  to  the  skin.  If  the  separation  between 
the  rectum  and  the  surface  is  greater,  the  bulging  of  the  distended  gut  must 
carefully  be  looked  for,  and  if  it  is  found  incision  should  be  made  in  front  of 
the  coccyx  and  be  carried  down  until  the  bowel  is  reached.  The  bowel  should 
then  be  opened,  drawn  down,  and  stitched  to  the  skin.  If  the  gut  cannot  be 
found  below  by  dissection,  then  an  operation  from  above  should  be  under- 
taken. Littre's  operation  of  opening  the  colon  through  the  groin,  or  Amus- 
sat's  lumbar  operation,  must  be  performed.     The  ojuniing  of  the  peritoneal 


858 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


II' 

H 


%\.  'n 


ps  III 


cavity  shoiiltl  be  atteuded  witli  the  usual  aseptic  precautions.     The  stop; 
the  operation  are  practically  the  same  as  those  in  the  case  of  an  adult, 

Laniphear  reports  a  case  of  absence  of  the  upper  rectum  in  which  tiic 
following  operation  was  performed,  apparently  with  success  :  "An  incision  was 
made  through  the  sphincter  to  the  coccyx,  and  dissection  was  made  through 
the  connective  tissue  to  near  the  promontory  of  the  sacrum.  A  small  sound 
was  inserted  into  the  bladder  as  a  guide.  After  dissecting  upward  for  alxmt 
an  inch  and  a  half,  the  peritoneum  was  reached.  This  was  cut  into,  the  sitr- 
moid  flexure  of  the  colon  easily  pulled  down  and  stitcheil  to  the  ujjpcr  cud  u\' 
the  rectum,  an  opening  three-quarters  of  an  inch  being  made  in  the  side  ot  tho 
bowel,  with  the  discharge  of  an  immense  amount  of  fwes.  There  has  been  no 
fever  and  no  peritonitis,  and  the  child  is  well  and  growing  nicely.'' 

In  cases  where  fecal  matter  has  been  passed  l)v  the  rectum  and  there  arc 
suddenly-developed  symptoms  of  obstruction,  volvulus  is  likely  to  be  the  cause. 
If  the  administration  of  laxatives  (castor  oil)  and  enemas  has  failed,  tlicii  it  is 
necessary  to  resort  to  abdominal  section  both  for  diagnosis  and  for  relief. 

Sometimes  during  infancy  (most  frequently  between  the  ages  of  four  and 
six  months)  a  portion  of  an  intestine  passes  into  another. 

Inguinal  and  Umbilical  Hernia. — In  infants  the  inguinal  canal  is  strai}j;ht 
and  short,  and  in  delicate  male  children  a  hernial  protrusion  including  a  1()()|) 
of  intestine  is  not  uncommon.  Most  of  these  cases  may  be  cured  by  tlio  Mcar- 
ing  by  the  child  of  a  properly-fitting  truss  for  several  months  or  years.  I 'm- 
bilical  hernia  may  be  acquired  in  poorly-develope<l  children  when  there  is  a 
large  cord;  the  hernial  sac  will  sometimes  contain  small  intestine  and  perito- 
neum. A  compress  or  a  disk  of  metal  or  hard  rublK>r  larger  than  the  pi-d- 
trusion  should  be  made,  and  held  in  position  by  means  of  a  bandage ;  knitted 
bandages  are  most  comfortable  and  useful. 

Peritoneal  abscess  rarely  occurs  in  early  infancy.  One  case  is  reported  in 
which  the  abscess  was  due  to  caseous  mesenteric  glands  (Ashby  and  Wright). 

Disturbances  of  the  Urinary  Organs. — Infants  frequently  pass  witii  the 
urine  considerable  uric  acid,  which  forms  a  visible  deposit  on  the  najjUin. 
This  passage  of  uric  acid  may  be  unaccompanied  by  any  discomfort ;  again,  it 
may  cause  disturbance  in  micturition,  or  even  convulsive  seizures  and  |)aiii. 
The  treatment  consists  in  administering  small  doses  of  citrate  of  potash  and 
sweet  spirits  of  nitre. 

The  malformations  described  on  page  303  are  also  accompanied  by  varimis 
disturbances  of  the  urinary  function.  Opening  of  the  rectum  into  the  iintlira 
or  the  bladder  is  evidenced  by  the  passing  of  fluid  feces  and  gas  through  tlio 
urethra,  or  in  the  female  it  may  i)ass  through  the  vestibule.  Later,  vesical 
irrit'ition  caused  by  the  decomposing  urine  may  take  ])lace.  The  health  of  the 
jKitient  is  not  always  interfered  with.  Contraction  of  the  urethra  may  uivo 
rise  to  incontinence  or  •"cteuiion  of  urine.  In  these  cases  catheterization  will 
give  temporary  relief.     Dilatation  may  become  necessary. 

Phimosis,  or  elongation  and  contraction  of  the  prepuce,  often  gives  ri>o 
to  nervous  disturbance  and  to  painful  micturition,  or  even  to  convulsidiis. 


ff''fff'1 


PATHOLOGY   OF   THE  NEW-BORN  INFANT. 


859 


A  U 


Treatment  for  Phimosis. — If  ])hiniosis  occurs  only  in  a  slijrht  do<froe,  dailv 
retraction  and  cleanliness  for  a  week  or  two  usually  ovcrcoino  the  difficulty. 
ICvon  when  the  prepuce  is  very  tij^lit  and  adherent  to  the  glans  penis,  it  is 
usually  sutficient  inunediately  or  soon  after  birth  to  separate  the  adherent  sur- 
iliccs  with  the  flat  end  of  a  probe,  followed  by  thorouf:;h  dilatation  of  the  ))re- 
puce  with  dressing-forceps.  The  foreskin  should  thereafter  daily  be  retracted, 
cleansixl,  and  a  fllni  of  cotton  covered  with  borated  vaselin  should  be  laid  over 
the  glans  penis  before  allowing  the  prepuce  to  recover  the  glans.  If  the  phi- 
mosis gives  rise  to  secondary  derangements,  such  as  irritation,  incontinence,  or 
retention  of  urine,  hernia,  prolapse  of  the  rectum,  and  more  severe  reflex 
nervous  troubles,  circumcision  should  be  performed  early  should  the  above- 
mentioned  plan  of  treatment  fail. 

lli/pospadias,  cpi.'^padids,  i\nd  e.rtrorerKion  of  the  bhidder  wiW  cause  incon- 
tinence of  urine  and  excoriation.  Operations  for  these  conditions  are  the  only 
moans  of  relief;  they  are  usually  delayed  until  after  the  child  is  one  year  old, 
and  are  not  always  successful. 

6.  Hygiene  and  Therapeutics  soon  after  Birth. 

1.  Hygienk. — Care  immediately  after  Birth. — The  air-passages  should 
be  cleared  of  mucus  by  inverting  the  child  and  brushing  away  the  mucus  with 
the  Hnger.  When  the  infant  has  cried  lustily  and  the  cord  has  been  severwl, 
the  little  one  should  be  wrapped  in  a  warm  flannel  rec(Mving-blanket.  The 
eyes  and  navel  should  iinme<liately  be  deanseil  with  sterilized  water  and  be 
washed  by  a  3  per  cent,  solution  of  boric  acid  ;  after  that  the  nurse  may  pro- 
ceed at  once  to  cleanse  its  body.  For  this  piu'pose  the  bath  is  not  always 
advisable.  Very  feeble  children  are  easily  chilled,  and  in  these  the  water-bath 
at  first  is  to  be  avoidetl ;  instead  of  the  bath  the  body  may  be  anointed  with 
olive  oil  or  with  plain  vaselin,  which  is  removed  with  absorbent  cotton.  Vig- 
orous rubbing  of  the  skin  should  be  prohibitetl.  The  room  shoidd  be  warm. 
The  child  should  be  bathcnl  every  day  with  oil  or  with  water.  The  dressing 
of  the  cord  has  been  fully  described  on  page  828.  Before  clothing  the  child 
a  careful  examination  must  be  made  to  detect  any  existing  malformation 
or  defect,  and  finally  the  cord  mnst  be  examined  to  see  that  there  is  no 
bleeding. 

From  the  first  the  infant  is  to  have  its  own  crib,  which  may  be  placed 
near  the  mother's  bed  or  in  the  adjoining  room  if  a  special  nurse  can  be  pro- 
vided. This  room  should  be  aired  regularly  night  and  morning.  During 
tlie  first  few  days  laying  the  baby  on  its  right  side  will  favor  closure  of 
the  fi»ramen  ovale. 

Food. — As  soon  as  the  baby  has  been  cleansed  and  the  mother  has  been 
eared  for  and  rested,  the  child  should  be  placed  to  the  mother's  breast ;  this 
being  done  both  to  satisfy  the  natural  instinct  of  the  child  and  for  the  benefit 
iler'ved  by  the  mother  fr<mi  the  reflex  contraetion  produced  in  the  uterus. 
Tiic  first  secretions  of  the  breast  will  usually  sup])ly  sufficient  nourishment, 
and  their  laxative  quality  is  beneficial  to  the  chikl.     In  the  course  of  from 


M 


.( 


H: 


MB  I 


1^' 


» 


ff 


*u  I 


.'4 


I 


860 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


thirty-.six  to  seventy  hours  the  secretion  of  milk  should  be  established.  It  j.; 
essential  that  from  the  iMJginning  the  child  shonld  acquire  re<;ular  haljjts  u\ 
feeding,  and  for  this  reason  it  should  be  applied  to  the  breast  at  rcguliir  in- 
tervals— for  the  first  month  every  two  hours  during  the  day  and  two  or  tlncc 
times  during  the  night.  Before  placing  the  child  to  the  breast  the  nipiilc 
shonld  be  washed  with  sterilizal  water,  and  again  after  nursing.  The  im- 
portance of  giving  proper  attention  to  leeding  babies  cannot  be  over-estiinatcil. 

Infant  mortality  is  very  great;  up  to  the  fifth  year  about  25  per  cent,  df 
babies  die.  One  author  shows  that  out  of  1940  deaths  of  infants,  onlv  >ixt\- 
one  were  nursing  at  the  breast. 

The  rapid  development  of  infants  involves  rapid  tissue-change  and  iicccs- 
sitatcs  constant  and  sufficient  supply  to  all  the  structures.  Well-fed  baljics 
are  usually  quiet  and  give  comparatively  little  trouble,  and  they  are  usuallv 
exempt  from  disease ;  while  poorly-no"rished  babies  are  fretful  and  are  par- 
ticularly liable  to  have  convulsions. 

No  artificial  food  can  take  the  place  of  the  mother's  milk  ;  nursing  infants 
usually  thrive  well ;  but,  unfortunately,  many  mothers,  especially  in  the  favored 
class  of  society,  are  unable  to  provide  this  milk.  Again,  many  who  can' arc 
unwilling  to  do  so.  A  wet-nurse  is  the  best  substitute  next  to  that  of  prdj)- 
erly  prepared  cow's  milk.  Mixed  food  is  likely  to  cause  diarrhea.  The  details 
of  artificial  feeding  have  been  discussed  on  page  668. 

2.  TiiKitAPEiTTlcs  AND  DosA(JE. — The  following  are  some  of  the  rem- 
edies most  commonly  requirefl  in  early  infancy : 

A.  External  Remedies. — Antiseptics. — The  stronger  remedies  in  this 
ji,.'onp  must  be  used  with  caution,  as  infants  arc  very  susceptible  to  their  toxic 
effects;  this  is  especially  true  of  iodoform  and  of  carbolic  acid.  Salicylic  acid 
and  bt^racic  acid  are  to  be  preferred.  The  former  may  be  diluted  with  starch 
(1  :  8  or  1  :  5).  Bichlorid  of  mercury  is  used  in  solution  of  1  :  oGOO  U> 
1  :  10,000. 

Protecfives. — Boric  acid  and  lycopodium  or  borated  talcum  jiowder  consti- 
tute an  excellent  baby  powder.  If  there  is  much  chafing,  subnitrate  of  l)is- 
muth  and  starch  (1  :  o)  may  be  substituted.  Simple  cerate  is  also  efficient  for 
chafing.  Oiled  silk  is  used  to  protect  the  skin  from  cold,  to  favor  perspira- 
tion, and  as  a  protective  in  swelling. 

Astringents. — The  formulae  of  salicylic  acid  and  boric  acid,  referred  Ut 
above,  are  excellent  astringents. 

Coitnter-iiritants  in  early  infancy  must  be  used  with  care.  Babies  do  mit 
bear  blisters  well.     In  colic  a  spice  poultice  is  a  good  counter-irritant. 

Heat  and  Cold. — Care  must  be  observed  in  ai)plying  heat  and  cold.  A 
warm  bath  is  a  good  nerve-sedative  and  often  reduces  temperatui'e.  Warm 
fomentations  may  be  used  on  the  chest  and  the  abdomen,  but  they  are  often 
dangerous  when  applied  to  the  head.  Ice  applied  to  the  head  must  be  used 
with  caution. 

B.  Internal  Remedies. — Xntvients  and  Tonics. — When  additional  nutri- 
tion is  required,  pcptonoids,  beef  extracts,  and  cod-liver  oil  are  beneficial ; 


PATIIOLOaV    OF    THE   NFAV-liORN  INFANT. 


861 


the  latter  may  be  used  by  imuictioii.  Amoiif?  tonies,  the  synip  of  the  itKlid 
(tf  iron  may  be  given  in  drop  doses,  two  or  three  times  a  day. 

Digestives,  antifermoits,  and  antacids  are  usually  required  only  by  babies 
who  are  fed  artificially.  Administeriu}^  these  agents  in  hot  water  adds  to  their 
efHcieney.  Pepsin  given  in  grain  doses  will  aid  digestion.  Aromatics,  sueh  as 
|(oppermint  and  anise,  are  given  in  the  form  of  an  infusion.  Salicylate?  of  bis- 
muth, calcined  magnesia,  and  charcoal  are  also  etticient  antacids.  Calomel, 
j'ly  to  \  of  a  grain,  is  very  efficient  in  fermentation  of  food. 

Laxatives. — Constipation  usually  depends  on  dietetic  errors  which  should 
l)c  corrected  before  drugs  arc  given.  The  addition  of  sodium,  of  sugar,  or  of 
l)t)th,  to  the  food  will  often  correct  the  trouble.  Among  drugs,  castor  oil, 
from  15  to  30  drops,  is  the  best  laxative.  Calcined  magnesia,  from  8  to  10 
ij;rains,  is  excellent  where  there  is  acidity  or  flatulence.  For  chronic  constipa- 
tion the  fluid  extract  of  caseara  sagrada  (5  to  30  drops)  or  compound  licorice 
powder  (J  teaspoonful)  may  be  used  occasionally. 

Stimulants  are  especially  indicated  in  the  prematurely  born  and  in  any  con- 
(lititm  in  which  the  circulation  is  impaired  and  the  vitality  is  low.  Amousr 
alcoholic  stimulants  whiskey  is  the  best :  1,  2,  or  3  drops  may  be  given  every 
liour.  Alcohol  is  especially  indicated  in  septic  diseases,  in  which  it  is  borne 
in  much  larger  doses.  Carbonate  of  ammonia,  ^  to  1  grain,  and  tincture  of 
digitalis,  h  minim,  every  hour,  are  excellent  cardiac  stimulants. 

Antijn/n'tics  are  not  often  indicated  ;  when  the  temperature  is  high,  it  is 
best  to  reduce  it  bv  the  use  of  the  bath. 

Antispasmodics  in  early  infancy  are  re(|uired  usually  for  colic,  in  which 
case  the  antiferments  may  be  given  ;  in  addition  the  milk  of  asafctida  in  from 
1")-  to  30-drop  doses  is  excellent. 

Nerre-sedidires  are  not  often  recpiired,  and  should,  as  a  rule,  be  avoided. 
Tiie  irritation  and  pain  may  usually  be  relieved  by  removing  the  cause;  this 
applies  especially  to  faulty  diet  and  its  sequences.  When  opiates  are  unavoid- 
able, paregoric  may  be  given  in  from  2-  to  o-droj)  doses. 

Alteratives  are  especially  indicated  in  hereditary  syphilitic  disease,  and  in 
tills  case  thev  should  be  continued  for  a  long  time.  If  the  babv  nurses  from 
its  mother,  both  should  l)e  under  treatment.  Mercurials  are  well  borne  in 
early  infancy.  Calomel  J  grain,  or  gray  powder  J  grain,  may  be  given  by  the 
month,  or  the  oleate  of  mercury  may  be  used  by  imuiction. 

Mercurial  ointment,  i  drachm,  mixed  with  ecpial  ])arts  of  vaselin  if  aj)plied 
to  the  body  of  the  child  from  axilla  to  pubes,  and  covered  by  an  armless, 
simg-fitting  flannel  jacket,  makes  a  good  ()ermanent  medicating  medium. 
Tills  binder  may  be  retained  day  and  night  until  it  becomes  soiled  or  worn, 
when  it  should  be  replaced  by  a  new  one  similarly  medicated.  For  onychia, 
biillaj,  or  fissures  due  to  syphilis,  the  protiodid  of  mercury  may  be  used. 

Diuretics. — Before  administering  a  diuretic  a  careful  examination  should 
be  made  to  exclude  the  existence  of  congenital  obstruction.  Diuretics  are 
oirasionally  required  diu'ing  the  first  days,  when  the  lu'ine  is  deficient  and 
whore  there  is  much  deposit  of  urates  or  of  uric  acid.     Sweet  spirits  of  nitre, 


1 


m'l 

i 

1 

ill 

if 

1 

r'    t 

1 

f^^^ 

r' 

Bi 

If'; 

802 


A  mi:  UK  AN  TExr-nooK  OF  niisTF/nurs. 


5  drops,  conihiiipd  with  citnitc  of  potiisli,  j   to  \  trrniii,  mav  Im'  <riv(>n  two  np 
three  times  a  <lay. 

Jfctitoxttilii's  are  reqiiivetl  with  the  heniorrhafrie  diatliesis  and  in  sin-i^, 
niek'iia,  et(!.  Fhiid  extract  of  erj^ot,  Croin  1  to  ,'J  drops,  gallic  acid,  1  i,,  •_> 
jrraiiis,  and  cracked  i<'e  are  the  nxwt  usefid  ;  hut  ice  nuist  he  used  with  cautinn 
when  tlie  vitality  is  hiw. 

7.  Premature  Infants. 

By  a  "premature  infant  "  is  meant  one  that  is  born  between  the  period  nl' 
viability  and  the  natural  end  of  ])regnaney,  whether  the  interruption  of  pivtr- 
nancy  l>e  spontaneous  or  be  induced.  The  exact  period  <tf  viability  cannot 
be  fixed  upon  accurately  in  any  ^fiven  ease,  for  the  period  may  vary  williin 
relatively  wide  limits.  In  this  respect  nuieh  depends  upon  the  nom-islini( m 
of  the  fetus  prior  to  its  birth,  the  condition  of  the  mother  durinj;  preirnancv 
the  conditions  neeessitatin*;  or  leadin<r  up  to  the  interruption  of  prejrnancv, 
the  duration  of,  and  complications  and  diiliculties  attendant  upon,  labor,  a<  well 
as  upon  the  natin-e  of  the  surroundings  ami  the  ability  of  those  intcit^iid 
properly  to  care  for  the  child.  It  has  l)eeii  customary  to  fix  the  period  of 
viability  at  twenty-eight  weeks.  As  a  mnnber  of  premature  iidimts  of 
twenty-four  weeks  have  successfully  been  raised,  the  suggestion  that  any  child 
that  breathes  at  birth  be  treated  as  viable  should  be  adopted  in  place  of  aiiv 
fixed  rule  based  upon  the  age  of  the  Ictus  or  upon  its  size. 

To  preserve  the  life  of  the  ])remature  infant  to  a  time  corresponding  td 
what  would  have  been  the  normal  completion  of  jiregnaney  it  is  important 
that  there  be  observed  certain  essentials  in  its  care  and  management.  riii> 
necessitates  that  we  pjiy  especial  attention  to — 

First,  the  maintenance  of  the  bodily  temperature. 

Second,  the  prevention  of  exhaustion. 

Third,  the  administration  of  the  proper  amount  and  kind  of  nourishniciit. 

The  nearer  to  the  end  of  fidl  term  the  child  is  born,  other  things  being 
equal,  the  more  favorable  are  the  chances  for  preserving  its  life,  under  proper 
care,  to  what  woidd  be  the  natural  time.  If  it  has  been  thus  preserved  and  it 
has  increased  suflfieiently  in  weight  and  strength,  its  chances  for  life  then  are 
the  same  as  that  of  a  child  born  at  fidl  term. 

The  Maintenance  of  the  Bodily  Temperature. — The  vital  organs  ol"  the 
])rematnre  infant  have  not  develope<l  sufTiciently  to  maintain  a  uniform  body- 
heat  independently  of  other  means.  During  intra-uterine  life  the  Utiis  is 
surrounded  by  a  fluid  of  a  uniform  temperature,  and  the  heat  of  the  blood  is 
regulated  by  means  of  the  placental  circulation.  We  can  best  imitate  tlu-e 
methods  of  natiu'e  by  surrounding  the  child's  body  with  a  suitable  non-c( in- 
ducting material  kept  constantly  at  an  even  temperature,  and  by  furnishing  to 
the  child  a  jdentiful  sii|)ply  of  j)ure  air  that  is  also  of  a  certain  definite  and 
uniform  temperature. 

This  condition,  the  maintenance  of  the  bodily  temperature,  is  best  met  by 
the  use  of  an  incubator  or  comruse.     There  are  several  patterns  of  incid)at()i's, 


II     tW'U  nr 

il.  1   \<>  2 
h  caiitiiiii 


peril  i<  I  ul' 
1  of  ]»r(if- 
ity  caiiiHit 
iry  witliiii 
urisliiiicut 
ir('jj;n!iiii'y, 
)r('triiiiiicy, 
)()r,  !l-  well 
intcn'Miil 
]u'ri(»l  tit' 
infants  ul' 
t  any  cliilil 
lace  (tl'  any 

ion(lin<:  t(. 

iniiuirlaiit 

lont.     'riiin 


Hirisliincnt. 
liin^s  l)i'in<r 
ulor  proiuT 
rvcd  anil  it 
ill'  tliL'ii  an' 

"i>ans  ul'  till' 


llorni 


l)i)il\ 


jlio  i'l'tns  is 
Itlic  blonil  is 
Initato  tlii-^c 
llo  non-riwi- 
jrnisliini:'  tu 
lloHniti'  anil 


Ihost  nu't  l)y 
incnlKitni's, 


J'ATJ/OLOaV    OF    TIIK    XFU-JlOhW    /.V/'^LV'/'. 


mG;{ 


l''lii.  111.— Auviiril  liiciiliatnr  (ir  coiivi'iise. 


iii»tal)ly  those  of  Tarnier,  of  Anvard  (Fi^s.  444.  44")),  and  of  ('rede,  wliieli 
kive  l)een  used  witli  es|)eeial  Mieeess  in  the  maternity  hospitals  of  Frame  and 
(iernnuiy.    They  are  more 

,ir     Ie.s.s    complicated    and  ^ <rr'''''''*^"'xir 

ixpcnsivc  structures,  and,  ^^.'^sja-J*"  "-<*if 

uiiile  of  tht'ijjreatest  utility 
in  hospitals  and  ainonir 
tilt'  wealthy,  they  would 
often  1)0  impraeticahle  in 
[irivato  practii-e,  especially 
anioni;  the  poor  and  in 
tnwns  remote  from  a 
metropolis.  A  modiiied 
Anvard  incubator  can  he 
made  by  any  carpenter  at 
a  tritlini;  expense,  and 
will  fjive  satisfaction. 
The  acconipanyinif  illus- 
tiations  explain  its  niechanisni  (Fijjs.  44(3-44cS).  ("rede's  iucnhator  and 
iiiodificatiou   of  it  consist  essentially   of  u  double-walled  copper  tub.     The 

space  between  the  walls 
is  filled  every  four  hours 
with  water  at  a  tempera- 
ture of  122°  F.  The 
tub  is  half  filled  with 
cotton-wool,  u])on  which 
the  child  is  ])laeed.  ini- 
dresst'd,  with  absorbent 
cotton  about  its  jjenitals. 
The  tub  is  then  filled 
with  cotton-wool,  with 
the  exception  of  a  space 
fi)r  the  child's  fiiee.  An 
extemporized  incubator 
may  l)e  made  in  any 
home  with  easily  procured  materials  that  will  answer  the  purpose  of  the  more 
i'lai)orate  manufactured  article  very  well.  A  lar^e-si/ed  market  basket,  a 
small-sized  clothes  basket,  or  an  ordinary  wooden  box  is  first  lined  witii  heavy 
wrapping  paper,  and  is  then  thorouirhly  ])ad(k'd  with  blankets  or  cotton  bat- 
tiiiir  or  both.  Half  of  the  basket  or  the  box  is  then  filled  with  some  soft,  non- 
conilucting  material,  such  as  cotton-wool  or  cotton  batting.  Hot-water  bottles 
or  hot-water  bags  are  to  be  so  arranged  about  tiie  sides  of  this  receptacle  that 
one  or  more  may  be  removed  or  exchanged  without  exposing  or  in  any  way 
disturbing  the  child.  The  child,  having  been  thoroughly  anointed  with  warm 
sweet  oil,  is  placed  in  this  receptacle  undi'essed,  with  an  absorbent  i)ad  arranged 


Flii.  415.— Intcriiir  view  iif  tlio  .Viivnrd  inriibatDr  (\'b^.  4111. 


» 

m 

f 

i 

f 


"i  ;i 


H(J4 


AMKUICAN    rEXT-liOOK    (tF    OliSTETUIVS. 


(11 


II 


I 


i 


"-' 

■;s  f 

IS  s 

%\ 

1 

P 

t-, 

*  i 

'< 

*ft  i' 

,:t 

gj  ji 

It 

S'S 

fcfr^ 


for  the  collection  of  Iwes  and  urine.     The  incubator  i.s  then  filled  with  cotton- 
wool or  cotton  battinj^,  the  chilil,  with  the  exception  of  its  hea<l,  being  (din. 

pletely  (jovered.  i  f 
necessary,  an  ad- 
ditional shawl  (II 
blanket  may  be 
thrown  over  the  in- 
cubator, care  beinj; 
taken  that  niinr  nf 
the  weight  be  Itoinc 
by  the  infant.  A 
thernionieter  .^hoiild 
J  be  put  alongside  tlic 
child,  and  the  teni- 

Kl.i.  llf..-M<Klino.l  Auviir.1  inciil>iitor:  a,  uliiss  pliitc  of  the  m..vnl.lc  lid  h;  j'^''*'  "'^'  «llOlll(l  he 
c,  vi'TitMiitiiiK' tiilH'  <(iiitiiiiiinK  siiuill  rotiiry;  Inn  :  A',  vi'iitilHtiiiK  slide  ;  .»/,  kept  between  87"^ 
hiit-wiltiT  cans;  O,  slldi'  I'lnsiiitJ  hiit-iiir  cIiiiiiiIhT.  mill      Q9°      l<^        Tl 

air  of  the  room  in  which  the  incubator  is  to  remain  should  be  kept  pure  and 
at  a  uniform  temperature  of  about  71°  F.  Constant  attention  by  day  and  hv 
night  is  essential  to  the  proper 
regulation  of  the  temperature  '• 
of  the  incubator. 

The  Prevention  of  Ex- 
haustion.— After  the  child  is 
placed  in  the  incubator  it  shouhl 
be  disturbed  as  little  as  pos- 
sible, as  all  movement,  whether 
j)assive  or  active,  requires  on 
the  part  of  the  infant  more  or 
less  expenditure  of  vital  force. 
For  tliis  reason,  and  for  the 
additional  reason  that  exposure 

will     rob     it    of    body-heat,     the      Fk;.  in.-nitorior  vlewof  nmddifiod  Auvurd  iiiciiliuior 

child shoidd  be  bathed  not  oftener  "'''^  '""• 

than  once  a  (hiy,  and  then  with  warm  sweet  oil,  and  this  bath  should  be  given 

with   as   little   exposure   and    handling   as   possible.      The  absorbent   pads 

arranged     about     the     genitals     should 

be   changed  sufficiently  often    to  ensure 

cleanliness,  but  this  change  shoidd   also 

be  made  gently  and   without   exi)osure. 

Another  source  of  exhaustion  would  be 

the  nniscular  effort   re({uired  in  sucking 

if  the  child   were  put  to  the  breast  or    fw.  hk— iint-waurcun  for  modiiiedAuvimi 

if  it   were    required    to    nurse    from    a  mcubutor. 

bottle,  so  that  some  other  method  of  nourishing  the  infant  should  be  adoj)te(i. 


\. 


fMI 


I  COttnli- 

11^;  I'uiii- 
ml.  If 
nil  a<l- 
lawl  or 
nay  1m' 
r  tin;  ill- 
re   lH'iii<j,' 

llOlIf     111' 

Ih!  I)nriit' 
liuit.      A 

cr  :-ll(iIllil 

ijjfsidc  the 
tli«'  tcm- 

(lioiild    Im' 

vccn  87^ 
F.  Tlir 
jMirc  ;m<l 

lav  ami  l)v 


III  iiii'iitiiiiui- 


1(1  l»o  trivcii 


rbeiit    I 


mds 


liilied  Aiiviinl 


PATi/oLOdV  OF  Tilt:  yi:\\'-ii(>iix  ixiant. 


«or) 


l>c 


adopt 


(■(I 


The  Administration  of  Nourishment. — Tiic  prcniatnro  infant  sliould 
receive  at  stated  intervals  a  deliiiite  amount  of  nonrisliinent,  tiie  )|iiantity  and 
rre(|ucncy  of  its  administration  de|H>nding  soiiu;\vliat  npoii  its  a^e  and  npon 
tlie  indications  arising  from  time  t()  time.  If  for  tny  reason  the  mother's 
milk  cannot  be  used  and  a  siiitablo  wet  nnrse  cannot  be  obtained,  the  child's 
nourishment  should  consist  of  cow's  milk,  |)ro|)erly  sterilized  an*l  diluted  and 
otliorwisc  modified  to  suit  tlu;  age  and  coiulition  of  tlu'  infant.  The  greatest 
cure  shonid  1hi  observed  in  the  preparation  of  the  noiirishiiieiit,  whether  it  bo 
taken  from  the  breast  or  be  prepared  from  cow's  milk,  and  in  its  administra- 
tion, so  that  the  child  will  receive  it  free  from  germs.  Milk  may  be  given 
from  the  beginning,  or  the  child  may  receive  (hiring  the  first  day  frctin  10  to 
20  minims  of  warm  water,  containing  2  minims  of  whisky,  every  one  or  two 
lioiirs.  From  1  to  2  drachms  of  warm  nonrishmont  should  be  giv(Mi  every 
hour  at  first,  the  amount  and  the  interval  being  very  gradually  increased  after 
the  child  shows  evidence  of  increasing  weight  and  strength.  In  the  admin- 
i.<itration  o'  tlic  nourishment  one  of  the  following  methods  may  be  chosen. 

The  simpler  procedure,  and  the  one  most  practicable  for  ordinary  cases  in 
private  practic(>,  consists  in  introducing  the  food,  a  few  (lro|>s  at  a  time,  into 
tile  back  part  of  the  mouth  or  pharynx  by  means  of  an  ordinary  medicine- 
dropper  or  small  glass  piston  syringe.  When  breast-milk  is  available,  the 
iiKitlicr's  or  the  nurse's  breast  slioidd  gently  be  stroked  witii  the  finger-tips 
until  the  milk  flows  freely,  when,  by  means  of  a  breast-piiiiip,  2  or  .'5  drams 
of  milk  are  withdrawn  and  placed  in  a  warmed  and  clean  rcceiUacle,  from 
which  the  amount  of  food  recjuired  is  immediately  given  to  the  infant. 

The  s(!i;ond  method  is  known  as  f/rrwf/yc.  The  infant  is  ])liiccd  horizoiitallv 
on  the  imrse's  lap,  with  head  slightly  raised.  A  No.  14  or  KJ  (I'reiich)  sol't- 
nihhor  urethral  catheter,  thoroughly  sterilized,  is  first  anointed  with  a  little 
of  the  food  to  bo  given.  The  end  is  introdiux'd  into  the  j)iiai'ynx,  and  from 
there,  as  tho  child  swallows,  it  is  gently  i)assed  on  into  the  stomach.  When 
thi!  catheter  has  been  introduced  lo  centimeters  ((]  inches)  its  tip  has  entered 
the  stomach.  From  a  small  glass  funnel  or  syringe  inserted  into  the  outer 
extremity  of  the  tube  the  milk  fresh  from  the  breast  or  the  artificial  food 
warmed  to  a  temperature  of  f>'")°  F.  (35°  ('.)  is  allowed  to  pass  slowly  into  the 
stomach.  In  wiihdrawing  the  tube  it  should  be  done  with  a  rather  ([uick 
motion,  in  order  t(.  prevent  the  milk  from  followiug  it.  liapid  withdrawal 
of  the  catheter  is  facilitated  by  j)lacing  the  forefinger  of  the  left  hand  upon 
the  tongue  and  depressing  it.  If  the  presence  of  the  tube  causes  no  incon- 
venience, it  may  be  left  hi  xltu  over  several  feedings,  being  removed  two  or 
throe  times  a  day  for  the  purpose  of  cleaning  it.  After  the  child  gains  strength, 
and  when  its  power  to  suck  is  sufficient,  it  may  be  given  the  breast  several 
times  a  day,  gavage  and  nursing  being  thus  alternated  until  nutrition  is  well 
estiihlished. 

The  carrying  out  of  these  several  essentials  in  the  proper  care  and  nian- 
agcnient  of  the  premature  infant  rc(]nires  the  most  patient  and  careful  atten- 
tion on  the  ])art  of  the  nurse.  The  temperature  of  the  incubator  will  reriuire 
55 


K- 


!.     I 


866 


AMERICAN   TKXT-IiOOK   OF   OBSTETRICS, 


'     \A 


dose  attention  to  prevent  too  Ugh  or  too  low  degree  of  heat.  The  eh^aiili- 
ness  of  tlie  child  and  of  the  appliances  used  at  each  feeding  is  also  an  iiiipoit- 
ant  detail.  The  slightest  neglect  in  any  particular  is  apt  to  prove  disasuoiis  i,, 
our  efforts.  While  this  is  especially  true  as  regards  the  child  born  hetwci  n 
the  twenty-fourth  and  the  thirtieth  week,  the  child  born  later  than  this  slioiiKl 
not  therefore  be  in  any  way  neglected.  If  the  eight  months'  children  wore 
treatetl,  for  a  time  at  least,  exactly  as  are  those  of  seven  months,  more  of  tluin 
would  be  savetl. 

The  following  statistics  show  what  has  been  accomplished  by  inciiljatlnn 
and  gavage :  Of  infants  born  at  the  sixth  month,  22  per  cent,  survived  ;  at 
the  seventh  month,  38  per  cent.  ;  at  the  eighth  month,  89  per  cent.  ;  at  oidit 
and  one-half  months,  1(5  per  cent.  The  probability  of  rearing  a  prematurclv- 
born  infant  after  the  period  for  incubation  and  gavage  has  passed  is  largolv 
dependent  upon  the  care  exercised  throughout  the  first  year  or  two  of  life. 
Children  born  j)rematurely  to  parents  in  good  cirv^umstances  will  very  ofUii 
survive  infancy,  while  the  infants  of  the  poor  not  infrequently  succuuih  to 
intercurrent  disease. 


r^P 


^\\e  cloanli- 
an  inn>(iit- 
lisa^ii'ims  lu 
urn  Uctwoi'n 
1  this  sliduKl 
liiklren  varc 
iiore  of  tluiii 


VI.  OBSTETRIC  SURGERY. 


f;? 

1  « 

!■■■ 

!        ?i 

t 

ll 

, 

J ;', 

»v  incuUiitiiui 
survivotl  ;  at 
>nt.  ;  at  c'\]ihi 
lircinatiiri'ly- 
sod  is  lar<i('ly 
ir  two  (if  lift'. 
ill  vovy  (ifti'ii 
y  succuinl)  tti 


I.  Instrumental  Operations. 

General  Requirements  and  Preparations  for  Operations. — Mo.st  of  the 
bad  results  following  obstetrical  operations  are  due  i  >  the  cari'lessness  rather 
tliaii  to  the  ignorance  or  incxpertness  of  the  operator.     Though  most  physi- 
cians feel  that  in  the  practice  of  medicine  and  surgery  they  must  be  pains- 
taking, methodical,  and  familinr  with  recent  advances  in  knowledge,  yet  in 
ol)stetrical  work  they  are  apt  to  be  careless  and  inditl'erent,  trusting  that  nature 
will  su])plement  all  deficiencies  and  somehow  pull  the  patient  safely  through. 
Many  who  pride  themselves  upon  their  scientific  precision  as  physicians  or  upon 
their  exi)ertne.ss  and  rigidity  of  techni(iuo  as  stn-geons  are  nevertheless sloveidy 
and  careless  as  obstetricians.     This  anomalous  state  of  affaii-s  may  be  ductotlie 
wide  dift'usion  of  the  erroneous  idea  that  pregnancy  is  a  physiological  process 
wliose  natural  termination  is  laboi-,  and  that  con.se(]uently  no  special  care  or 
precaution  is  necessary.    '  INIoddlesome  nudwifery  is  bad  "  is  a  half-truth  which 
\\[\<  done  much  harm,  cramping  scientific  effort  and  serving  ivs  an  I'vcr-ready 
excuse   for  the  delays  and   procrastinations  of  incompetence  and   ignorance. 
Obstetricians  can  never  do  good,  safe  work  until   they  learn  to  regard  even/ 
ctinfinement  as  a  surgical  case  with  many  pathological  possibilities  to  be  avoided 
or  to  be  overcome,  rather  tiian  as  the  natural  termination  of  a  physiological 
process.      Oj>erative    midwifery  is  a  department  of  surgery  governed  by  the 
liriiiciples  and  rules  of  surgery.     Operative  precision  cannot  be  attained,  nor  can 
iiKirtality  and    morbidity  be    reduced  to  the  utmost,  unless  practice  is  based 
upon  broad  surgical  principles,  and  the  same  attention  is  paid  to  technique  as 
in  operations  u\)o\\  other  parts  of  the  body.     In  the   main,  modern  surgery 
owes  its  success  to  the  observance  of  a  rigid  antis(>psis.     Surgical  cleanliness  is 
imperative  in  even  the  smallest  operations  if  the  best  results  are  to  be  obtained. 
Ill  no  department  is  this  more  important  than  in  operative  obstetrics,  and  in 
none  does  disaster  follow  carelessness  and  neglect  more  speedily  and  surely. 
It  camiot  therefore  be  too  strongly  impressed  u|)()n  all  who  practise  the  ol)- 
stctric  art  that  <i  rU/UJ  technique  Ik  eKsentin/,  and  that  success  or  faihire  will 
ihpciid  more  upon  surgical  cleanliness  than  u|)on  mere  e.\j)er(iiess  in  operating. 
Septic  niicro-organisnis  do   not  normally  exist  in  the  uterus  nor  in  the  upper 
pai't  of  the  vagina;  tlicy  are  not  formed  iJenorn  in  the  jtarturient  canal.  l)iit  must 
lie  introduced  from  without.     Indeed,  the  micro-organisms  wiiich  do  e.\ist  in 
the  vagina  seem  to  lie  ])art  of  nature's  line  of  defence  against  invaders  from 
willioiit.     Tiie  doctrine  of  aiitolnj'ecll'm  as  conimoidy  expounded,  if  allowed  to 

8«7 


5>i^ 


">'^m:i.    i 


1 


i  it 


I! 


# 


868 


AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 


P% 


I,  < 


\i\ 


influcneo  our  rules  of  prtuiticc,  cau  do  uotliinj^  hut  harm,  aud  therofore  oaiiiint 
too  sevorcly  he  eoudeniiied.  Tlie  man  wlio  hclievesthata  patient  ran  goiiorati' 
in  her  own  hody  septie  matters  dc  /(oro,  aud  eau  therehy  iufeet  lierself  notwiili- 
.stan(hng  riyid  autiseptie  preeautions,  will  sooner  or  later  relax  those  precau- 
tious, aud  have  ready  to  hand  a  salve  for  his  eouseience  when  septieeiuia  dors 
arise;  but  the  one  who  makes  it  his  working  hypothesis  that  septieemia  alwavs 
arises  fnmi  infection  iutrodueed  from  without  as  the  result  of  some  failun;  in 
techni(ine  will  be  stinmlated  to  wateh  his  methods  with  ever-iucreasiug  care, 
seeking  for  the  weak  points  in  his  defeuee  aud  profiting  by  his  errors  and 
failures.  It  has  well  aud  truly  been  said  that  the  doctriue  of  autoiufeetiou  is 
the  gospel  of  desj)air  aud  tends  to  paralyze  honest  effort. 

In  obstetrical  as  in  all  other  operations  it  is  of  prime  importaueeto  sec  tliat 
the  field  of  operation  and  everything  coming  in  contact  therewitjj  (hands, 
instruments,  dressings,  etc.)  are  thoroughly  asei)tic,  and  are  kept  so  througlioiit 
the  operation  and  as  nuich  as  possible  during  convalescence.  This  is  ])erliaj)s 
harder  to  do  in  obstetrical  than  in  general  surgical  work,  on  account  of  the  ana- 
tomical arrangement  of  the  ])arts  and  the  difficulty  and  inconveniences  under 
which  operations  must  be  performed.  The  external  genitals  and  the  vagina 
should  receive  special  attention,  being  thoroughly  scrubbed  and  washed  with 
soap  aud  hot  water  and  then  douched  with  a  liot  solution  of  some  reliable  disin- 
fectant according  to  the  circumstances  of  the  case.  Some  use  corrosive  subli- 
mate (1  :1000,  1  :2000,  1  :  4000) ;  others  prefer  creoliu,  lysol,  carbolic  acid, 
permanganate  of  potash,  etc.  Good  or  bad  results  can  be  obtained  with  anv 
of  these  agents,  as  more  depends  upon  the  thoroughness  of  the  cleansing  than 
upon  the  choice  of  the  autisc])tic.  Plenty  of  hot  boiled  water  is  sufficient  in 
most  cases,  Avith  perhaj)s  the  addition  of  a  little  creoliu.  Lubricants  are  unnec- 
essary and  had  better  be  avoided.  Sponges  are  a  fruitfid  source  of  trouble  ;  a 
fairly  good  substitute  can  be  niadc  by  sewing  up  rolls  of  absorbent  cotton  or 
of  sterilized  gauze  of  convenient  size  in  a  gauze  covering  ;  they  can  be  stcrili/ed 
just  before  operation  and  be  do»stroyed  afterward.  Instruments  are  now  made 
with  metal  handles,  so  arranged  that  tlicy  can  easily  be  taken  to  pieces  and 
cleaned.  Sterilized  sutures  and  ligatures  are  also  readily  obtainable,  and  tiicre 
is  no  good  reason  why  an  obstcitrician  nowadays  should  ever  use  instruments  or 
dressings  which  are  not  siu'gically  clean.  Great  <;are  should  betaken  with  the 
hands  aud  the  nails,  aud  precise  directions  should  be  given  to  the  nurse  as  to 
the  cleansing  of  the  vulva  and  the  perineum  aud  the  renewal  of  pads.  These 
are  all-important  matters  of  detail,  but  they  camiot  here  be  discussed  thor- 
oughly. Different  operators  have  different  methods,  but  all  have  the  same  aim 
— the  maintenance  of  surgical  cleanliness.  The  tendency  seems  to  be  toward 
simplification  of  method  ;  details  may  aud  do  change,  but  principles  never. 

Passing'  the  Catheter. — This  little  operation  may  be  required  diiiini.'' 
pregnancy,  labor,  or  the  puerperal  period.  During  }nr(/)i<nu'i/  two  lactois 
co-operate  in  causing  retention  of  urine:  (1)  Mechanical  disturbance  of  tlio 
natural  relations,  and  (2)  loss  of  tone  in  the  muscular  fibres  of  the  bladder. 
During  Ittbor  retention  of  urine  from  mechanical  pressure  is  a  common  caiisL' 


9 


OBSTErniC  SURGERY. 


8G9 


fore  ciiniiiii 
;an  gonenUi' 
elf  notwiili- 
jose  imciui- 
ticemiii  dots 
ieniiii  iilwnys 
le  fill  In  IT  ill 
reasinji;  <"ii'''i 
is  errors  ami 
toinfoc'tiun  is 

HOC  to  sec  tliat 
Dwith  (haiiils, 
so  tliroiiii'liinit 
Ills  is  ])erli;ii>s 
mt  of  the  aiia- 
enienees  iiiuler 
und  the  vagina 
(I  washed  with 
,e  reliable  di>iii- 
LHirrosive  siihli- 
[,  earbolie  a('i<l, 
tallied  with  any 
cleansing  than 
is  sufficient  in 
•ants  are  unnee- 
•c  of  trouble  ;  a 
•bent  cotton  or 
•an  be  sterili/e«l 
s  are  now  maile 
11   to  pieces  ami 
liable,  and  tlu-re 
c  instruments  or 
0  taken  with  the 
the  nurse  as  to 
)f  iiads.     'rii<'>»' 
discussed  tlioi- 
A-e  the  same  aim 
;ins  to  be  toward 
lieiples  never, 
required    dmin.ir 
l>i(V/   two   liiciors 
iturbanee  of  tin' 
of  the   bladder. 
a  common  ci>iise 


of  delay  in  the  second  stage,  and  emptying  the  distended  bladder  often 
removes  the  so-called  "  uterine  inertia"  and  allows  labor  to  j)rocee(l.  During 
\\\c  inicrpcrlinn  retenti<jn  fretiuently  occurs  from  the  sudden  removal  of  intra- 
abdominal pressure.  Tiie  uterus  is  smaller  and  the  abdominal  walls  are 
laxer  than  before;  the  bladder,  suddenly  deprived  of  its  wonted  support  from 
l)efore  and  behind,  is  apt  to  distend  and  to  be  unable  to  empty  itself. 

C/ioice  of  Lttifnonrid. — A  soft-rubber  male  catheter  (Xo.  8,  10,  or  12 
I'jiglish)  is  most  suitable.  Ha.d  instruments  of  metal  or  of  glass  and  tlu; 
gum-elastic  catheter  with  stylet  are  usually  more  readily  rendered  aseptic,  but 
i((|uire  very  gentle  manipulaticm. 

Potiition  of  P((tic)if. — The  dorsal  position,  with  limbs  drawn  up  and  crcrtcff 
so  that  the  vestibule  may  be  put  upon  the  stretch,  is  pieferable,  because  it 
brings  the  meatus  within  easy  reach.  The  lateral  position  presents  no  special 
ailvantages  and  greatly  imjiedes  manipulation. 

Method. — The  meatus  is  exposed  and  thoroughly  cleansed  with  a  pledget 
(it  cotton  and  an  antiseptic  solution.  Two  fingers  of  one  hand  are  used  to 
separate  the  labia,  and  after  locating  the  meatus  the  catheter,  chemically  clean 
and  lubricated  with  an  antiseptic  lubricant,  is  held  in  the  other  hand  and 
]);\ssed  visually  into  the  meatus  to  avoid  carrying  into  the  uretiira  any  infective 
material  that  may  be  near  the  urethral  orifice. 

During  labor  it  may  be  difficult  to  get  the  catheter  through  the  urethra 
into  the  bladder  if  the  ])resenting  ])art   is  wedged  low  down  in  the  pelvis. 
Tiie  following  maneuvres  will  generallv  suffice  to  overcome  the  difficultv  : 
First:  place  two  fingers  of  one  hand  upon  the  presenting  part,  and  lift  it  up 
out  of  the  pelvis  as  far  as  possible  while  the  catheter  is  guided  into  the 
hladder  with  the  other  hand.     It  maybe  necessary  to  hold  the  presenting  part 
away  until  the  bladder   is  em])ty.     Second:  should   the  first  nianeuvre  tail, 
place  the  patient  in  the  knee-chest  ])osition  ;  the  uterus  and  the  presenting 
part  will  gravitate  away  from  the  pelvis,  allowing  the  catheter  to  slip  easily 
into  the  bladder.    The  latter  method  seldom  fails  unless  the  presenting  part 
is  too  firmly  wedged  to  be  displaced.     In  the  puerperal  })eriod  considerable 
diliiciilty  may  be  encountered  during  the  first  few  days,  esjiecially  in  primipariB. 
Kdeina  or  laceration  of  the  parts  may  so  distort  the  natural  relations  that  the 
meatus  may  be  drawn  over  to  one  side  or  even  down  under  the  anterior  vaginal 
iiorder.     It  is  sometimes  necessary  to  expose  the  vestibule  before  the  dis|)laced 
iiuatus  can  be  found.     When  the  catheter  has  been  pass*. I,  one  should  make 
sine  that  the  bladder  is  completely  emptied  by  pressing  upon  the  liypogastrium 
wliile  the  urine  is  flowing.    The  instrument  must  be  perfectly  clean  ;  preferably 
a  new  one  should  be  used  fiir  each  case.     If  needed  from  day  to  ilay,  the  cath- 
eter should  be  cleansed  tlnn'oughly  immediately  after  usciand  be  kept  in  a  2  per 
cent,  solution  of  carbolic  acid  ;  before  being  used  again  it  should  be  rinsed  and 
wiblicd  with  hot  water  to  remove  all  traces  of  the  acid,  or  an  irritating  ure- 
thritis or  cystitis  may  be  set  uj).     It  is  important  to  have  the  vestibule  freed 
t'nmi  all  discharges  iiefore  the  catheter  is  passed  ;  to  do  this  properly  the  labia 
^liuiild  be  well  separated,  the  vestibule  exposed,  and  a  vulvar  ihjuche  be  given. 


I 


% 


870 


AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 


The  Douche. — Tliore  arc  three  kinds  of  doudie,  the  vulvar,  the  vaf/iva'. 
and  the  uterine.  The  first  two  are  usually  entrusted  to  the  nurse ;  the  la-i 
should  be  given  by  the  physician. 

Vulvar  Douche. — As  the  vulvar  cavity  extends  to  the  vaginal  entrance.  ,i 
vulvar  douche  should  clean  all  that  ])ortion  of  the  genital  tract  which  lies  ante- 
rior to  the  vagina.     To  do  this  properly  the  patient  should  be  in  the  dor.sil 

position,  with  the  limbs  everted  and  tli.- 
labia  separated  with  two  fingers;  tli.- 
vulvar  cavity  can  then  easily  be  fiiislicd 
out  with  an  ordinary  vulcanite  or  ghws 
nozzle  (straight  or  rose;  Fig.  44!))  nr 
by  j)ouring  water  from  a  pitcher  or  :i 
bottle,  or  it  can  be  washed  clean  with  jute  or  gauze  pads,  which  can  tiieii  he 
destroyed.  Unless  ]iropo"lv  instructed,  nurses  are  very  apt  to  wash  over  tlie 
outtidc  of  the  vulva  only,   iistcad  of  cleansing  the  whole  vulvar  cavity. 

Vaginal  Douche. — The  vaginal  douche  may  be  given  warm  or  hot,  a  cold 
douche  being  rarely  rccpiired  ;  it  may  be  ])lain  or  medicated,  the  latter  bcintx 
required  only  in  special  cases.  The  patient  should  be  in  the  dorsal  positidii. 
If  a  large  vaginal  douche  is  required,  she  should  be  placed  across  the  bed  with 
the  hips  well  over  the  edge,  the  thighs  everted,  and  the  feet  resting  upon  a 
cliair.     A  Kelly  pad  or  a  rubber  sheet  should  be  so  arranged  as  to  carry  the 


Fir..  419.— Curvert  intra-utoriiu'  nozzlo. 


:i:^ 


l''ii;.  l')0.— Iiitm-utoriiu'  nozzk'.  IjciiiK  iilmost  striiit-'lit  innl  biiroly  oiitoriiiR  tlii'  cervix,  is  iiimlilc  lullnsli 

nut  tliL'  iitLTiuo  cuvily. 

water  into  a  sufficiently  large  receptacle  below.  A  vaginal  douche  during  lalMir 
or  the  puerperium  should  be  given  in  large  (juantity,  the  object  being  to  coiiviy 
a  volume  of  water  with  but  little  force,  cleansing  the  parts  by  the  aminiii!  of 
fluid  rather  than  by  the  force  with  which  it  is  introduced.  Nozzles  are  iiiinlc 
of  glass,  of  metal,  or  of  vulcanite;  they  are  straight  or  curved,  with  upeiiiii^-  :it 
the  point  or  at  the  sides  in  the  form  of  pinholes  or  of  longitudinal  eyes  ui-lll-. 
Glass  nozzles  are  good,  l)ut  tiiey  are  fragile  and  nuist  be  handled  witii  «:in  ; 


II    i 


• 


Hi 


(UiHTETniV  NURdER  Y 


871 


(luriiii:  liilii'f 
hiui^  to  roiivfv 
\\v  amiHinl  nl' 


»1\  npCuillL!-  lit 


iiictiil  is  such  a  good  conductor  of  heat  tliat  a  very  hot  douche  through  a  metal 
nozzle  can  hardly  he  home  ;  vulcanite  is  the  he.st,  hut  it  is  apt  to  lose  its  .shape 
wlien  hoiled.  The  openings  should  l)e  in  the  form  of  slits  rather  than  pinholes, 


Fiii.  l")!.— Intra-utcrinc  iiozzlo  imssed  ititn  lower  ulcrinc  Kctrniciit,  llio  utiTiiu' ciivily  not  t)cinK  sutisfuc- 
torily  flushed  out;  tlio  iieriiu'iil  body  is  strongly  ilopressud  to  uluviUu  the  tip  of  tlie  tube. 

and  on  the  sides  of  the  nozzle,  never  on  the  point.  In  giving  a  vaginal  douclie 
tlic  practical  point  i.-'  to  make  sure  of  a  sutticient  outflow.  The  Huid  should 
flow  out  as  rapidly  as  it  flows  in,  otherwise  there  will  he  hallooning  and  dis- 
tintion  of  the  vaginal  canal.      Two  fingers  should   he  introduced  into  the 


I'hi,  I.'i2.— Anterior  Up  drawn  down  witli  volsoUii,  nnd  rurvc<l  nozzle  passed  up  to  tlio  funilus:  whole 
uterine  cavity  beiiij;  IIusIhmI  fnini  above  <luwinvard. 

vu!j;ina  and  be  .separated  like  a  glove-stretclier ;  the  nozzle  is  passed  hetwecii 
llie  fingers,  and  a  good  outflow  is  thus  maintained.  Where  the  parts  are 
I'ooinv  the  same  result  mav  he  obtained  bv  i»ressinir  the  nozzle  firmlv  ajjrainst 


f 


a  ■  • 


I  '■ 


t 


i  \ 


872 


AJ/EiiicAX  Tj'LXT-jiooK  OF  onsTirrRics. 


l( 


Bvt 


I 


\i  ^ 


one  side  of  tlio  vii<>iii;i.  Double  eatlieters  are  uiineces.suy ;  they  are  exi)ensiv( 
hard  to  keep  clean,  and  do  not  <^ive  suilieient  flow  for  obstetrie  work  niilc.- 
tiiey  are  of  extra  lartre  size.  When  the  donelie  is  finished  the  vagina  sIkhiM 
be  einjUied  of  tlnid.  If  corrosive  sublimate  or  other  poisonous  antiseptic  Ims 
been  employed,  a  pint  or  two  of  plain  hot  water  slioidd  be  run  throu<>'ii  i., 
wash  away  or  to  dilute  any  fluid  that  may  have  remained  in  tiie  va>i;iiia  tliii- 
diminishing  the  risk  of  abs(»rption. 

Vtcrhw  Douche. — The  position  of  the  patient  and  the  general  arrangeinenls 
for  the  uterine  douche  should  be  the  same  as  those  for  the  vaginal  douche.  A 
large-sized  inflexible  nozzle  of  glass  or  of  vulcanite  with  a  i)elvie  curve  should 
he  selected.  The  delivery-tube  should  be  of  large  ealibrc;  in  order  to  <;ive  a 
full-sized  stream  ;  the  small  tubes  attached  to  the  ordinary  douche  apparatii-; 
of  the  shops  are  useless  for  obstetric  work.  Objection  is  sometimes  taken  to 
the  large-sized  uterine  nozzle,  but,  as  a  general  rule,  a  uterus  that  ww^U 
douching  easily  admits  the  passage  of  a  good-sized  nozzle  (Figs.  450-452).  In 
the  puerperal  period  the  uterine  douche  is  employed  to  flush  out  the  uterine 
cavity  and  to  remove  del)ris,  shreds,  clots,  and  discharges.  This  removal  can 
be  effected  thoroughly  and  satisfactorily  oidy  by  discharging  a  large  <|uantitv 
of  fluid  at  the  fundus  without  force  and  by  flushing  the  uterine  cavitv  from 
above  downward;  the  nozzle  nuist  therefore  be  carried  up  to  the  fundus.  Xo 
diftieulty  will  be  found  in  passing  the  nozzle  if  the  anterior  lip  of  the  cervix 
is  seized  with  a  jiair  of  blunt  bid  let- forceps  and  drawn  gently  downward,  so 
as  to  straighten  the  canal  and  to  bring  its  axis  more  in  line  with  the  vagina. 
Care  should  be  taken  that  tube  and  nozzle  contain  no  air  and  that  the  vagiiiii 
be  washed  out  before  the  nozzle  is  passed  into  the  uterus.  The  fundus  should 
be  supported  by  the  hand  while  the  douche  is  being  given,  and  a  good  outflow 
should  be  secured  to  j)revent  distention  of  the  uterine  cavity.  Slight  traction 
upon  the  anterior  lip  will  generally  sufHce  to  keep  the  cervix  open  and  to 
allow  the  fluid  to  flow  freely  away.  If  sublimate  has  been  employed,  some 
plain  hot  water  should  be  used  as  in  the  vaginal  douche.  When  the  nozzle 
is  witlulrawn  the  uterus  should  be  made  to  expel  any  fluid  that  may  remain 
before  the  bullet- forceps  is  removed. 

The  chief  dangers  of  the  uterine  douche  are  tliat  fluid  or  air  may  be  forced 
into  the  Fallopian  tubes  and  thence  into  the  peritoneal  cavity ;  or  that  clots 
may  be  dislodged  from  the  placental  site,  causing  hemorrhage  or  permitting 
the  eitrance  of  fluid  or  air  into  the  sinuses;  or  that  poisoning  may  result  from 
the  f.bsorption  of  some  of  the  anti«eptic.  Ciiill  and  rise  of  temperature  often 
occur  a  few  hours  after  a  uterine  douche,  especially  in  nervous  or  debilitated 
])atieuts.  These  unpleasant  syn»pt.)ms  may  be  avoided  or  be  minimized  (!)  by 
giving  a  stimulant  a  few  minutes  before  the  douche;  (2)  by  having  the  iMJcc- 
tion-fluid  hot;  (3)  by  raj)idity  and  gentleness;  and  (4)  by  so  covering  the 
patient  that  she  is  not  exposed  to  chill  while  the  douche  is  being  given. 

Curettage. — This  operation  is  indicated  (I)  in  cases  of  incomplete  abortion 
when  portions  of  the  ovum  or  placenta  are  retaincnl  that  cannot  be  removed 
by  means  of  the  finger  or  the  ovum  forceps,  and  (2)  in  the  pucrperiam  wlieii 


OliHTETRlC  SVllUKR  Y. 


873 


septic  syinptoius  have  appeared  which  are  prohahly  attributable  to  the  deeora- 
nosition  of  pieces  ot"  phieeiita  or  ineiubrane.s  in  the  uterine  cavity. 

In  cases  of  incoiu})lete  abortion  before  the  end  of  the  tiiird  mouth  it  is 
ocneraily  possible  t(»  remove  the  ovum  completely  by  means  of  the  Hnger. 
The  vaj:;ina  havin<:;  been  thoroughly  douched  and  the  operator's  hands  disin- 
llctedjthe  patient  is  placed  in  the  dorsal  jmsition  and  anesthetized.  The  fundus 
is  then  depressed  as  far  as  possible,  so  that  a  finger  may  be  passeil  up  to  expl«;re 
tlie  uterus  thoroughly  and  remove  any  portions  of  the  ovum  which  may  still  be 
adiierent.  Occasionally  the  greater  part  of  the  hand  must  be  introduced  into 
the  vagina  to  enable  the  finger  to  reach  the  fundus.  If  the  finger  is  found  to  be 
iiisuflicient,  the  hand  should  be  withdrawn,  and  the  anterior  lip  seized  with  a 
vnlsolla  or  a  strong  bullet-forcej)S  to  steady  the  uterus.  Schultze's  ovum  forceps 
(Fig.  453)  may  be  introduced  first  and  an  attemj)t  made  to  remove  the  retained 


(D=- 


'liSfSiJ 


(T 


I'Ui.  l.");i.— Scliultzu's  ovum  forci'ps. 


1"'.(;.1M.— Blunt  curcttp. 


fragments.  If  this  instrument  fails  also,  a  blunt  curette  (Fig.  454)  shoidd  be 
passed  into  the  uterus  and  gently  manipulated  until  all  adherent  pieces  are 
(lotached.  It  is  important  that  the  fundus  be  kept  well  depressed  and  the 
uterus  steadied  by  the  volsella  while  curetting  is  being  done. 

Fn  the  i)Hci'pcrinm,  if  portions  of  placenta  or  membranes  remain  attached  to 
tiic  uterine  wall,  a  douche  will  be  insutticient  to  remove  them,  and  they  will 
not  come  away  until  uterine  contraction  has  separated  them  entirely  from  their 
attachments.  If  septic  symj)toms  have  appeared,  it  would  be  dangerous  to 
wait  for  their  slow  natural  separation,  and  the  blunt  curette  may  be  employed 
to  remove  them  immediately.  The  instrument  should  be  long  and  iiiHexible, 
tiie  beak  being  bent  at  an  angle  with  the  shaft.  The  patient  having  been 
placed  in  the  dorsal  position,  the  anterior  lip  is  seized  with  a  volsella  and 
drawn  well  down  in  order  to  straighten  the  uterus  and  open  the  cervical  canal. 
The  curette  is  then  introduced  and  nuule  to  explore  the  whole  uterine  cavitv 
carefully.     The  scraping  should  be  done  very  lightly,  no  force  being  used,  as 


iK 


Fui.  ■15.'i.— DoK'ris's  i^coiivillun. 


Fl(i.  4.'iri.— MdclilU'd  Ocduvilltin. 


the  uterine  walls  are  thin  and  softened,  and  there  is  always  danger  of  perfor- 
ation uidess  the  utmost  gentleness  is  used.  The  greatest  ditticulty  is  experi- 
I'lued  when  the  retained  piece  of  placenta  is  situated  at  the  fundus  or  in  one 
of  the  eornua.  After  the  uterus  has  been  curetted,  a  hot  intra-nterinc  douche 
sliould  be  given  and  an  iodoform  bougie  passed  uj)  to  the  fundus.  Some 
(mcrators  prefer  packing  a  strip  of  iodoform  gauze  into  the  uterine  cavity  and 
allowing  the  end  t(»  protrude  through  the  cervix,  in  t)rder  to  promote  eontrac- 


JH 


« 


'  I 


874 


AMKliWAN    TKXT-nOOK    OF    0:'.STi:TI{H'S. 


*Sii 


^ 


m^ 


\*A 


tion  and  socuro  free  drainago.  AVIion  no  portion  of  the  phuienta  lias  been 
retained,  hnt  the  canse  of  septic  infection  is  dccfidnal  dCbris  or  siireds  of  mem- 
brane, the  brush  (ecouvl/lon  of  Doleris,  Figs.  455,  456)  is  more  et!"eetive  than 
the  curette  and  is  much  safer.  Having  been  soaived  in  very  hot  wat(!r  to  soften 
the  bristles,  it  is  passed  into  the  uterine  cavity  and  gently  rotated  until  it  reacliis 
the  fundus.  A  few  turns  are  usually  suificient  to  free  the  uterine  walls  tVom 
ddbris.  The  brush  is  then  withdrawn,  a  hot  intra-uteritie  douciie  administered 
and  an  iodoform  bougie  or  strip  of  gauze  introiluce<l  as  after  curettin<r.  The 
writer  has  modified  the  brush  somewhat  to  enable  it  to  reach  the  cornua  in  dif- 
ficult cases.  The  t)perations  of  curetting  and  brushing  are  sometimes  of  irrcMt 
service,  but  are  always  attended  with  risk.  They  should  be  employed  only  in 
selected  cases,  and  shouhl  be  practised  with  the  utmost  gentleness.  Neither  cu- 
rette nor  brush  should  ever  be  used  until  the  uterus  has  been  steadied  and  its 
walls  jHit  on  the  stretch  by  means  of  the  volsella.  When  the  uterus  is  curetted 
or  brushed,  the  operation  should  be  done  so  thoroughly  that  it  may  not  re(|iiirc 
to  be  repeated.  If  the  septic  symptoms  continue,  some  practitioners  are  in  tlie 
habit  of  curetting  again  and  again,  in  the  vain  hope  of  thereby  removing  the 
focus  of  infection.  Such  jiractice  cannot  be  too  severely  condemned,  since  it  is 
rarely  necessary  to  curette  or  brush  more  than  once  or  twice.  Ft  has  been 
urged  as  an  objection  to  these  operations  that  the  brush  and  curette  denude 
the  uterine  walls  and  open  up  fresh  aveinies  for  infection.  Experience  proves 
that  such  objections  are  groundless  if  the  operator  is  careful  of  his  technique. 

The  Tampon. — The  tampon  may  be  aj)plied  to  the  vulva,  the  vagina,  the 
cervical  canal,  or  the  uterine  cavity.  The  vulrnr  tampon  is  used  in  eases  of 
labial  thrombus  where  rupture  has  taken  place  and  there  is  contimious  oozing 
or  free  hemorrhage.  The  clots  are  turned  out  of  the  ruptured  sai;  'uid  the 
cavity  is  tightly  packed  with  strips  of  iodoform  gauze.  Occasionally  it  may 
be  necessary  to  pack  the  vagina  also,  in  order  to  secure  sufficient  comj)ressi()ii 
to  make  the  tampon  etfective.  The  raglnal  tampon  is  useful  in  cases  of  inev- 
itable abortion  in  the  early  months  of  pregnancy,  when  the  (cervix  is  not  suf- 
ficientlv  dilated  to  allow  the  finger  to  be  passed  into  the  uterin(.'  cavity  in  order 
to  remove  the  ovum.  When  properly  applied  in  such  cases  the  vaginal  tani|)(>ii 
checks  hemorrhage,  stimulates  the  uterus  to  more  active  contraction,  and  allows 
time  for  the  patient  to  rally  from  the  ette(!ts  of  hemorrhage  befont  other  meas- 
ures are  employed.  The  tampon  is  sometimes  used  to  induce  lai)or  by  stim- 
ulating uterine  action  :  the  infraccn-lcal  tani])on  is  then  employed,  reinibrced 
by  the  vaginal  tampon.  J>ut  in  i)lacenta  |)rievia  the  tampon  is  of  tlie  greatest 
value;  the  cervical  canal  and  the  vagina  are  packed  lirndy  enough  to  elieck 
hemorrhage  and  to  |)revent  the  escape  of  blood  from  the  vulva.  The  tampon 
acts  directly  and  indirectly:  directly  by  dilating  the  cervix,  distending  the 
vaginal  vault,  and  making  ilirect  compression  ;  indirectly  by  exciting  tlie 
uterus  to  vitrorous  contraction.  The  tam|)on  is  used  also  in  hvdatidifoini 
moles  as  soon  as  the  diagnosis  is  certain  and  hemorrhage  has  begini.  It  i- 
occasionally  of  service  in  the  treatment  of  post-partum  hemorrhage,  when  the 
uterine  muscle  is  weak  and  inert  and  cannot  be  stimulated  to  contract  by  other 


OBSTETIt IC   S I  '/ifJE/t  1 '. 


875 


i;ioaiis.  Ill  cases  of  rigid  cervix  or  i)r(»l()iigo(l  first  stage  in  primipariu  it  is 
romotimes  employed  as  a  dilator;  it  is  daiiued  that  l)y  its  use  lal)or  is  short- 
ened, the  mother  is  spared  mueh  pain,  and  the  child's  lite  is  placed  in  less 
i('oj)ardy. 

Materials  for  Tampon. — Various  materials  liave  l)een  used  for  tampons, 
.'^uch  as  sponges,  tents  (sponge  and  tupelo),  halls  or  pledgets  of  cotton  wrung 
(lilt  of  an  antiseptic  solution,  strips  of  linen  or  cotton  or  sterilized  gauze,  either 
plain,  borated,  carholated,  sublimated,  or  iodoformed,  (Miarpie  is  us(;d  exten- 
>ively  in  France.  A  favorite  tampon  in  (Jermany  and  in  France  is  a  rul)ber 
l)ag  (col peury liter)  introduced  Haccid  and  subsecpieiitly  dilated  with  air  or  with 
water.  When  used  as  vaginal  tampons  these  rubber  dilators  cannot  Ik;  so 
lirinly  api)lied  and  <lo  not  make  such  even,  steady  pressure  as  the  oid-l'ashioned 
liimpon.  They  are  more  useful  as  cervical  dilators  in  cases  of  placenta  pnevia. 
(iauze,  charpie,  and  absorbent  cotton  are  safer  than  sponges. 

Vaxjlual  Tampon. — Absorbent  cotton  is  s(»aked  in  carbolized  water,  the 
excess  of  fluid  being  squeezed  out,  and  fifty  or  sixty  l)alls  or  jdedgets  are  pre- 
pared, each  being  about  the  siz<!  of  a  walnut.  Some  obstetricians  use  these 
]»l('dgets  separately  ;  others  attach  them  to  a  string  or  a  .strong  thread  at  inter- 
vals of  6  or  8  inches,  as  in  a  kite-tail.  Astringents  are  unnecessary,  li)r 
tlicy  do  not  come  in  contact  with  the  bleeding  surfiice  and  they  only  serve 
ti)  irritate  the  vaginal  mucous  membrane;  a  weak  solution  of  carbolic  acid  is 
better.  Tire  pledgets  having  been  prepared,  the  patient  is  placed  in  the  Sims 
pdsition,  the  perineum  is  retracted  with  a  Sims  speculum,  and  the  cotton  l)alls 
arc  carried  up  with  long  dressing-forceps 
and  packed  closely  around  the  vaginal 
portion  of  the  cervix,  then  over  the  os, 
then  from  above  downward  into  the  va- 
gina until  it  is  sufficiently  well  filled 
(Fig.  457).  It  is  seldom  necessary  to 
])ack  the  whole  vagina,  altiiough  in  some 
cases  this  must  be  done.  A  T-bandage 
is  then  applied  to  keep  the  tampon 
in  xUn.  When  carefully  packed  about 
tiie  cervix  and  filling  out  completely 
the  dilatable  upper  portion  of  the  va- 
<;iiia,  the  tampon  is  a  perfect  safeguard 
iinaiiist  hemorrhage.    The  tampon  mav    i<"'suiy  in  tiic  i  .wor  pdrti.m  ..r  nw  v.i«iMii;  inmrd 

'       ,     .  ,.  i       1       /•  ,'     '        '""1    T-lmii(liini'    lire    MpplkMl;     ciise   of   |ilu(.'iiitii 

1)0   left    undisturbed     tor    twenty-tour    ,,r;uviii  witi.  uiMihit..i  irrvix. 
Iiiiurs,  and  is  then  removed  piece  by  piece 

frnni  without  inward,  the  vagina  is  thoroughly  douched  out,  the  bladder  and 
rectum  are  emptied,  and  another  tampon  is  intnuhu'ed  if  necessary.  A  third 
tampon  is  seldom  required.  Too  freipient  tamjK)niiig  irritates  the  vagina, 
causes  more  or  less  odor,  and  exposes  the  patient  to  tiie  risk  of  septic  infection. 
Aitcr  twenty-four  hours'  tamponing  many  operators  ])refcr  to  use  carefully 
prepared  sponge  or  tupelo  tents,  but,  as  a  rule,  tents  are  not  to  be  recommended. 


Kk;.  I'i7— Tain pdiii lie  tlio  viisriii'i  witli  i>U'(l,m'ts 
(if  cottdii  tinlitly  packed  ariniiid  the  crivix,  iiiiirt' 


m 


1:1 


■A- 

'I 
I 


87G 


AMEIiWAN    TKXT-nOOK    OF    OJiSTKTIilCS 


W: 


T:/; 


The  Sims  speculum  is  not  always  availal)le,  and  it  may  ho  (Uspeiised  with.  The 
patient  is  tiieii  phieed  in  the  dorsal  position  with  legs  and  thighs  Hexed.  Thr 
labia  iiaving  been  separated  with  two  fingers,  tiie  pledgets  of  cotton  are  carried 
lip  to  the  vaginal  vaidt  and  firndy  packed  about  the  cervix.  Tiie  ilrsi  lulls 
may  be  smeared  over  with  an  (.intment  containing  iodoform,  boric  acid,  (,r 
carbolic  acid.  ( )ne  hiyer  after  another  is  thus  introduced  until  half  the  vagina 
is  well  tilled.  Afany  obstetricians  prefer  strips  of  absorbent  cotton  instead  of 
balls  or  pledgets,  because  they  arc  more  easily  removed  ;  others  use  strips  o|' 
sterilized  gauze,  either  plain  or  medicated  (Fig.  458).    The  strips  should  l)e  25  or 


Fig.  458.— Tamponing  the  vagina  with  strips  of  gauze  or  t'otton. 

30  centimeters  (10  or  12  inches)  long  and  5  or  7.5  centimeters  (2  or  3  inches) 
wide;  they  should  be  smeared  on  one  side  with  ointment,  and  be  packed  about 
the  cervix  in  the  same  way  as  the  pledgets.  French  obstetricians  useoiiitiuents 
and  cerates  in  large  quantities  when  applying  the  vaginal  tampon.  Charpen- 
tier  says  that  a  pound  or  moi'e  of  chai-pie  may  be  re(piiivd  to  seal  the  vagina 
hermetically;  he  prefers  a  borated  cerate.  Auvard,  who  uses  cerates, says  that 
sometimes  as  much  as  500  grams  (16  ounces)  may  be  recjuired;  he  lays  great 
stress  upon  the  abundant  use  of  cerate.  In  applying  the  vaginal  tampon  some 
obstetricians  begin  by  packing  the  cervix  first,  and  then  the  anterior  and  jios- 
terior  cul-de-sac,  while  others  reverse  this  order.  At  all  events,  the  occlusion 
of  the  uterus  and  the  vagina  must  be  hermetic,  otherwise  the  tampon  will  be 
]>ainfid  as  well  as  ineffectual ;  it  is  therefore  necessary  in  all  cases  to  take  great 
pains  in  packing  the  cul-de-sac  gently  and  thoroughly,  but  not  foiribly.  (mt:U 
differences  of  opinion  seem  to  exist  as  to  the  length  of  time  the  tampon  may 
be  left  in  situ.  From  one  hour  to  thirty-six  hours  are  the  limits  that  have 
been  suggested. 

hdra-uterine  Tampon. — The  intra-uterine  tampon  was  introduced  in  l.S<S7 


by  Diihrssen.  Plain  antiseptic  gauze  is  the  best  material ;  it  attaches  itself  to 
the  uterine  walls,  soaks  up  and  drains  away  fluid,  and  swells  when  moistened 
without  becoming  liai-d  or  inicomfortable.  It  is  used  in  strips  45  centinie((  is 
(18  inches)  long  and  from  2.5  to  7.5  centimeters  (1  to  3  inches)  broad.  When 
well  applied  it  can  be  retained  for  forty-eight  hours  without  danger  or  iiicoii- 


OBSTETRIC  SURGEIt  Y. 


877 


pi!1 


inches) 
iilxml 
itinciits 
arpon- 
vatriiiii 
iay«  that 
's  great 
on  Honu' 
nd  pos- 
'hisitni 
will  1)0 
vo  L-Tcat 
(J  real 
on  may 
Kit  liavo 

in  18.S7 
itself  to 
loistened 
ti  meters 
When 
ir  ineoii- 


veiiicnce.  In  oases  ol"  post-iKirtnm  hemorrliajre  the  (jnantity  which  can  he 
siuiletl  into  tho  litems  is  very  great.  Half  ti  (U)zen  sterilized  gauze  handages 
7.5  or  10  centimeters  (3  or  4  inches)  wide  are  not  too  much.  'J'lie  intra- 
uterine tampon  is  useful  in  hemorrhage  at  full  term  or  after  abortion,  or  where 
there  is  sejttic  matter  in  the  uterus  after  labor  or  abortion,  whether  curetting 
has  been  (Kme  or  not ;  it  is  useful  also  when  the  uterus  contracts  imperiectly 
or  irregularly  after  labor  or  abortion.  In  subinvolution  it  stimulates  uterine 
contraction,  relievos  the  turgid  veins,  and  secures  good  drainage  ;  in  such  cases 
it  is  gonerally  ])receded  by  irrigation  and  curetting. 

Method  of  App/ieation, — The  bladiler  and  the  rectum  having  been  emptied 
and  the  vulva  and  the  vagina  having  been  thoroughly  cleansed,  the  anterior 
and  posterior  lij)s  of  tiie  cervix  are  drawn  down  by  means  of  two  volselhe. 
11"  the  hemorrhage  has  occurred  just  after  delivery  and  the  hand  can  be  passed 
into  the  uterus,  the  volselhe  are  unnecessary.  The  uterine  cavity  having  been 
cleared  of  clots  and  debris,  a  strij)  of  gauze  is  carried  up  to  the  fundus  and 
packed  in  until  the  free  space  about  the  fundus  is  completely  filled.  The  firm- 
ness of  packing  is  determined  by  the  cireumstaiices  of  the  (!ase;  allowance 
should  be  made  for  the  swelling  of  the  gauze  wlien  soaked  with  secretions. 
When  the  uterine  cavity  has  been  sufficiently  filled  tho  volselhe  are  removed, 
tlic  vagina  is  lightly  ])acked,  and  a  firm  abdominal  bandage  is  applied.  The 
tampon  may  be  left  in  phice  for  one,  two,  throe,  or  even  four  days,  according 
to  circumstances,  or  it  may  be  removed  and  renewed  from  day  to  day.  Tam- 
poning has  been  kept  up  in  a  myomatous  uterus  for  a  week.  Tho  state  of  the 
bladder  and  the  rectum  must  carefully  be  watched  while  tho  tampon  is  in  place. 
There  are  no  contra-indications  to  the  intra-utorino  tampon  if  it  is  modified  as 
to  quantity,  firmness,  and  length  of  application  according  to  circumstances.  It 
is  easily  removed  by  simple  traction. 

Episiotomy. — Tho  term  cpmotomy  is  applied  to  the  operation  of  incising  the 
genitals  during  delivery  to  jM'event  their  laceration,  substituting  a  clean  cut  of 
definite  size  in  a  place  where  it  ciin  do  no  liarm  for  a  ragged  tear  of  indefinite 
size  in  a  place  whore  it  may  cause  immediate  danger  and  subsequent  injury. 
This  name  was  given  tho  operation  by  ^lichaelis  (17i)i)),  who  incised  the  median 
raphe  of  tho  perineum  to  prevent  extensive  laceration,  but  it  is  now  apj>lied  to 
any  incision  of  the  external  genitals  for  a  similar  jmrpose.  Episiotomy  has 
fallen  into  comparative  disuse  in  England,  America,  and  Franco,  but  is  still 
common  in  Germany  and  Austria.  The  indications  are — threatening  central 
riij)turo  of  the  perineum  ;  great  narrowness  of  the  external  genitals;  excessive 
rigidity  of  the  soft  parts,  especially  fnmi  the  presence  of  cicatricial  tissue;  faulty 
presentation  ;  and  undue  size  of  the  child's  head.  Opinions  vary  as  to  tho  site, 
number,  and  size  of  tho  incisions,  but  each  case  must  bo  treated  according  to 
the  indications  present.  French  obstetricians  prefer  the  oblifpie  incision  (nvom- 
niended  by  Tarnier)  which  passes  to  one  or  the  other  side  of  the  anus.  Clian- 
troiiil  recommends  that  where  rupture  into  tho  rectum  is  threatened  a  median 
incision  bo  made  along  tho  raphe  and  then  be  carried  obliquely  off  on  both 
.sides  of  the  rectum,  the  incision  taking  the  shape  of  an  inverted  Y.     German 


878 


AMEIUVAX    ThWf.JiOOK   OF   OliSTETlilCS. 


V\  \: 


obstctricimis  in-d'cr  iiu-isioiis  diivotod  ol)li(iiicly  toward  tlio  posterior  ooruinijsHnro. 
Jt  is  claiiuotl  that  an  incision  of  1  i'('iitiriu'tcM-('|  inch)  incrtusfs  the  circuinCtn'iuc 
(»f  the  vulvar  orifice  2  centinietorH(\»  inch).  Tiie  incision  should  1h;  made  dnriiK' 
a  pain  with  a  pair  of  straight,  hhuit-poiuted  scissors.  WincUel  and  S  lniUzc 
advise  waiting  until  the  epidermis  at  tlie  frenulum  begins  to  tear.  In  America 
most  authorities  depend  more  upon  care  and  skill  in  delivering  the  head  than 
upon  incisions  for  the  prevention  of  perineal  laceration.  Hut  when  the  ruiiture 
of  the  j)erincum  threatens  to  involve  the  rectum,  as  in  ditlicult  forceps  cases  uv 
where  rapid  delivery  is  necessary,  an  oblique  incision  passing  well  to  one  sidi; 
(»f  the  anus  will  often  save  the  rectum  and  Icavi;  a  wound  which  can  iiiorccasih' 
and  satisfactorily  be  repaired.  Moreover,  it  is  not  so  liable  to  l)e  contaminated 
with  the  lochiii,  and  primary  union  generally  results.  Tiie  technique  of  epis- 
iotomy  has  been  described  and  illustrated  on  page  .'{7.'i. 

Premature  Induction  of  Labor. — The  course  of  gestation  may  be  arrested 
artificially  at  any  period  in  the  interests  of  either  mother  or  child.  If  it  is 
arrested  before  the  child  is  viable,  the  operation  is  called  the  "induction  of 
abortion  ;  "  if  after  the  child  is  viable,  it  is  called  the  ''  induction  of  prematine 
labor."  The  date  of  fetal  viability  is  therefore  the  dividing-line  between  these 
two  operations. 

Ind i cation. s  for  the  Induction  of  Abortion. — When  the  further  eontiiuianco 
of  gestation  would  seriously  endanger  the  mother's  life,  it  is  juslifiable  to  induce 
abortion  in  the  interests  of  the  niothi-r.  In  uncontrollable  vomiting  with  pro- 
gressive emaciation,  where  all  other  treatment  has  failed,  abortion  is  indicated. 
In  grave  heart,  lung,  and  kidney  troubles,  pernicious  anemia,  severe  chorea, 
advancing  jaundice,  etc.,  prompt  arrest  of  gestation  may  be  the  oidy  means  of 
saving  the  mother's  life.  Whenever  there  is  such  mechanical  obstruction  in 
the  genital  tract  that  the  birth  of  a  viable  child  is  impossible,  abortion  may  be 
induced.  Excessive  contraction  or  deformity  of  the  pelvis,  tumors  mechani- 
cally blocking  the  pelvis,  extensive  cicatricial  contraction  of  the  vagina  or  the 
cervix,  and  advanced  carcinoma  of  the  uterus  or  the  vagina  are  the  commonest 
forms  of  such  mechanical  obstruction. 

Indication/ifor  f/ie  Induction  of  Premature  Labor. — When  the  continuance 
of  gestation  to  full  term  would  expose  iiiotlier  ,)r  child  to  serious  risks  which 
might  be  diminished  or  avoided  by  the  an  .^t  of  gestation,  the  induction  of  pre- 
mature labor  is  indicated.  No  absolute  rulen  can  be  formulated,  but  each  case 
nuist  be  judged  upon  its  own  merits.  The  success  which  has  attended  modern 
Cesarean  section  and  symphysiotomy  has  limited  the  range  for  this  operation. 
If  the  mother's  life  is  not  imperilled,  it  is  better  to  allow  the  child  to  attain  its 
full  development,  and  to  deliver  by  section  or  by  symi)hysiotomy  than  to  bring 
into  the  world  an  immature  child  whose  chances  of  living  and  thriving  are  fic- 
quently  less.  Peh-ic  deformity  which  would  jircvent  the  birth  of  a  living  i'liii<l 
at  full  term,  but  which  would  allow  the  safe  delivery  of  a  premature  viable  cliiiti, 
used  to  be  considered  one  of  the  main  indications  for  the  induction  of  j)rcmatiiii' 
labor.  A  conjugate  of  6.75  to  7  centimeters  (2'^  inches)  in  the  simple  flat  pelvis 
and  of  7.5  to  8  centimeters  (3  to  3y\  inches)  in  the  generally-contracted  pelvis 


oiiSTirriiK  •  s(  naKii  v. 


H7y 


i 


luv  tlio  lowest  limits  iisiiallv  set.  Hut  hv  svinplivsiotoiuv  u  I'lill-toriii  child  can 
jrciiorally  ho  (Iclivcrccl  through  a  ju'lvis  as  small  or  even  smaller  with  prohahly 
li  il(<  more  risk  to  the  mother.  In  tlccidiii;;  upon  the  operative  measures  to 
|i  adopted  in  cax's  of  moderate  pelvic  coMtraetioii  it  ismdyjust  to  remend)er 
tl  '  claims  of  the  iiiduetiou  of  pr«inature  lahor  and  the  good  results  it  has 
vl'  Ided  in  the  past.  In  certain  f^rave  diseases  which  threaten  the  mother's 
Jili'  this  o|H'ration  will  alwnys  hold  its  place.  In  ji/iKriila  ftnrria,  when  a 
severe  homorrha}:;e  has  taken  placo  laltor  should  he  indiicetl  in  the  inlere>ts 
of  hoth  mother  and  child.  In  crldinjiKld  many  authorities  helievc  that  the 
siifest  treatment  is  the  induction  of  lahor;  others,  howev<r,  strnn<jjly  advocate 
tlir  expectant  plan.  In  chorea,  advanced  hciirt  and  Inn;;  troubles,  general 
(dcma,  jaundice,  etc.,  tile  operation  is  sometimes  imperative.  When  there  is 
a  (lead  fetus  //(  iitero  injuriously  atlectin^-  the  mother's  health,  or  where  the 
iiiiitlier  is  likely  to  die  hefore  lahor  sets  in,  there  can  he  no  donht  as  to  the 
advisability  of  the  operation. 

Time  to  Operate. — The  best  time  to  .select  for  operation  is  from  two  hundred 
and  forty  to  two  hundred  and  tifty  days  front  the  cessation  of  the  last  menstrual 
|M  riod.  It  is  better  to  operate  too  early  than  too  late.  Hchroeder  generally 
operated  in  the  thirty-sixth,  rarely  before  the  thirty-fourth,  week. 

I'rof/nosin. — The  progiK..  s  tor  the  mollier  is  generally  good,  but  should 
;il\vays  be  guarded.  JJesides  the  increased  risk  of  septic  infection,  the  state  of 
the  mother's  health  may  materially  atfei-t  the  progin.,sls.  If  there  has  been 
serious  orgaidc  disease,  the  chances  of  recovery  will  be  lessened.  For  the  I'hild, 
the  more  inunature  it  is,  the  worse  is  the  prognosis;  between  the  thirty-second 
and  the  thirty-sixth  week  its  teinirc  of  life  is  feeble  and  it  will  re(|uire  the 
ifrcatest  care.  The  use  of  the  incid)ator  and  artificial  feeding  greatly  improve 
the  chances  of  rearing  very  feeble  infants  (see  j).  8(i2). 

Metlioih  of  Operation. — A  great  many  methods  have  been  employed  for  the 
iiuliiction  of  labor.  Some  are  elHcient,  but  more  or  less  dangerous  ;  others  are 
safe,  but  less  ef!i(!ient.  Some  are  prompt,  and  are  most  usefid  when  speedy 
results  are  required  ;  others  are  slow,  and  are  applicable  oidy  when  time  is  not 
of  importance.  It  is  obvit)Us,  therefore,  that  no  one  method  is  applicable  to 
all  cases. 

1.  Paneturimi  the  Membranes  (\\\w\\\\  n^  l^eheeVx  }[ethod). — A  sound,  .'unll, 
or  other  pointed  instrument  is  passed  through  t'.ie  os  uteri  and  is  made  to  riip- 
tiii  the  presenting  bag  of  mendmuus.  The  liquor  anniii  drains  away  and 
uterine  action  is  set  up.  This  method  is  safe  if  the  rules  of  antisepsis  are 
observed,  and  is  most  useful  when  it  is  desired  to  relieve  uterine  tension  ;  but 
it  is  slow,  and  labor  is  apt  to  be  tedious  and  painftd  on  account  of  the  early  loss 
of  the  waters. 

2.  Intrnduetion  of  an  Elastic  Bniir/ie  into  the  Uterus  (known  as  Kr<nise\s 
Miihinl). — After  a  vaginal  douche  has  been  given  two  lingers  are  passed  up  to 
the  external  os,  and  if  possible  through  the  cervix  to  the  internal  os  ;  a  well- 
oiled  solid  bougie  (Xo.  10  or  12)  is  passed  aK)ng  the  Hngers  and  is  guided  by 
tlicm  into  the  uterine  cavity  between  the  membranes  and  the  muscular  wall 


(H 


880 


i^ 


•Hi 


AJflJRJCAX    Ti:XT-2iOOK   OF   OliSmTlUVS. 


(Fi«;.  459).  It  is  tlioii  ojontly  rotated  and  made  to  work  its  wav  sovoral  iiidios 
ni)\vard  toward  tlio  f.mdiis.  Tlio  hij-hur  it  can  bo  made  to  go,  tho  more  certain 
aiul  rapid  s.  \\\  bo  tiie  onset  of  labor.  A  light  vaginal  tampon  of  iodoform  gaiize 
1.S  then  applied  to  kooj)tlie  bougie  from  slipping  out  and  to  prevent  thoontraneo 
of  air  or  septio  matters  into  the  uterino  eavity.  U  active  labor-pains  hove  not 
begun  ill  twenty-four  hours,  the  tampon  and  the  bougie  are  removed,  a  thorou-di 


Fio.  459.— Bougie  passed  through  tho  curvix  nml  liotwocn  the  incml)rnnos  niul  tho  utoriiio  wiill,  ami 

rotainod  Iiy  a  light  vaginal  tiiniiKm. 


?, 


vaginal  douche  is  given,  and  another  bougie  is  introduced  on  tho  opposite  side 
of  the  uterus.  Ustially  one  introduction  t)f  a  bougie  suffices  to  induce  labor, 
though  sometimes  two  or  throe,  or  even  more,  nitty  bo  roqiiirod  ;  oxcoption:illv 
the  method  may  fail  altogether,  and  other  measures  will  have  to  bo  emplovtHl. 
Krauso's  method  is  the  safest  and  best  for  ordinary  purposes  when  a  speodv 
result  is  not  required,  and  it  is  the  one  in  most  coinnion  use. 

3.  Tampnuhuj  thcVitgina. — A  vaginal  tamjion  of  gauze  or  of  cotton  pledgets, 
or  a  rubber  bag  (colponryntor,  Fig.  460)  ptissed  up  to  the  cervix  and  dilated 

with  air  or  water,  is  sometimes  a  useful 
auxiliary  in  the  induction  of  labor,  but 
is  too  slow,  uncertain,  and  painful  to  be 
relied  upon  alone.  It  is  of  great  ser- 
vice in  placentii  pnevia  and  in  some 
cases  of  accidental  hemorrhage.  It  is 
useful  also  to  strongtlien  labor-pains 
which  are  growing  weak  or  to  apply 
counter-pressure  to  a  presenting  bag  of  monibranes  which  it  is  desirable  to 
keep  unruptured.  The  method  of  applying  a  tampon  has  already  been 
described. 

4.  Dilatation  of  the  Ccvvlr. — AVhen  it  is  required  to  empty  the  uterus  :is 


Kid.  Itili.— ('iil|ioiirynlor. 


rapidly  as 


possi 


ble,  it  mav  bo  necessarv  to  dilate  the  cervix  artiticiallv.     Fo 


r  a 


description  of  this  method  see  ]>age  882.     There  is  more  or  le.ss  risk  atteiuiin 
forcible  dilatation,  and  it  should  not  be  tittempted  luile.^s  the  case  is  urgent. 


5.   Intm-utcrlnc  Injection  (known  as  Cohni'x  McthotJ). — A  ,><peeial  nozzl 


('  or 


an  elastic  catheter  is  passed  between  tho  membranes  and  the  uterino  wall,  as  in 


OBSTETlilV  Sr lid  Eli  Y. 


881 


il  inclios 
13  certain 

entrance 
liino  not 
tliorouii'h 


ino  Willi,  liiul 

positc  side 
luce  labor, 
roptionally 
employed. 
I  a  speedy 

In  pledijets, 
Ind  dilated 
|es  a  iisefnl 
labor,  but 
int'ul  to  be 
iii'eat  ser- 
1(1  in  some 
\o;e.      It  IS 
abor-])ains 
!•  to  apply 
llesirable  to 
•eady  been 

I  uterus  as 
llv.  For  a 
|<  attending:; 

uri^ent. 
|l  noz/le  or 

wallas  in 


Krause's  niethod  ;  water  or  some  oflier  fluid  is  injected  tlirouj^h  the  nozzle  until 
tension  is  complained  of.  The  injected  fluid  separates  the  membranes  I'roiu 
their  uterine  attachments  and  stimulates  contraction.  The  nearer  to  the  fundus 
the  fluid  is  conveyed,  and  the  larger  the  area  of  detachment,  the  more  certain 
and  active  will  be  the  contraction.  This  method  is  eftieient  but  danj^erous ; 
several  fatal  cases  have  been  reported  from  shock  and  from  entrance  of  air  into 
il  13  uterine  veins. 

6.  Va(/inal  IrHf/at ion  (known  as  7v7/r/,s(7<'«  Method). — A  stream  of  hot  water 
(100°  to  120°  F.)  is  directed  against  the  cervix  for  ten  or  iifteen  minutes  at  a 
time  every  two  or  three  hours  until  labor-pains  set  in.  Some  obstetricians  use 
cold  water,  while  others  follow  the  hot  douche  immediately  with  a  cold  douche 
tor  the  purpose  of  obtainiuo;  a  more  stimidating  effect.  This  metho<l  is  tedious, 
painfid,  and  uncertain,  and  it  involves  risk  of  congestion  and  metritis.  A  iiot 
(louche  se(!ms  occasionally  to  augment  the  action  of  other  measures,  but  the 
cold  douche  is  apt  to  do  harm,  and  is  not  to  be  recommended  for  general  use, 

7.  Elcctriciti/. — The  mild  faradic  current  is  said  to  be  sometimes  very  effec- 
tive. The  negative  pole  is  applied  to  the  cervix  in  the  posterior  vaginal  cul- 
de-sac,  while  the  j)ositive  pole  is  |)laccd  over  the  sacrinn  or  the  lund)ar  vertebra\ 
This  method  has  not  come  into  general  use,  although  it  has  recently  attracted 
some  attention  ;  it  is  worthy  of  trial. 

8.  AKpirofioii  of  the  llfentu  per  Vaf/iunm, — When  ordinary  means  fail  and 
the  case  is  very  i)ressing,  the  uterus  may  be  punctured  and  the  liquor  amnii 
aspirated.  Two  fingers  are  passed  into  the  vagina  and  the  most  prominent  por- 
tion of  the  corpus  uteri  is  located.  The  aspirator-needle  is  then  passed  along 
the  fingers  and  made  to  enter  the  uterine  wall  at  right  angles.  After  the 
liquor  anniii  has  been  aspirated  the  needle  is  withdrawn  and  uterine  contraction 
closes  the  puncture. 

9.  lujcvtion  of  Gli/cerin  (known  as  Pchcr'x  Method.) — A  special  nozzle  or  a 
flexible  catheter  is  passed  through  the  os  internr.Mi  as  in  the  Krause  method, 
and  half  an  ounc-  of  pure  asepti'  glvierin  is  s'owly  injected  between  the 
membranes  and  the  uterine  wall.  Some  operator,  then  apply  a  tampon  to 
the  cervix  to  prevent  the  escape  of  the  glycerin.  I'elzer  first  used  100 
t'libic  centimeters  (3.}  ounces)  of  glycerin  ;  he  now  prefers  a  smaller  (jtiantity 
(;)0  to  50  cubic  centimet  rs)  and  rejieats  the  injection  if  the  first  is  unsiic- 
eesstul.  He  explains  tin  action  of  glycerin  as  an  exciter  <-f  uterine  con- 
traction in  three  ways:  (1)  By  mechanical  separation  oi' the  membranes; 
(2)  by  a  direct  irritant  efl'ect  on  the  uterine  nnicous  men.brane,  as  in  like 
manner  recital  glycerin  injections  set  up  muscular  contracilons  which  persist 
as  tenesmus  after  the  bowel  has  been  emptied  coin})let(  ly  ;  and  (.">)  by  the 
allinity  of  glycerin  for  \,ater,  the  licpior  amnii  being  drawn  tluv-.iigh  the 
Muinbranes,  causing  more  or  less  collapse.  1'  '  cr  does  not  use  glycerin  in 
eclampsia  or  in  placenta  pnevia  uide^s  llu  attachment  is  lateral  and  the 
iiijeetion  can  be  made  without  injuring  the  plaii'r'.ia.  Some  operators  claim 
('(|iially  good  results  from  tamponing  he  "crviv  wiili  pledgets  of  absorbent 
cotton    soaked   i.'i    glycerin.       Pfannenstiel    hold     that    I'clzer's    method    is 

56 


^^^' 


882 


AMERICAN    TEXT- ROOK   OF   ORSTETRICS. 


dangerous,  because  several  cases  have  been  reported  in  wliich  glycerin  produced 
nephritis.  The  method  is  still  on  trial ;  it  has  been  warndy  advocated  by 
some  obstetricians  and  severely  criticised  by  others.  The  data  are  not  vet 
sufficient  to  warrant  a  positive  conclusion.  Personally  the  writer  has  exjic- 
rienced  most  difficulty  in  securing  the  retention  of  the  glycerin  long  enough 
to  produce  any  decided  effect. 

As  the  operation  of  induction  of  abortion  or  of  premature  labor  always 
involves  more  or  less  risk,  it  is  advisable  to  obtain  the  advice  and  support  of  a 
colleague  in  consultation.  Moreover,  there  often  crop  uj)  certain  moral  and 
religious  questions  which  the  physician  should  not  attempt  to  settle,  but  should 
leave  to  the  decision  of  the  family  and  its  religious  advisers.  There  have 
been  employed  for  the  induction  of  labor  many  other  methods  which  do  not 
merit  serious  considei'ation  here. 

Artificial  Dilatation  of  the  Os  Uteri. — Labor  may  be  delayed  by  the 
rigidity  of  the  cervix  or  the  external  os,  and  it  may  be  found  necessary  to 
dilate  artificially  in  order  to  overconie  the  obstruction.  Similar  measures  mav 
be  required  when  the  condition  of  mother  or  child  compels  immediate  deliverv 
and  the  cervix  is  not  sufficiently  dilated  to  permit  the  use  of  forceps  or  other 
instruments.  The  dilators  most  com- 
nioidy  used  for  this  jjurpose  are  either 
hard  or  soft.  The  hard  dilators  are 
made  of  metal  or  of  vulcanite ;  the 
soft  dilators  are  various  patterns  of 
rubber  bags  'which  are  introduced 
into  the  cervix  collapsed  and  are 
then  distended  with  air  or  witli 
water.      In  Germany  Hegar's  dila- 


o 


^ 


Fi(i.  4t>l.— IIoKnr's  liilntors. 


Fio.  'KVJ.— Actiuil  calibre  of  Ili'K'ur's  diliitors, 
Nos.  8  uiul  14,  showing  tliu  miiount  of  ililiiliitloii 
produced. 


tors  are  much  used  (Fig.  ^Gl).  They  are  made  of  vulcanite,  of  polished 
steel,  or  of  aluminum,  and  graduated  from  No.  1  to  No.  44  or  upward 
(Fig.  462).  The  smaller  sizes  can  be  passed  through  the  cervix  as  easily 
as  an  ordinary  uterine  sound  ;  the  larger  produce  sufficient  dilatation  to 
permit  the  application  of  force|)s  or  the  introduction  of  one  of  the  larger 
rubber  bags.*  The  patient  is  placed  across  the  bed  in  the  dorsal  position. 
with  limbs  everted  and  feet  supported  on  a  couple  of  chairs.  The  vagiiiii 
is  thort)Ughly  douched  out,  the  anterior  and  posterior  lips  of  the  cervix  :iiv 
steadied  with  volselhe,  and  the  fundus  is  pressed  well  down  and  sunported 
by  an  assistant.  The  dilators,  having  been  made  aseptic  and  v/ell  o'.l'd,  arc 
passed  in,  one  after  another,  oeginning  with  the  smaller  niJiMjers.  It  is  nfteii 
*  The  circumference  of  No.  44  is  14  cciitinieters  (about  5/  ini'lu'^J. 


Jl 


oducod 
itetl  by 
not  yet 
i  expo- 
euough 

always 
)ort  of  a 
n-al  and 
it  should 
ei'e  have 
I  do  not 

d  by  the 
pessary  to 
;ures  n<av 
e  delivorv 
s  or  othei' 


ir's   (li\atiirs. 
(if  ililiiliiti""! 


i)t'  polislit'd 
|or  upward 

as  easily 
llatation  to 
the  larjier 
\\  position, 
'he  vajriiiii 
cervix  :irf 
support  CI  1 
ll   ;hi"d.  :nv 
It   is  nlti'll 


m 


OBSTETRIC  SURGER  V. 


883 


possible  to  dilate  the  cervix  sufficiently  in  half  an  hour  or  an  hour,  especially 
if  the  patient  has  been  anesthetized.     A  speculum  is  seldom  required.     In 


Fio.  163.— Six-branched  dilator. 


France  a  six-branched  metal  dilator  (Fig.  463)  or  Tarnier's  uterine  dilator 
(Fig.  464)  is  preferred.*     The  latter  instrument  consists  of  two  blades  which 


Fi(i.  464.— Tarnii'r's  uterine  dilator. 


are  introduced  like  forceps-blades,  locked,  and  then  kept  separated  by  means 
of  a  rubber  ring  slipped  over  the  end  of  the  handles.  The  elastic  pressure  of 
the  rubber  gradually  overcomes  the  resistance  of  the  cervix,  while  the  presence 
of  the  instrument  stimulates  uterine  contraction  in  a  reflex  manner. 


»«*M«imniWi 


Fio.  465.— Barnes's  bag. 


Fiii.  inc.— McLean's  model  of  H. 


sbaR. 


The  siofl-rubber  dilators  are  of  various  kinds.     Barnes's  fiddle-shaped  bags 
;Fig.  4<.?5),  which  are  made  in  three  sizes,  are  introduced  by  means  of  a  sound. 


Fiu.  467.— Cbampetier  do  Ribes's  \n\^:  A,  inlluted  ;  H,  folded  for  iiitroiliiction  into  the  uterus. 

McLean's  modification  (Fig.  466)  is  folded  up  as  small  as  possible  and  pas.<ed 

ui  the  rervix  in  the  grasp  of  a  ])air  of  uterine  forceps.     When  once  fairly  in 

place  the  bag  is  gradually  inflated  with  air  or  with  water  until  the  required 

tlilatatiou  is   secured.     Tarnier's  dilator  (Fig.  468),  consisting  of  a  rubber 

*  Honnaire  pivos  a  full  deMoription  of  this  instruincnt,  its  mode  of  application,  its  action, 
and  its  efli^cts  in  the  Archiven  </<■  Tncoloyie  rl  ik  (h/iierolngii',  181)1,  pp.  778,  881. 


f 


f.fl  " 


« 


884 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


T 


tube  terniinatiug  at  one  end  in  a  dilatable  ball,  is  introduced  by  means  of  a 
special  sound.  When  properly  placed  the  sound  is  withdrawn  and  water  is 
pumped  into  the  tube  by  means  of  a  syringe  fitting  into  the  mouth-piece. 
The  best  of  the  soft  dilators  is  that  of  Champetier  de  Ribes  (Fig.  4G7). 

The  bag  is  made  of  silk  covered  with 
rubber,  and  when  distended  it  forms 
an  inverted  cone  8  centimeters  (;5| 
inches)  in  diameter  at  its  base.  Tiic 
silk  prevents  bursting  of  the  bag — a  se- 
rious objection  to  the  other  soft  dilators. 
The  bag,  folded  as  small  as  ix)ssible, 
well  oiled,  and  grasped  between  the 
blades  of  an  ajiplicator  (Fig,  467,  b),  is 
slowly  pushed  through  the  cervix  until 
half  of  it  has  passed  within  the  internal 
OS.  The  applicator  is  then  relaxed, 
but  is  not  removed  until  the  bau  has 
been  pumped  half  fuii  of  warm  water 
to  ensure  its  retention.  The  applicator 
is  then  withdrawn,  and  the  batr  is 
slowly  pumjied  full  and  left  in  situ.  It 
acts  as  an  artificial  bag  of  membi-aues 
and  produces  safe  and  easy  dilatation. 
Uterine  action  may  further  be  stimu- 
lated by  making  traction  upon  the  bag 
during  a  pain.  The  bag  also  prevents 
injurious  pressure  of  the  presenting  part  upon  flu;  matei-nal  passages.  Before 
the  bag  can  be  introduced  the  os  must  be  dilated  sufficiently  to  allow  one  finger 
to  pass  easily.  It  may  be  necessary  to  dilate  to  this  extent  with  the  finger  or 
with  Hegar's  dilators.  A  similar  dilatation  may  be  required  when  Barnes's 
bags  or  other  soft  dilators  are  used.  It  is  not  essential  for  the  membranes 
to  be  ru])tured  before  the  bag  is  introduced,  though  it  is  generally  safer  and 
better  if  they  have  been  naturally  or  artilicially  ruptured.  Champetier  de 
Ribes's  bag  is  a  more  powerful  dilator  than  that  of  Barnes  or  Tarnier,  aiitl  is 
also  less  liable  to  be  displaced.  Besides  its  use  in  placenta  pnevia  and  in  the 
artificial  induction  of  labor  it  has  been  found  of  great  value  in  the  treatment 
of  a(.'ci(lental  hemorrhage,  i)rolapse  of  the  funis,  shoulder  presentation  with 
pr()laj)se  of  an  arm,  and  too  early  rupture  of  the  membranes  in  slightly  cdM- 
tracted  ])elves.  The  objections  urged  against  it  are  that  it  may  dis])hu'e  the 
presenting  ])art  or  rupture  the  lower  uterine  segment  if  it  is  nmeh  thinned 
out ;  but  if  care  is  taken  that  the  bag  be  not  too  suddenly  or  too  forcibly  dis- 
tended, such  accidents  should  not  occur. 

The  Forceps. — So  far  back  as  the  time  of  Hippocrates  it  was  reconi- 
mended  in  certain  difficult  cases  of  labor  to  seize  the  child's  head  with  the 
liands  and  pull  it  down.     This  procedure  was  practically  inijwssible  until  the 


Fig.  468.  -Tarnier's  uterine  dilator  in  situ  :  the 
Img  is  round  in  shape,  but  is  couipresseij  by  tlie 
iutra-uterine  tension. 


OBSTETRIC  SURGERY 


885 


1 

T 

■ 

aus  of  a 

water  is 

th-pieco. 

g.  467). 

•ed  witli 

it  lonns 

tevrt    (oj 

se.     The 

ig — a  se- 

:  dilators, 
possible, 

ween  the 

167,  r),  is 

rs'ix  until 

c  internal 

I    relaxed, 

e  bag  lias 

irm  water 

applicator 

le    bag   is 

'n  situ.    It 

uenibranes 

dilatation, 
be  stinui- 

on  the  bag 

o  prevents 

s.     lleiore 

one  tinger 

lie  finger  or 
n  Barnes's 
neinbranes 
\-  safer  and 
nipetier  <le 
|nier,  and  is 
and  in  the 
treatment 
tation  with 
ightly  eon- 
lisplaee  the 
c'h   thiniud 
[oreibly  di^- 

kvas  reconi- 
Id  with  the 
lo  until  the 


Fio.  469.— Forceps  of  Davis. 


Km.  470,— Forceps  of  Simpson. 


Fio.  471.— Forceps  of  Barnes. 


ra 


Fig.  472.— Forceps  of  Sawyer. 


Fi(i.  47S.— Forceps  of  White. 


Ficj.  47J.— Forceps  of  Hodge. 


Fig.  47.">.— Forceps  of  Dubois. 


Fig.  47t).— Forceps  of  Wallace. 


II 


Ml 


\i 


836 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


Fig.  477.— Forceps  of  I'ajot. 


Fig.  478.— Forceps  of  Xuugele. 


Fig.  479.-Forceps  of  Elliott. 


'L 


Flo.  480.— Forceps  of  Lazariewich 
(straight). 


Il^i 


•\  I 


i- 


Fio.  481.— Axis-traction 
forceps  of  Tarnier  (to 
siiow  tlie  details  the  hand 
is  represented  in  an  im- 
proper position  for  trac- 
tion ;  below  is  one  of  the 
traction-rods). 


Fio.  482.~Lusk'8  modification 
of  the  Tarnier  forceps  (the  trac- 
tion-rods are  shown  ''■ce  from  the 
catches  that  hold  th  mi  durinp;  ap- 
plication of  the  blades  and  ready 
for  attachment  of  the  tractor). 


OBHTETRW  S  UR  QER  Y. 


887 


I       ii 


Fig.  483.— Axis-traction    forceps   of 
Simpson. 


gelo. 


lott. 


Fig.  484.— Axis-traction  forceps  of 
llreus  (the  rofls  having  the  right- 
iiiigled  bend  are  against  the  shiiiik 
when  application  is  made). 


azariewieh 


Fig.  485.— Axis-traction  forceps  of 
Poullet  (tapes  nin  through  eyes  in  blades 
and  through  ring  on  traction  shunk,  and 
fastened  to  a  cross-bar). 


Axis-traction 
Tarnier  <to 
etails  the  hand 
ited  in  an  iiu- 
ition  for  trac- 
is  one  of  the 
ds). 


Fig.  486.— Axis-traction  forceps 
modified  by  Jewett  (after  Milne- 
Murray's  specifications,  with  details 
of  lock). 


modificftticiii 

2eps  (the  trac- 

<".ee  from  the 

>m  during  ap- 

des  and  ready 

le  tractor). 


T 
T 


888 


AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


invention  of  the  lbr(;ei)s  supplied  tlie  obstetrieian  with  an  instrument  capahlc! 
of  being  applied  to  the  liead  while  still  in  the  parturient  euual,  and  of  exerting  an 
amount  of  tractile  force  greater  than  that  of  the  unaided  hand.  Although  the 
use  of  forceps  in  obstetrics  was  mentioned  by  Aviceniia  (980-H);J0)  and  subse- 
quently by  other  writers,  it  was  not  until  the  middle  of  the  seventeenth  century 
that  the  modern  fon-eps  was  invented.  The  gradual  development  and  jjerfecting 
of  the  instrument  from  the  time  of  the  Chamberlens  to  the  present  dav  make 
an  interesting  and  instructive  chapter  in  the  history  of  medicine.  Spnci;  docs 
not  permit  a  consideration  of  the  historical  side  of  the  subject,  nor  a  descrip- 
tion of  the  numerous  mo<lels  which  have  been  constructed,  with  their  relative 
merits  and  demerits;  it  must  suffice  to  point  out  the  essential  points  of  a  good 
forceps  and  to  indicate  those  models  which  are  in  most  common  use.  No  forceps 
is  perfect  or  is  equally  adapted  to  all  cases,  and  if  a  physician  provides  himself 
with  only  one  pair,  he  should  be  careful  to  select  a  moilel  which  will  be  gener- 
ally useful,  even  though  it  may  be  inferior  for  certain  special  cases.  More- 
over, he  must  use  his  forceps  intelligently,  knowing  its  limitations  as  well  as 
its  advantages,  if  he  would  minimize  the  risk  of  disappointment  and  failure. 

The  obstetric  forceps  consists  essentially  of  two  arms  or  branches,  curved  on 
the  side  so  as  to  grasp  the  fetal  head,  articulated  to  maintain  their  hold,  and 
provided  with  handles  to  facilitate  traction.  All  forceps  have  this  cephalic 
curve.  The  blades  are  usually  fenestrated,  to  make  them  lighter  and  to  give  a 
better  grip  of  the  head  with  less  compression.  The  wider  the  fenestration  the 
firmer  the  grasp.  In  the;  Davis  forceps  (Fig.  -169)  great  care  has  been  taken  to 
adapt  the  cephalic  curvi'  accurately  to  the  contour  of  the  head,  and  this  cui-ve 
has  been  adopted  by  Wallace  (Fig.  476),  Sawyer  (Fig.  472),  and  others  in  the 
construction  of  the  instruments  which  bear  their  name.  Most  modern  forceps 
have  a  second  curve  (pelvic),  to  accommodate  the  instrument  to  the  siiape  of  the 
j)elvigenital  canal  and  to  enable  it  to  grasp  the  head  firndy  when  situated  at  or 
just  below  the  brim  of  the  pelvis.  Such  instruments  are  sometimes  called 
"double-curved"  forceps.  The  pelvic  curve  is  usually  greater  in  French  than 
in  English  and  American  instruments.  Those  possessing  a  marked  pelvic  curve 
are  more  suitable  for  high  operations;  those  with  moderate  curve  are  more  suit- 
able for  the  low  and  medium  operations,  as  they  are  less  likely  to  interfere  with 
natural  rotation. 

When  the  branches  cross  each  other  like  scissors,  they  articulate  at  the 
jui  "on  of  blade  and  handle;  when  they  are  parallel,  as  in  the  Asselini 
forceps,  they  articulate  at  the  extremity  of  the  handles.  In  some  varie- 
ties the  blade  is  joined  to  the  handle  by  a  shaidv,  which  gives  solMity  to 
the  instrument  and  diminishes  the  elastic  spring  of  the  blades.  The  articula- 
tion is  in  the  form  either  of  the  open  English  lock  (Fig.  487)  or  of  the  more 
complicated  French  mortise  and  tenon,  tightened  by  means  of  a  screw  to  j)i'e- 
vent  the  blades  from  disarticulating  (Fig.  487).  In  some  forceps  there  is  a 
fixed  tenon  on  one  branch  and  a  mortise  on  the  other,  but  no  screw  to  lix  the 
joint.  For  general  use  the  English  lock  is  preferable.  The  handles  may  iu' 
quite  plain,  or  be  serrated,  grooved,  or  roughened,  to  give  a  better  hold.     Sf)iiie 


e  I 


capalile 
■rtinj;  ail 
ougli  tlio 
1(1  subsc- 
1  century 
erfoctiiig 
ay  make 
)a(!0  does 
descrip- 
•  rolativo 
)t"  a  good 
so  forceps 
s  himscll" 
he  gcnor- 
!.     More- 
s  well  as 
failure, 
curved  on 
hold,  and 
s  cephalic 
1  to  give  a 
tration  the 
m  taken  to 
[this  curve 
lers  in  the 
rn  forceps 
lape  of  the 
ated  at  or 
ines  called 
•ench  than 
vie  curve 
more  suit- 
■rfere  with 

ate  at  the 
e  Asselini 
me  varie- 
Bol'dity  to 
articulii- 
the  more 
c\v  to  pi-e- 
therc  is  a 
to  Hx  the 
lies  may  he 
Id.     Some 


»^ 


OJiSTETRW  SmOERY. 


880 


Fio.  4«7.-English  (A)  nud  French  (B) 
locks. 


have  a  ring  in  tiie  shank  (IJarnes's,  Fig.  471),  or  projecting  shoulders  (Simp- 
son's, Fig.  470)  to  facilitate  traction.  Forceps,  whetlier  single-eurvetl  or  double- 
i  iirved,  are  either  long  or  f^hort.  The  short  forceps  is  usually  from  22.r)  to  2>) 
centimeters  (9  to  10  inches)  in  length,  the  long  forceps  from  32.6  to  40  centi- 
meters (13  to  16  inches) ;  Tarnier's  axis-traction 
torceps  is  about  45  centimeters  (18  inches)  long. 
The  short  forcejis  is  now  very  little  used  ;  it  is 
a  relatively  feeble  ii  trument,  adapted  only  for 
tlie  low  operation,  and  has  no  spe(;ial  advantages 
over  the  longer  instrument,  wliich  is  equally  fit- 
ted for  high,  low,  and  medium  operations.  Saw- 
yer's is  the  best  model  of  the  short  forceps. 

Jn  recent  years  much  attention  has  been  paid 
to  oxis-fradion — that  is,  traction  in  the  axis  of 
the  parturient  canal.  Whenever  traction  is  not 
in  the  right  direction,  a  certain  amount  of  the  tractile  force  is  wasted  against 
tiie  pelvic  walls,  and  the  maternal  soft  parts  are  apt  to  be  injured.  The  fetal 
head,  too,  is  subjected  to  more  compression,  since  a  greater  amount  of  tractile 
i'orce  is  re(piire<l  to  etfect  delivery.  The  best  axis-traction  forceps  is  that  of 
Tarnier  (Fig.  481),  either  the  French  model  or  Lusk's  modification  (Fig.  482). 
The  Breus  forceps,  so  much  used  in  Germany,  is  lighter  and  less  clumsy,  hut 
not  so  powerful  as  that  of  Tarnier.  Simpson  added  axis-traction  rods  to  the 
ordinary  Simpson  forceps  (Fig.  483),  and  tractoi-s  have  been  contrivetl  for  most 
of  the  well-known  long  double-curved  instruments.  Stevenson  fits  a  blunt-hook 
tractor  to  the  lock  of  the  ordinary  forceps  and  thus  makes  axis-traction.  Poulet 
aeeomplishes  the  same  result  by  means  of  cords  passed  through  holes  drilled  in 
tiie  cephalic  portions  of  the  blades  (Fig.  48.")).  The  axis-traction  forceps  is  use- 
ful in  the  high  operation,  but  is  unnecessary  and  cumbrous  in  the  low  opera- 
tion ;  the  higher  the  head  the  more  useful  will  this  kind  of  forceps  be  found. 

A  good  forceps  should  be  made  of  well-temi)ered  steel ;  the  blades  should  be 
well  polished  and  nickel-plated,  and  heavy  enough  to  be  firm  without  too  much 
spring.  The  cephalic  portion  should  be  comparatively  light  and  the  shanks 
strong,  the  edges  of  the  blades  and  the  fenestne  being  rounded  and  smooth. 
The  fenestra?  should  be  of  uKKlerate  width  (from  IJ  to  1>,  inches);  the  tips  of 
tiie  blades  should  be  from  1.3  to  2.5  centimeters  (h  to  1  inch)  apart  when 
closed,  the  greatest  distance  b(!t\veen  the  blades  in  the  cejihalic  portion  being 
from  0.3  to  7.5  centimeters  (2|  to  3  inches).  The  blades  should  lock  easily  ; 
the  handles  should  be  of  metal,  smooth,  and  provided  with  a  convenient  shoul- 
der for  traction.  Wooden  handles,  complicated  locks,  and  compression-screws 
should  be  avoided,  and  the  instrument  should  be  so  constructed  that  it  can 
easily  and  thoroughly  be  rendered  aseptic.  In  England  the  fiivorite  forceps  is 
that  of  Simpson  or  of  Barnes,  or  the  Simpson-liarnes,  which  has  the  Barnes 
hlade  and  the  Simpson  handle.  Jn  America  the  Simpson  (Fig.  470),  Barnes 
(Fig.  471),  Hodge  (Fig.  474),  Wallace  (Fig.  47(5),  White  (Fig.  473),  and 
Sawyer  forceps  are  extensively  used.    In  France  some  modification  of  the  orig- 


'^ 


I  h 


890 


AMERICAN   TEXT-BOOK    OF   OBNTETBIVS. 


inal  Lcvrot  is  used,  such  as  the  Dubois  (Fijr.  470),  l>.,j„t  (Fig.  477),  or  Stoltz 
forceps;  for  axis-traction  the  Tariiier  forceps  (Fig.  481)  is  the  favorite,  thoiigii 
many  prefer  the  simpler  Poulet  (Fig.  48r)).  In  Germany  the  Nacgele  (Fig. 
478)  or  liraun's  mo<lification  of  the  Simpson  forceps  seems  to  l)e  in  coimuonest 
use;  for  axis-traction  the  Brens  (Fig.  484)  and  the  Simpson  (Fig.  48;})  models 
are  preferred  to  that  of  Tarnier.  Generally  speaking,  those  obstetricians  \vi»o 
follow  the  English  method,  and  apply  the  forcej>s  to  the  sides  of  the  pelvis  re- 
gardless of  the  position  of  the  fetal  head,  use  the  Simpson  or  the  Jiarnes  for- 
ee[)S  or  some  moditicatiou  of  them ;  while  those  who  follow  liandelocciue  and 
use  the  Continental  method,  applying  the  forcei)s  to  the  sides  of  tlu;  child's 
head  regardless  of  its  position  in  the  pelvis,  prefer  the  Continental  model  of 
forceps,  which  is  usually  a  modifieatit)n  of  that  of  Levret. 

Action  of  the  Forceps. — The  obstetric  forceps  may  act  in  four  diflfbrent  ways: 
(1 )  As  a  tractor,  (2)  as  a  comprcasor,  (.'})  as  a  lever,  and  (4)  as  a  rotator. 

1.  Tractor. — Traction  supplements  a  deficient  via-a-tergo  by  sufficient  rw-(/- 
fronte  to  effect  delivery,  or  ivplacies  it  altogether  if  the  driving  power  of  the 
uterus  has  become  exhausted.  The  amount  of  fon*  applied  is  under  the  con- 
trol of  the  operator;  it  may  be  much  or  little,  continuous  or  intermittent, 
according  to  the  necessities  of  the  case.  During  traction  there  is  always  a  cer- 
tain amount  of  compression  and  leverage,  and  usually  more  or  less  rotation. 
The  forceps,  tlierefore,  cannot  be  used  as  a  tractor  only,  but  becomes  a  lever,  a 
compressor,  or  a  rotator  of  greater  or  lesser  power  according  to  the  amount  and 
direction  of  tractile  fon^e  employed.  To  be  a  good  tractor  the  forceps  must 
have  a  good  grasp  of  the  head,  and  the  blades  must  not  slip  or  spring  apart 
when  traction  is  made.  To  effect  delivery  with  a  minimum  of  force,  traction 
must  be  made  in  the  axis  of  the  parturient  canal. 

2.  Compressor. — In  normal  labor  the  head  is  elongated  and  moulded  as 
it  descends  by  the  resistiuice  of  the  pelvis  and  the  soft  parts.  During  forceps 
delivery  a  similar  compression  and  moulding  take  ])lace.  While  the  head  is 
being  pulled  thrt)Ugh  the  resistant  canal  it  dilates  the  passages  as  it  advances 
and  at  the  same  time  is  compressed  by  them.  When  traction  is  a|)plied  com- 
pression begins ;  when  traction  is  stopped  compression  ceases.  The  amount 
of  compression  is  dire(!tly  proportional  to  the  amount  of  tractile  Ibrce  employed. 
As  undue  compression  imperils  the  child's  life,  it  is  obvious  that  too  much  tractile 
force  is  dangerous  for  the  child  and  should  therefore  be  avoided.  Long-continued 
comjH'ession  is  more  apt  to  be  injurious  than  intermittent  compression,  and  a 
child  may  safely  bear  a  greater  amount  of  compression  applied  intermittently 
than  if  it  is  applied  continuously.  It  is  evident,  therefore,  that  in  the  interests 
of  the  child  traction  should  be  gentle  and  intermittent,  not  forcible  and  contin- 
uous. Compression  also  may  be  made  by  the  direct  action  of  the  blades.  When 
the  handles  are  long,  as  in  the  French  forceps,  the  head  can  be  compressed 
powerfully  by  forcibly  pressing  the  handles  together,  since  the  leverage  is  good ; 
but  when  the  handles  are  short,  as  in  the  English  instruments,  there  is  little 
leverage,  and  consequently  only  feeble  compression.  Some  forceps  are  iittal 
with  a  screw  by  which  the  blades  can  be  brought  together  so  forcibly  as  to  ex- 


OBSTETRIC  SVRGKIi  Y. 


891 


)r  Stoltz 
,  tlu)U}:;li 

iniuoiH'st 
i)  iiuuli'ls 
iaiis  wlio 
pelvis  ro- 
inu's  I'or- 
»c(iiu'  and 
10  cliild's 
iihkIi!!  of 

ent  ways : 

;ieut  r'lx-ii- 
t'or  of  the 

r  tlu!  COM- 

terniitteiit, 
vays  a  cer- 
s  rotation. 
■i  u  lover,  a 
mount  and 
rcops  must 
>rinn;  apart 
w,  traction 

iionldod  as 
njj;  forceps 
;he  head  is 
t  advances 
died  coni- 
he  anionnt 
eniployetl. 
iioh  tractile 
continued 
sion,  and  a 
ermittently 
bo  interests 
iind  contin- 
les.    When 
leoni  pressed 
kge  is  ifood : 
■e  is  little 
are  fittcnl 
V  as  to  ex- 


ler 


I'rt  powerful  compression  upon  the  head.  Such  contrivances  are  daufferous,  and 
^liould  be  used  only  in  exceptional  (uses.  The  forceps  is  chiefly  and  primarily 
I  tractor,  not  a  cephalotribe.  It  is  usually  stated  that  the  head  may  be  com- 
pressed from  .6  to  1.3  centimeters  {\  to  \  inch)  without  danger;  however,  this 
lannot  be  taken  as  an  invariable  rule,  since  a  great  deal  depends  uj)on  the 
degree  of  ossifieatiou  and  mouldability  of  the  head,  as  well  as  upon  the 
rapidity  and  continuousncss  of  the  compression. 

3.  Lever. — The  usefulness  or  the  harndulness  of  the  lever  action  depends 
upon  what  constitutes  the  fulcrum.  If  the  instrument  be  swayed  violently  from 
side  to  side,  pivoting  first  upon  one  side  of  the  pelvis  and  then  upon  the  other, 
delivery  may  be  ettected  rapidly,  but  the  maternal  soft  parts  will  surely  be 
bruised  between  the  forceps-blades  and  the  pelvis;  but  if  the  fortiops  be  used 
as  a  double  lever,  lus  recommended  by  Barnes,  each  branch  being  made  to  act 
alternately  as  a  fulcrum  for  the  other,  a  gentle  oscillating  movement  of  the 
licad  will  be  produced,  and  less  tractile  force  will  be  re(pnred  than  if  a  straight 
pull  be  employed.  A  box  or  a  barrel  may  more  easily  and  safely  be  nn)ved 
along  a  narrow  passage  by  tilting  or  canting  it  from  side  to  side  :  so,  too,  the 
ll'tal  head  may  be  drawn  through  the  narrow  curved  parturient  canal  more 
easily  and  safely  by  a  gentle  to-and-l"ro  lever  movement  than  by  a  straight, 
steady  pull.  It  is  important  to  remember  that  this  pendulum  movement  must 
not  be  used  alone,  but  always  while  traction  is  being  made;  it  is  nieant  to  sup- 
plement traction,  not  to  replace  it.  Some  o|M;rators  use  the  forceps  as  a  lever  of 
tlio  first  or  third  order.  I'ajot  frecjuently  adopted  this  plan  ;  Dr.  A.  H.  Smith 
of  Philadelphia  for  many  years  taught  and  practised  a  sinular  method,  using 
one  hand  as  a  fulcrum  at  the  lock.  Considerable  strength  and  dexterity  are 
i'('(|nired  to  use  the  forceps  in  this  way,  and  there  is  always  danger  of  the  blades 
pivoting  uj)on  tho  under  surface  of  the  symphysis  ov  the  arch  and  injuring  the 
soft  parts. 

4.  Rotator. — If  there  be  used  a  good  model  which  has  not  too  great  a  pel- 
vic curve,  and  if  traction  be  made  properly,  the  head  should  rotate  in  tho  nor- 
mal way  as  it  descends.  If  the  handles  bo  hold  too  firndy,  the  head  is  apt  to 
he  dragged  straight  through  without  rotation ;  but  if  traction  be  made  upon 
the  shoulder  or  the  ring  of  the  instrument  at  the  level  of  the  lock,  the  handles 
lu'ing  left  comparatively  free  -uid  not  tightly  grasped  by  the  hand.  1.  forceps 
will  seldom  interfere  with  t'io  natural  mechanism  of  rotation.  In  'i..  one  case 
tiio  forceps  determines  t'",e  way  in  which  the  head  shall  descend  ;  in  the  other 
case  the  head  descends  according  to  the  natural  mechanism  and  carries  the 
forceps  along  with  it.  Some  operators  use  the  forceps  to  rotate  the  head  arti- 
ficially for  the  purpose  of  correcting  faulty  positions.  Such  a  practice  is  dan- 
gerous, and  should  not  be  attempted  by  any  one  who  is  not  sure  of  his  diagnosis, 
IHissessed  of  wide  exjxM'ience,  and  expert  in  obstetric;  manipulation.  It  is 
^f(  iierally  safer  to  allow  the  head  to  rotate  naturally  as  it  descends ;  but  if  arti- 
ficial rotation  is  to  be  done,  tho  straight  forceps  should  be  used  in  preference 
to  the  double-curved  instrument  (see  p.  \i^(S). 

Indications. — The  forceps  may  be  applied  to  the  presenting  head,  tho  after- 


ii    * 


r. 


I 

rili; 


fv 


892 


AAf/:/i/(A\  Ti:.\r-iiOftK  in-   tuisri/nncs. 


r  1 1  . 


V-:i 


H-. 


forniiijr  hriul,  or  \\\i\  hrnrli.      Ff  lh»-  JikuI  Ih  |m'H«'iitinj;,  it  wlioiild   I 
in  fli<-  [xlvJM,  \\  shoiild  U;  <»('  iif»rriiiil  finriiK-Hrt  and  |»ro|Hirtl(tn;it 
parfiiricnt  fjinal,  and  tlifrr;  must  Iw  tn.  nicrlianifid  olrHtiidc  t<.  dd 


H'  '•n^.'ai'fi 


*'  111  MIZi-  f(i  the 


tatin^  tlic  iH<;  of  jjn-at  fiirff  to  ov<noni<'  it.     'I'lic  nu-rnl 


I  very  in:<'«s-i- 


»rancs  ^tlionld   Ik-  riin- 


tiir«;d  and  tlic  oh  should   U-  dilat«'<l  or  dilatal)I<-.     Tin-  o|MTation  is  indicated 

fl)  In   liiif^friiif;  lalxtr  when  tlif  natural  effort 


s  arc   iinalilf  to  i 


\W\ 


oelivrv 


CI)  wl 


icn  Hpccdy  <lcli very  is   ini|K!rativ«'  in  the  interest  of  the  mother 


as   IP 


hemorrhage,  eonviilsion-,  exiiaiisf ion,  advanced  cardiac  or  |nilmoiiarv  disea->e 
etc.  ;  (.'{)  when  s|M-ed\-  delivery  is  indicated  in  the  inteiof  *,f  the  rrhild,  as  in 
impendini;  death  of  the  mf»ther  or  threafeiiinj;  asphyxia  of  th<!  child. 

Thr  <}i,f:inHini. — Kver  .since  tlie  days  of  Smellie  aiifl  Ii<fvret  thftre  has  Ikch 
a  keen  controversy  respecfiiifr  the  he«t  metlio<l  of  applyinir  the  forceps.  Kniellic 
formulated  the  rule  that  the  hiades  should  always  Ix-  applied  to  the  .sides  of  the 
child's  head,  sr>  that  it  may  he  ^'ra-ped  in  the  hipaiirtal  diameter,  l/vrrt 
adopted  Smellie'-  rule.  Saxtorph  »if  I)emriarl<  f  1  7  10-IM()(»(,  a  pupil  r>f  .Sme||i,. 
criticised  tliis  metliod,  anti  adv(K»ited  the  appli»-atioii  of  the  l)la<les  Xo  the  .>^i(|es 
of  the  pelvis,  rej^ardless  of  the  pr)sitioii  of  the  child's  head.  Ffe  arj^ued  that 
the  iH'lvic  «'urve  was  added  to  accommo«lale  the  forceps  to  the  natural  curve 
of  til'-  pelvis,  and  that  its  maximum  advantage  is  ol)t:iinai)le  onlv  when  the  two 
curves  exactly  coinr-ide.  ;Viy  diverf^en<'e  hetween  them  is  accompanied  hy  lo«-, 
of  advantai^e  from  the  (wlvic  curv(!.  flis  tear'hini.f  had  many  follr)werH  until 
l>au<l'loc(pie's  powerful  advfK'acy  of  the  old  .Smellie  method  re-estaijlislied  i 
a-'  the  rule  of  practice  on  the  (-'ontinent.  fii  Kiii^land,  llamshotham,  Simpson, 
aiKJ  r»arue-  have  done  rniir-h  to  aholi-h  (he  use  of  short  forceps;  a-  tln-e 
instriirncnt-    have    <li^appeare<l    Smellie's    nietlifKl    has    ^'one    too,    and    Sax- 


torttli 


pli  s  rule   IS   now  (generally  adopt<'d 


It 


IS  very  curious 


that. 


aithoii(.'|i 


ajiplication  of  the  hiades  to  the  -ides  of  the  head  ori(.'iuated  in  Kiiirhiiid,  it  liiis 
heeti  replnccd  in  that  country  liy  the  old  ("ontiiieutal  m<tliod  of  appJirnnriM  to 
the  .-ides  of  the  pelvis;  wliile  on  flic  Continent  the  old  Saxtorph  method  lia- 
heen  ahandoiied  for  the  r)rifriiial  Smellie  rnetho<l  of  applicsition  to  the  side-  of 
the  head.  .At  the  pivsent  day,  therefr)re,  we  find  two  di-tiiict  metlirxls  in  u-e. 
oiif!  adopted  l>y  the  Kii^di-h,  the  other  hy  the  (,'oiitiiieiital  school.  The  Kiiirli-li 
appiv  the  hiades  to  the  sides  of  thr*  pelvi-i,  reirardle—  of  the  liea<l  ;  ( 'ontiiieutal 
ol).-tetricians  apply  them  to  the  sides  of  the  head,  re^Mnlle-s  of  the  pelvis. 
The  Knirlish  method  is  simjiler,  ea.-ier,  and  less  likely  to  injure  tlicr  maternal 
pa.s.saj.'es  ;  tli(!  Continental  method  is  more  complicated  and  diflicult,  hut  le-- 
likelv  to  injure  the  child's  head.  On  the  whole,  it  is.saflirand  hetfer  for  heL'in- 
ner-  to  Ii  irii  and  pract;  'c  the  l'iii<,dish  method  ;  when  they  hecoine  rnon;  ex|xri- 
enced  and  expert  thev  mav  sometimes   find  the  (Vintinental  method  prefeniile. 


The  f: 


"orceps  ofwration   is  divided    into  the 


hiffh,  tl 


le  rruflliiin,  and  the 


operation.  Ft  is  called  /ilf/fi  when  the  head  is  at  fir  in  the  hrim,  i)iit  h,'i-  im/ 
vet  de.sceiided  into  the  excavation  ;  i/irtlliini,  when  the  head  has  passed  tli'- 
hrim  and  entered  the  excavation,  hut  has  not  yet  comedown  upon  the  pelvic 
f|f)or;  loir,  when  the  head  is  pre^sinj^  upon  the  floor  and  pres«'iitiii(.' at  theoiitl'f. 
When  we  say  that  tli(;  h<ad  is  at  or  in,  hut  not  through,  the,  hrim,  we  mean  thai 


irrnr-* 


UllSTETIlK '  SIKdl'Ji  >'. 


«5)r} 


ic  rnat<  riiMl 


its  wifict  pliiiD'  ftlif  liipiirit'tiil)  i■^  iit  or  in  liif  |il:iii)'  iif,  luit  \\n^  imt  v«'t.  (mHscd 
fliroii^li,  til*'  iiriiii.  'i'lic  lii;.'li)'r  tlic  IiokI  the  mon-  tlifli'iilt  iiiul  (liiii^croiH  tlx' 
iIMTiitioii.  'I'Ik;  low  (i|MTiitioii  is  ijcin'rjilly  cnsy  iiiid  Hafi-  lor  hotli  iMutlitr  iui'l 
'liilfl  ;  tlif  fiiifliiiiii  i-i  li;inl<r,  lull  not  ii-iially  fldiii^croiis  \u  citlur;  \\\i-  \\'\]r\\ 
u|i(  ration  i-.  (lilliiiilt  and  ilan^troii-,  ami  ■^lioiild  Ix'  att('rM|iti'd  unlv  in  rxccn- 
tional  ciiM-ri.  Tlu!  tMidciicy  of  modern  practice  is  to  limit  v<rv  mM<'li  tlw  field 
of  ilie  Iii(_r|i  o|Miaiioii.  I'inard  inwi^tH  very  stroni^ly  tlial  l"ore(|M  should  not 
lie  nsed  to  r.venome  osseous  resistance,  wlietlier  at  the  hrim  or  at  the  outlet. 
Version  and  synipliy-iolonty  are  then  ■^at'er  alternativf's.  '['he  method  of 
ipplyint^  forceps  in  the  low  and  medium  o|«"rations  is  practicallv  the  -ame, 
itrid  will   he  deMril)ed   fnvt. 

I'nxitloii. —  In  Kn^land  it  is  customary  to  confine  in  the  left  lateral  position; 
cin  tin-  (-'ontinent  and  in  America  th(t  dorsal  position  is  i^erirra I ly  preferred.  In 
the  latter  position  the  l)la<les  are  more  easily  applied  ;  in  the  forfner  extraction 
is  easier  and  safer.  A  very  j^riod  plan  i^  to  comhine  thr-  advantat^rs  of  hnth 
positions  liy  applying  the  hiades  in  the  dr)r.«al  |)osition  and  then  tinning  the 
patient   into  the  left   lateral  position  for  delivery. 

flinrriil  I'lC/KirnH'iiix. —  IJefore  hc^imiini^  th«' operation  the  l)la<lder  and  the 
rectum  >honld  always  he  r-rnptied,  the  va(.'ina  sho  Id  he  donched  thoroii^rhlv 
with  a  hot  antiseptic  solution,  and  the  vidva  should  can-fully  he  washed  and 
-eruhhed.  '{'he  opirator's  han«l.s,  the  in-truments,  and  cverythinij;  which  may 
conic  in  r'r)ntact  with  the  parturient  canal  shouM,  of  coin>e,  he  made  a-eplic. 
Luhricants  are  umi(!ces,suy  if  the  hands  and  the  instruments  are  dipped  in  a 
'  icolin  solution  ;  soap  is  pr<'feral)le  to  oil  or  va-<liu  il  creolin  is  not  at  hand. 
It  is  well  to  provide  jilenty  of  hoiled  water,  hoth  hot  and  cold,  and  to  jilace 
within  C'asv  reach  u  l)a>iu  of  warm  wat<'r  for  rinsing  the  hands,  and  another  of 
creolin  for  u-e  duritiy;  the  (tpcration,  as  well  as  jute  or  ahsorlient  cotton  to  cleanse 
til"'  vidva,  perineum,  and  amis.  'I'he  hed  should  he  protected  with  a  clean 
iiiackinlosh  -hect,  and  a  siiilaMc  receptacle  should  he  arran^'cd  to  catcii  tlut 
(li-char<res.  .Anesthesia  should  always  he  iiscd  unless  specially  contra-iiidicaled, 
for  it  not  on  I  v  saves  the  patient  much  |)ain,  hut  also  makes  the  operation  casifsr 
iiiid  diminishes  the  risk  of  injury  to  the  |)arturient  canal  ;  if  po-T^il)|e,  the  maii- 
iii.'r'mr'nt  of  the  anesthetic  should  he  entrusted  to  a  com|)ctent  assistant. 

Ofurdfi'iii  III  till'  l)(iix(il  /'iixiflfiii. — The  patient  is  placed  acro-s  the  hed, 
with  the  hr'ad  supporte<l  on  a  pillow,  the  hips  well  over  the  cd^rc  of  the  hed, 
llie  tiiij^hs  evert«:d,  ami  the  feet  rc-tiu(f  on  a  cf)Uple  of  chairs.  Some  operators 
prefl^T  placinj;  the  patir-nt  in  the  lithotomy  position,  the  knee-,  hein<,'  ^uppf)rtc<l 
and  steadied  hv  a  couple  of  assistants.  The  operator  sits  in  front  of  the  patient, 
hetween  the  everted  thitrh-.  The  lower  Made  of  the  forceps  is  pjissid  first  into 
thr'  left  side  of  the  |)elvis,  then  the  upper  hiaile  is  passed  into  the  ri<:ht  side; 
when  i)rr)|K'rly  adjii-ted,  the  hiades  are  locked  and  extraction  is  hcjrun.  To 
introduce  a  forceps-hladc  properly  hoth  hand-  are  ii-ed,  one  to  pa-s  the  liladr-, 
the  other  to  ^Miidc  it  up  to  and  around  thr-  head,  'i'lic  /i,in ,■  hlade  is  passr-d  hy 
the  /(ft  hand  into  the  /r/f  side  of  the  jiclvis,  while  the  finjrers  of  the  ri^dit  hand 
f.'iiide  it  internally  ;   the  '//>/>o'  hlade  is  pas-ed  hy  the  rif//il  hand  into  the  ri;//if. 


• 


894 


AMl'JIilVAjy    TKXT-llOOK   OF   OBSTETRIVS. 


side  of  the  pelvis,  while  the  fiiifrers  of  the  left  hand  guide  it  internally.  To 
make  sure  of  the  proper  blade,  it  is  always  well,  before  introduciufr  the  blades, 
to  loek  them  and  hold  them  with  the  pelvie  curve  looking  upward,  and  then 


^/ 


I''i(i.  ISK  — Mftliixl  111' livlitly  KiiispiiiK  mill  placing  tliu  Idwit  hliuU'  for  iippliciitioii ;  the  iirriiw  .sliuws  the 
lire  liiUowi'il  hy  the  Imiiilk'  us  the  liliiilc  passes  upwanl. 

seleet  the  lower  blade.     The  lower  i»lade,  i)eak  upward,  is  held  lightly  in  tlie 
left  hand,  with  the  knuckles  up,  the  tlunnb  U|)on  the  flat  of  the  handle,  and 


\''"* 


■"•V 


x 


\ 


^"^  ■  ^  ■     dab 


Flo.  489.— BcKinnini;  application  nf  llic  si'cdikI  or  upper  blade.    Tin-  liamlle  fullnws  the  ilireitimi  nf  tin 
iirriiw  to  reaeh  tlie  pii.sitloii  shown  faintly  near  the  lirst  blade  in  plaee. 

four  fingers  upon  the  outer  ])ortion,  as  shown  in  Figure  488.  \o  force  is 
needed  to  pass  the  blade  ;  it  is  slipped  along  the  lingers  of  the  internal  IimihI, 
and  is  guided  by  them  around  the  convexity  of  the  head;  the  handle  is  tlicii 


•ow  ssliows  tlu' 


OBSTETRIC  sums  E It  Y. 


895 


>\vopt  downward  along;  the  internal  surface  of  the  mother's  left  thif^h,  and  the 
blade  passes  easily  into  [wsition  between  the  head  and  the  left  lateral  wall  of 
the  ])elvis.  Then  the  upper  blade,  held  in  the  rifjjht  hand  in  sinnlar  fashion, 
Is  passed  alonj?  the  finp;crs  of  the  left  hand,  well  u|)  around  the  head-globe,  and 
I  lie  handle  is  swept  downward  along  the  mother's  right  tliigh  into  its  proper 
position  in  the  right  side  of  the  pelvis  ( Fig.  489).  If  the  pelvic  curve  of  the  in- 
>trument  corresjurnds  witii  that  of  the  jx-lvis,  the  handles  should  be  horizontal, 
looking  one  to  (he  right  thigh  and  the  other  to  the  left.  The  handles  are  then 
depressed,  and  by  gentle  manipulations  are  maneuvred  into  Io(;king  without 
the  exercise  of  any  force.  Care  should  always  he  taken  not  to  include?  hair  or 
the  labia  in  the  bite  of  the  lock.  When  the  blades  h)ck  easily,  it  is  usuallv 
(unsidered  that  the  case  is  suitable   for   the  forceps  operation.     The    proper 


,  Axis  of  Met 
\  and  of  traction 
\  with  head  at  irim. 


Kkj.  liKl.— Axis  (if  tnirtion  in  tlic  liitili  (ipiTiiliiiii  corrcBpoiMUnK  with  tlic  nxis  nf  llio  iiilrl.  Iiinctinn 
'if  till'  tnictiiin,  lis  tlu'  fiiri'liuiid  cschiil'S,  Is  iifiirly  at  ri^'lit  iiiihIl'S  to  i\\v  liniK  iixis  (if  llic  iiiiitliii's  lioily. 
Thr  iirniw  fullciwN  the  course  tiikoii  liy  the  end  of  the  ImiKlle. 

ninuagement  of  the  internal  hand  greatly  facilitates  the  introduction  of  the 
liladcs  ;  in  fact,  much  of  the  difficulty  experienced  by  bcgiiuicrs  in  introducing 
the  blades  is  '';i.is(kI  by  failure  to  use  the  internal  hand  properly.  To  guide 
tli((  lower  blade  into  position,  two  fingers  of  the  right  hand  should  be  ])asscd 
along  the  left  lateral  wall  of  the  vagina  into  the  cervix  and  be  ptishcd  up  as 
high  as  possible  U])on  the  left  side  (tf  the  presenting  head-globe;  then,  with  the 
liiiger-tips  ])ivoting  U|)on  the  head,  the  bacik  of  the  Hugcrs  and  the  hand  should 
!)(■  made  to  press  the  cervix,  vagina,  and  vulva  as  fin  as  ))ossible  toward  the  left. 
Tlic  forceps-l)lade  can  then  casilv  be  slipped  along  the  palmar  aspect  of  the 
fiii'_n'rs  wt^ll   uj)  ov«'r  the  convexity,  when(!e  it  glich's  aromid  the  head  without 


1 

m 

i 

:. 

;i 

896 


AMERICAN    TEXT- BO  OK   OF   OBSTETRICS. 


,  'Sli 


difficulty  and  with  little  or  no  expenditure  of  force.  The  commonest  error  is 
the  failure  to  pass  the  fingers  of  the  internal  hand  far  enough  and  to  press  the 
cervix  and  vagina  sufficiently  to  the  left.  In  passing  the  upper  blade  (Fig. 
489)  the  fingers  of  the  left  hand  are  passed  into  the  cervix  in  a  similar  man- 
ner, and  the  lateral  walls  are  pressetl  as  far  as  possible  toward  the  right.     In 


Fig.  491.— Low  forceps  application;  side  view  of  tlio  application  of  the  second  blade:  1,  blade  started; 

II.,  blade  in  jiosition  and  forceps  locked. 

the  low  operation,  if  the  head  has  emerged  from  the  uterus  and  the  cervix  has 
retracted,  the  introduction  of  the  blades  is  much  easier,  as  the  cervix  need  no 
longer  be  considered  (Fig.  491). 

After  the  blades  have  been  locked  slight  traction  should  be  made,  to  det(>r- 
mine  whether  the  head  is  firmly  seized  by  the  forceps,  and  whether  any  portion 


Fii;.  Iit2.— Horizontal  traction  on  a  head  whieli  is  beRiniiint,'  to  distend  the  pelvic  floor,  the  (iccipiil  lieiiit; 

under  the  pubic  iircli. 

of  the  cervix  or  membranes  has  been  included  in  its  grasp.  Extraction  is  tlicn 
effected  by  pulling  steadily  or  with  a  .slight  ijcndulum  movement  in  the  axis 
of  the  pelvi(!  canal.  Some  authorities  utterly  condemn  the  ])endulum  niovc- 
ment,  and  insist  that  the  straight  pull  is  always  .safer  (Fig.  492).  In  the  high 
operation  the  handles  must  be  pressed  back  against  the  perineum  as  iar  as 


!f    i 


bliulB  started ; 


OlhSTETIiW  SUIiaEE Y. 


897 


possible  (Fig.  490),  to  make  the  line  of  traction  correspond  with  the  axis  of 
the  brim  ;  as  the  head  descends  the  traction  becomes  horizontal  (J^\^.  492), 
and  is  finally  directed  npward  (Fig.  493)  as  the  head  distends  the  perineum 
and  emerges  from  the  vulva.  In  the 
medium  and  low  operations  the  line  of 
traction  is  not  so  far  backward.  If 
the  pains  are  strong,  traction  should  be 
made  during  a  pain  and  intermitted 
during  the  interval ;  but  if  the  pains 
are  feeble  or  absent,  traction  should  be 
made  for  a  minute  or  two  and  then  be 
stopped,  so  as  to  avoid  the  dangers  of 
too  forcible  compression  of  the  fetal 
head  and  too  rapid  dilatation  of  the 
parturient  canal.  To(»  speedy  delivery 
endangers  the  child's  life  and  exjxises 
the  mother  to  the  risks  of  laceration 
and  hemorriiage.  In  the  high  and 
medium  ojx'rations  it  is  a  good  jdan  to 
keep  the  left  index  finger  upon  the  pre- 
senting part  during  traction  (Fig.  494), 
to  determine  whether  traction  is  being 
iiKule  in  the  right  direction  and  whether 
the  head    is   descending   and    rotating 

properly  or    is  being  too   forcibly  com]>ressed.      If  the  head    rotates   as   it 
(Icscends,  the  fbrce|>s  will  rotate  along  with  it,  and  the  handles  will  turn  fron» 


l''i(i.  4'.il?.— I'pwiinl  Inictidii  wluii  tlu'  occiiait 
has  pussL'd  tlie  pubic  urcli  and  tliu  polvic  Hour 
is  on  tilt'  stri'lcli. 


w ' 

p 

. 

.     ,l 

(iccipul  licing 


Fic.  ■ISM.— I'iniitT  tli'tcrniininn  diri'ftion  of  tniction  niui  amount  of  rotation  and  descent. 

the  horizontal   position  into  the  ol)li(|Ue  or  the  antero-posterior ;    the  blades 
."^liould  be  unlocked    and    readjusted    before  the  antero-posterior  diameter   is 
ri;«' !ied,  or  injurious  pressure  may  be  made  upon  the  vestibule  and  urethra 
67 


m 


mn  V 


898 


AMERICAN   TKXT-BOOK   OF   OBSTETItJVS. 


ill  front  or  the  periiuMiiii  and  rcftiim  heliind.     Soniotinios  the  blades  require  to 
be  readjusted  several  times  before  delivery  is  eoiiipleted. 

i^lion/d  flic  hiadex  he  removed  hefore  (he  head  is  completelif  driieeredj'  Opinions 
are  divided  on  this  point.  Those  who  favor  non-removal  elaiin  that  the  foreeps 
gives  the  operator  greater  control  over  the  head  as  it  comes  through  the  vulva, 
and  enables  him  t(»  Hex  or  extend  it  at  pleasure,  or  hold  it  back  if  a  viohiiit 
pain  drives  it  down  too  suddenly  upon  an  insufficiently  dilated  perineum. 
Those  who  favor  the  removal  of  the  blades  claim  that  thereby  a  certain  amount 
of  room  is  gained,  and  the  vulva  does  not  need  to  be  so  much  distended  to  permit 
the  passage  of  the  head  ;  moreover,  the  head  can  more  safely  be  piloted  beneath 
the  pubic  arch  by  the  hand  than  by  the  forceps.  Upon  the  whole,  better 
results  arc  obtainable  if  the  blades  Ix;  removed  when  the  head  has  descended 
sufficiently  to  bring  the  «'liin  to  the  tip  of  the  coccyx.  They  should  be  re- 
moved slowly  during  an  interval  between  the  pains,  and  in  the  reverse  direc- 
tion from  that  in  which  they  were  introduced. 

In  forceps  operations,  when  the  head  descends  in  the  transverse  diameter 
and  does  not  rotate  forward,  the  blades  should  always  be  removed  as  soon  as 
the  head  reaches  the  muscular  pelvic  floor.  Non-rotation  is  apt  to  occur  in 
flat  or  funnel-shaped  ])elves,  or  when  the  fetal  head  is  large  and  the  occiput 
wide.  Ill  such  cases  the  head  may  become  impacted  in  the  pelvic  outlet, 
whence  it  cannot  be  dislodged  by  the  natural  efforts,  and  the  child  may  perish, 
or  the  maternal  passages  may  slough  from  pressure  if  the  application  of  forceps 
be  too  long  delayed.  Before  resorting  to  forceps,  however,  the  patient  should 
be  anesthetized  and  an  attempt  made  to  rotate  the  head  by  means  of  two 
fingers  passed  up  behind  the  ear  which  lies  close  to  the  .symphysis,  as  recom- 
mended by  Tarnicr.  This  maiKUivre  will  probably  fail  in  cases  of  contracted 
pelvis.  Care  having  been  taken  to  promote  flexion,  the  forceps-blades  should 
be  apj)lied  to  the  sides  of  the  j)elvis  and  traction  made  until  the  head  reatlics 
the  muscular  floor,  when  they  should  be  removed.  The  head  can  then  he 
rotated  by  means  of  two  Angers  placed  on  the  posterior  fontanelle,  the  f()relK'ad 
being  jinvscd  backward  by  two  fingers  of  the  other  hand.  If  the  head  he 
dragged  through  the  outlet  in  the  transverse  diameter,  extensive  laceration 
will  certainly  take  j)lace.  Some  operators  prefer  the  oblique  application  of 
the  forcej)s  ;  others  attempt  to  rotate  the  hetid  by  means  of  the  forceps.  Tiie 
latter  ])ractice  is  dangerous  and  should  ho.  avoided  if  possible. 

T/ie  High  Openifiou. — Opinions  are  divided  as  to  the  indications  for  the 
high  operation.  Some  operators  claim  that  in  certain  emergencies  the  forceps 
mav  be  used  even  if  the  head  is  not  yet  engaged  in  the  brim;  others  hold  ihe 
operation  to  be  unjustifiable  until  tlie  head  is  well  engagctl  ;  while  others, 
again,  insist  that  the  largest  diameter  of  the  head  shall  have  passed  the  lnim 
before  fi)rcei)s  can  safely  be  applied.  There  can  be  very  little  question  of  ihe 
great  danger  to  both  mother  and  child  if  the  head  is  nt)t  well  engaged  in  ihc 
brim;  under  such  circnmstances  version  is  safer  and  better.  But  when  tiie  liead 
is  well  engaged  and  there  is  no  (lisproj)ortion  between  it  and  the  pelvis,  iiiid 
the  OS  is  fairly  dilated  or  dilatable,  there  need  bo  no  serious  risk  to  the  moll  id' 


Xhf 


OBSTETRIC  SURGER  V. 


899 


or  tlic  ohild.  The  chief  (lim<>;ci' to  the  child  is  from  comprossioii  duriii«;  the 
proh)ii<fc>d  and  somctinu's  forcible  traction  which  may  be  required  to  overcome 
the  resistance  of  the  maternal  soft  parts.  The  ilanger  to  the  mother  is  from 
laceration  and  brnisin<>;  of  the  lower  uterine  seijjment,  the  cervix,  and  the  vaj^ina 
duriiifi;  extraction.  However  opinions  may  ditfer  as  to  the  proper  way  of  apply- 
ing the  blades  in  the  medium  and  low  operations,  there  can  be  no  doubt  that  in 
high  operations  it  is  best  to  apply  them  to  the  sides  of  the  pelvis  without 
regard  to  the  position  of  the  child's  head.  As  the  head  usually  engages  in  the 
brim  either  in  the  transverse  or  the  oblique  diameter,  it  will  be  grasped  by  the 
forceps  antero-posteriorly  or  obliquely.      If  antero-postcriorly,  one  blade  will 


!  V 


ri 


f  18 


Fi(i.  ■!',•■).— Dinjinim  slKuvinn  tlio  ri^tit  iii'.il  wmii};  mttluids  of  puUini;  mi  tlio  Imndlc-lnir,  nr.il  that  the  line 
ol  traction  is  dirertly  in  tlu'  axis  iif  tlio  inlot  (nmcli  nuidiiicd  liDni  Kibi'inont). 

he  over  the  forehead  ;uid  the  otiier  over  the  occiput ;  if  ol)li(|UeIy,  one  will  be 
(tver  a  parietal  protuberance  and  the  other  over  the  opposite  coronal  sutiu'e. 
During  traction  the  forceps  is  liable  to  slip  ami  to  wound  the  soft  [)arts  unless 
tlie  handles  are  well  compressed  ;  or  the  Hexion  of  tiie  head  may  be  imptiired 
and  extraction  be  made  more  difficult.  It  is  of  tiie  utmost  importance  that  trac- 
tion should  be  made  in  the  axis  of  tlie  pelvis  to  minimize  the  amount  of  traction 
torco  employed.  The  axis-traction  forceps  has  been  devised  for  this  purpose. 
W\\\\  the  ordinary  forceps  more  or  less  force  is  wasted  against  the  symphysis, 
witii  the  residt  that  the  maternal  tissues  are  bruised  and  the  fetal  head  is  need- 
lessly (compressed.  A  glance  ;;t  Figure  41)5  will  show  the  advantiige  of  axis- 
tvaction  at  the  brim  and  tli(>  impossibility  of  securing  it  with  the  ordinary 
t'oiccps.     Another  great  ctmse  of  tlifficulty  and  dangi'r  in  the  high  operation  i.s 


% 


|s. 


f\ 


n 


901 


AMERWAN   TEXT-BOOK   OF   OBSTETIUCS. 


the  .'mperft'ct  ililatiition  of  the  os  and  the  resistance  offered  by  the  cervix.  If 
the  operator  attempts  to  overcome  this  by  sheer  force,  he  will  most  probablv 
need  to  use  an  amount  of  traction  that  will  prove  dangerous  to  mother  and 
ciiild.  It  is  better  to  overcome  cervical  resistanc-e  by  artificial  dilatation  before 
the  forceps  is  applied  than  by  main  force  afterward.  If  there  is  no  time  for 
artificial  dilatation,  the  cervix  should  be  incised ;  accouchevient  force  is  now 
rarely  justifiable.  IJy  the  use  of  axis-traction  forceps  and  artificial  dilatation 
of  the  cervix  the  high-forceps  operation  may  be  shorn  of  its  (;hief  dangers. 
Extraction  should  not  be  hurried,  but  jdenty  of  time  should  be  allowed  for  the 
moulding  of  the  head  and  the  dilatation  of  the  soft  parts.  The  axis-traction 
forceps  offers  no  advantages  at  the  pelvic  outlet,  while  it  takes  up  more  room  ; 
nuiiiy  oj)crators  remove  it  when  the  head  comes  tlown  upon  the  perineum,  and 
complete  the  delivery  with  a  lighter  and  less  bulky  instrument. 

In  (kcipUo-poHtvnor  PonitioiiK. — When  the  occiput  is  directed  posteriorly, 
the  case  should  be  left  to  nature  so  long  as  possible,  in  the  hope  that  forward 
rotation  may  take  place.  Some  authorities  rcconunend  in  such  cases  the;  use 
of  forceps  to  turn  the  occiput  forcibly  to  the  front.  Such  a  maneuvrc  rarely 
succeeds  ;  it  is  capable,  moreover,  of  seriously  injuring  the  child  by  rotating 
the  head  upon  the  trunk  more  than  it  is  safe  to  do.  liut  if  the  natural  efforts 
fail,  or  there  is  need  for  speedy  delivery,  the  forceps  may  be  applied  and  simpler 
traction  be  made.  Natural  rotation  may  still  take  place,  but  if  it  does  not  the 
head  may  safely  bo  delivered   in  the  occipito-posterior  position.     The  blades 


Kill,  lilfi.— Forceps  extriictidii  in  jHTsisti'iit  orri)!-  Fig.  4il7.— Over-distontioii  (if  the   piTiiiciiiii 

itii-piistcrior  iMisitiiiii :  .\,  iiiitiiil  liiii' of  Inu'tion ;  H,        In   piTsistunt  occipitopo.storior  cluliverii's;   tin' 
(linclioii  in  wliicli  Ibnupsliiindlcs  are  lifted;  (',  di-       nosi'  rests  under  the  pubie  arch, 
rcction  of  force|>s,  after  occiput  has  esca])e(l,  In  order 
to  deliver  the  face. 

are  applied  as  in  the  ordinary  low  operation,  and  they  adapt  themselves  usuallv 
to  the  sides  of  the  child's  head,  since  the  long  diameter  is  nearly  or  (piite  in  the 
antero-posterior  diameter  of  the  jH'lvis.  In  using  traction  the  natural  nieeli- 
anisin  of  delivery  in  this  position  should  be  borne  in  mind  and  the  forceps  he 
u.sed  merely  to  tiid  nature.  The  head  becomes  arrested  in  the  pelvis  because  it 
has  undergone  extension;  therefore, as  IJarnes  a])tly  puts  it,  the  essential  tliiiio- 
to  do  is  to  get  the  occi|)ut  down — that  is,  to  restore  Hex  ion. 

Traction  is  made  downward  or  hori/ontally  until  the  forehead  emerges  siil- 
ficiently  for  the  root  of  the  nose  to  pivot  beneath  the  pubic  arch  (Figs.  liKi. 
497);  the  handles  are  then  raised  in  order  to  roll  the  occiput  out  over  tlie 


I 


i 


onsTKTiiic  smn/:/!  v 


901 


])orinouni,  and  tliov  arc  tlicn  finally  doprosscd  ti)  deliver  tlie  face  and  tlie  chin 
bencatli  tlu'  piibes.  If  u])\vard  traction  is  made  too  soon,  the  blades  will  be 
apt  to  slip  off.  Extraction  should  not  be  hurried,  but  plenty  of  time  should 
be  allowed  for  the  inouldinjjf  of  the  head  and  the  dilatation  of  the  perineum. 
The  bulky  (>'.'eiput  distends  the  jierineum  more  than  does  the  foi-ehead  in 
oceipito-anterior  deliveries  (Fig.  4t)7) ;  hence  more  time  should  be  given  the 
])erineum  to  stretch,  and  special  precautions  should  be  taken  against  rupture. 
With  proper  care  and  attention  forceps  delivery  in  occipito-posterior  ]>ositions 
sliould  not  be  much  more  diilieult  or  dangerous  than  in  ordinary  low 
•  )l)erations  (see  also  p.  453). 

In  Brow  and  Face  PreHrntafiouti. — Brow  presentations  usually  flex  into 
vertex  or  extend  into  face  presentations  as  the  head  descends  into  the  ])elvis. 
Forceps  should  not  be  applied  early  in  face  presentations,  but  amj)le  time  should 
be  allowed  for  the  natural  mechanism  of  forward  rotation  of  the  chin.  When 
the  face  is  presenting  at  the  brim,  vei-sion  is  preferable  to  forceps,  if  manipula- 
tion has  failed  to  convert  the  face  presentation  into  one  of  the  vertex.  When 
the  face  is  descending  transversely,  forceps  slioidd  not  he  used,  for  traction 
woukl  be  (hmgerous  from  pressiu'e  on  the  neck  and  thorax.  When  the  chin  is 
pointing  posteriorly  the  forceps  is  contra-indicated  ;  but  if  the  chin  has  r(»tated 
anteriorly  and  the  natural  efforts  are  insnflicient  to  complete  delivery,  the  for- 
ceps may  be  used  with  advantage.  The  blades  should  be  ap|)Iicd  as  nearly  as 
])ossil)le  to  the  sides  of  the  child's  head,  and  far  enough  i)aek  to  give  a  good 
grasp  of  the  occiput  (Fig.  49(S). 
Traction  is  made  downward  until 
the  chin  has  been  brought  fairly 
under  the  pubic  arch ;  it  is  then 
directed  gradually  forward,  and 
finally  ni)ward,  as  the  forehead  and 
oceipjit  sweep  out  over  the  ]>eri- 
neum.  J)elivery  should  be  slow 
after  ])i voting  takes  place,  because 
the  perineum  becjomes  enormously 
distended  and  is  ai)t  to  tear  deeplv.  Fi.i.4ns,-F,.rco,.s  oxtmotio.,  in  a  fa,..-  i-nsmta- 

'  _  '    •  tion  :  tlif  ('lull  lias  imsscil  tlu'  arcli,  iiml  a|i|iiars  at 

8onie  operators  use  the  forceps  to  tiu' vulva,  wiiiiu  tiio  luco  is  stiiidi.sioiuiing  the  poivic 
correct  faulty  jiositlons  and  to  rotate  "'""^' 
the  chin  forcibly  to  the  front.  Occa- 
sionally such  manipulations  may  succeed,  but  they  are  always  fraught  with 
danger.  If  an  early  diagnosis  is  made  by  external  palpation,  there  is  lu  good 
reason  why  a  face  presentation  should  not  be  conveited  in'o  a  vertex  one  by 
external  manipulation  if  the  patient  be  deeply  anesthetized  ;  l)Ul  if  rectification 
is  impossible,  version  is  usually  easy,  and  is  far  preferable  to  a  forceps  operation. 
If  labor  has  gone  on  for  some  time,  and  the  head  is  too  low  down  for  rectifi- 
cation or  version,  the  claims  of  symphysiotomy  should  be  considered.  In  such 
ii  case,  if  the  symphysis  be  divided  the  faulty  position  can  be  rectified  and  the 
lu'ad  be  <lelivered  with  less  traction,  and  therefore  less  comi)ression,  while  the 


i      1 

:  i 

I 


fi 


M 


ii': 


M 


902 


AMJ'JhWiA.y    Ti:XT-JiO()K   OF   OliSTETIUCS. 


i;i 


i  -ft  •! 


niatcriial  soft  parts  ai'o  less  cxjioscd  to  sorious  l)nii>ihg  and  laceration. 
Kxternal  palpation,  external  ••;rtiii('ation  of  I'aulty  positions,  and  tiie  modern 
symphysiotomy  have  jjjreatly  altered  the  old  ideas  respecting  forceps  operations 
anil  have  vastly  improved  the  resnlts  (see  also  p.  402). 

In  Jhrcch  I'rexeiitafioiix. —  In  certain  dilticult  hreccli  presentations,  vhcn  it 
is  impossible  to  brinu;  down  a  foot,  the  forceps  sometimes  succeeds.  When  the 
lind)s  jM'e  exten«led  and  the  feet  are  on  a  level  witii  tlie  shoulders  {^nindc  f/cs 
/*r,s'sc.s)  the  forceps  proves  particularly  serviceable.  Tarnier's  axis-traction 
forceps  sxives  a  better  hold  than  the  ordinary  forceps  and  is  less  liable  to  slip, 
since  it  enables  traction  to  be  made  more  certainly  in  the  pelvic  axis.     The 

blades  shoidd  be  ap- 
plied over  the  tro- 
chanteric or  bisiliac 
diameter,  in  order 
that  the  pelvis  may 
be  trrasped  as  nearly 
as  possible  trans- 
versely (Fiji".  "JT.s, 
p.  47!>).  If  api)lic(l 
otherwise,  tli(>  blades 
are  apt  to  slip,  cans- 
ins;^  injury  to  the  fetal 
abdomen  and  n'cni- 
tals.  Traction  should 
always  be  made  »;en- 
tly  and  in  the  pelvic 
axis;  the  pendulum 
movement  is  to  be 
avoided,  Care  should 
j    also  be  taken  not  to 

"     compress    the    blades 
Fu!.  499.— Forceps  cxtractionof  the  iif[or-<M)inlii);  lioiitl:  tho  arrows  show      ^^^^   forciblv    for    fear 
till' (liroctioii  of  tructidU.  _•  ' 

of  fracturinu;  the  iliac 
bones.  The  forceps,  properly  applied,  will  injure  the  child  far  less  than  the 
Hllet  or  the  blunt-hook  (sec  also  p,  478). 

To  the  Aftcr-comuKj  llvdd. —  In  breech  cases,  when  there  is  difficulty  in 
deliverinj^  the  head  (piickly  enou<>;h  to  save  the  child's  life,  the  forceps  is  some- 
times of  j!;reat  use  as  a  dcniicr  rcusorf.  In  such  cases  it  is  a  (piestion  whether 
the  Iiead  can  be  delivered  soon  enough  to  prevent  thcchihl  from  aspliyxiatin'j, 
not  whether  it  mi«>ht  not  possibly  be  delivered  after  a  time  by  some  oilier 
means.  When  ordinary  measures  have  failed  and  the  clnld's  life  is  in  im- 
minent danifer,  tlu'  forceps  should  be  tried.  The  old  ride  is  to  apply  the 
blades  alont;  the  child's  abdomen;  if  the  occiput  is  to  the  I'ront,  the  child'-; 
body  is  lifted  u|)  over  the  pubes  and  the  blades  are  applied  to  the  head  iVoiii 
beneath  (Fig.  49!)) ;  if  the  face  is  to  the  front,  the  child's  Innly  is  carrie.l  biiek 


(UiSTKTIilV  SC'h'C.h'h'  V 


903 


iH'iiuiiluin 


ovor  tlie  porinciim  aiul  the  bliuUs  arc  .'ipplicil  iVdiu  above.  Traction  is  iiiado 
ill  tho  direction  tliat  will  secure  speediest  delivcrv.  It  will  sonietiiues  Ik" 
luiind  more  convenient  to  reverse  tlie  ride  anil  to  apply  the  blades  aloM"-  llic 
child's  back,  especially  if  the  perineum  is  very  lon«>;  and  riuid.  The  bi'st  plan 
is  to  apply  the  blades  wherever  there  is  most  room.  The  application  of  for- 
ceps to  the  al'ter-comin<«:  head  is  the  only  means  of  savini;-  the  child  when  tho 
cervix  has  retracted  about  the  necU  antl  resists  all  cHbrts  to  deliver  bv  trac- 
tion upon  the  body. 

To  the  iSctrird  Jlcad. — When  deca))itation  has  been  performed,  it  is  some- 
times ditticult  to  deliver  tlii'  head.  If  an  assistant  brinn's  the  head  down  over 
tho  brim  and  holds  it  tirndy  there,  the  operator  can  <!;cnerally  pass  his  hand 
into  tho  uterus  and  tinido  the  blaiJes  over  tho  head  until  they  jjrasp  it  securelv. 
Care  must  be  taken  that  no  spicules  ol'  bone  protrude  to  lacerate  the  parturient 
canal  durinu;  extraction. 

Applicidion  of  Forceps  in  the  Lcft-httcrnl  Position  {Vav^W'Ax  Method). — Tho 
patient  is  placed  across  the  bed,  lying  on  her  lel't  side,  with  both  knees  drawn 


\^  fiAHt.     '       tfrt'tv 


liii.  rilK).— Apiiliciitiim  111'  till'  Idfci'iis  in  tlic  Ifft  liitcral  iMisition:  tlu'  iirmws  show  tlic  imirsi'  takun  tiy 

t'llcll    llllKil'. 

iipand  the  hips  brought  well  over  tho  right  edge  of  the  bed.  Hoth  blades  are 
jKissed  with  th(!  right  iiand,  while  tho  left  guides  them  around  the  head.  Two 
liiigersof  tho  left  hand  are  passed  along  the  posterior  wall  of  the  vagina  (Fig.  /JOO), 
tlii'ongh  the  cervix  to  tho  presenting  part,  and  are  pushed  up  as  lin- as  possible. 
\\  ith  the  finger-tips  j)ivoting  upon  the  head-gloi)e,  the  backs  of  the  fingers 
and  ilie  hack  of  tho  hand  {)rcss  back  the  cervix,  the  posterior  vaginal  wall,  and 
the  perineum  as  far  as  the  coccyx  will  permit.  The  lower  blade,  held  in  the 
right  hand  with  the  beak  d<»wnward  and  the  cephalic  curve  directed  forward,  is- 


%f 


L-  't  I' 


i  ,'4 


I 


904 


AMEIiKWX    TEXT- HOOK    OF    OliSTh'T/ilCS. 


passed  liorizoiitally  aloiiij  tlu-  jjuidinj;  fiiifrcrs  of  the  left  IiuikI  until  its  tip  is 
directi'd  over  the  ("oiivcxity  of  tlu;  lu'ad-j^lolM'.  Tlu'  iiandlc  is  then  raised  and 
carried  baekward  aloDt;  the  mother's  right  thigii,  wiiicili  luovemeiit  causes  the 
j)<)int  of  the  hlade  to  travel  around  the  »)i^/fr  surface  of  tlie  iK'ad-glohe.  Finallv 
tlie  handle  is  carried  backward  and  downward  until  the  shaidv  falls  behind  the 
operator's  left  wrist,  which  keeps  the  blade  from  shifting  during  the  ])assage  of 
the  second  blade.  An  assistant  is  not  rcfpiired  to  hold  the  first  blade,  as  in  tiie 
dorsal  operation.  The  upper  blade,  held  in  the  right  hand  in  precisely  tlie 
same  way  as  in  tlu;  dorsal  operation,  is  then  passed  hori/ontally  along  the  guid- 
ing fingers  of  the  left  hand,  above  i]w  shank  of  the  firM  bladi^,  until  the  finger- 
tips direct  it  over  the  convexity.  The  handle  is  then  lowered  and  carried 
backward  along  tiie  mother's  left  thigh  ;  this  movement  causes  the  blade  to 
travel  around  the  lijtpcr  surface  of  the  head-globe  until  it  lies  in  the  rigiit 
ilium.  The  left  hand  is  then  withdrawn  from  the  vagina,  and  a  handle  is 
seized  in  each  hand.  The  handle  of  the  first  blade  is  made  to  retrace  its  course 
a  little  until  it  lies  directly  over  the  secon<l  blade ;  with  a  little  nianeuvrinf 
the  blades  can  easily  be  locke<l  if  the  case  is  suitable  for  the  forceps  operation. 
When  the  blades  are  locked  oni^  handle  should  look  vertically  upward,  the  other 
vertically  downward.  When  extraction  is  about  to  begin  the  iiandles  are  car- 
ried well  back  against  the  j)erineum  in  order  to  make  traction  approximatelv 
in  the  axis  of  the  brim.  As  the  head  descends  the  handles  are  carried  more 
and  more  forward.  The  introduction  of  the  blades  is  somewhat  more  com- 
jdicated  than  in  the  dorsal  jwsition,  but  in  extraction  the  lateral  position  has 
the  great  advantage  of  enabling  the  operator  to  estimate  more  accurately  the 
line  of  traction,  and  to  modify  it  more  easily  as  circumstances  may  retpiire. 
During  extraction  in  the  dorsal  ])osition  the  handles  describe  a  vertical  arc  from 
below  upward  ;  in  the  lateral  position  they  describe  a  horizontal  arc  from  left 
to  right. 

The  amount  of  tractile  force  can  better  be  graded,  and  the  line  of  traction 
can  more  easily  be  kept  in  the  pelvic  axis,  when  the  operator  is  pulling 
around  the  horizontal  arc  of  the  lateral  jiosition  than  when  pulling  at  a  disad- 
vantage around  the  vertical  arc  of  the  dorsal  position.  As  the  tendency  is 
generally  to  j)ull  too  much  and  too  soon  to  the  front,  and  as  modern  beds  are 
low  and  the  patient's  jielvis  is  usually  on  a  lower  level  than  the  arms  of  the 
operator,  the  dorsal  position  is  apt  to  increase  the  tendency  to  pull  too  niiieli 
to  the  front.  A  certain  amount  of  force  is  (!onse(piently  wasted  against  the 
front  wall  of  the  ])elvis,  and  more  force  is  required  to  effect  delivery  than  it' 
the  pull  had  been  in  the  ])r()j)er  direction  ;  moreover,  the  perineum  is  more 
fully  in  view  throughout  the  operation,  and  can  more  easily  be  safeguarded, 
than  in  the  dorsal  position.  In  private  ])ractice  the  lateral  position  is  ofteii 
more  convenient,  since  a  skilled  assistant  is  not  required.  On  the  contrary, 
the  dorsal  position  permits  the  use  of  pressure  on  the  fundus  to  supplement  the 
operator's  tractile  force,  and  there  is  less  loss  of  power  from  want  of  coinci- 
dence of  the  uterine  and  pelvic  axes.  Each  method  has  its  advantages  as  wdl 
as  its  disadvantages;  in  some  cases  it  may  be  more  convenient  to  use  one,  and 


r?' 


r' 


OliSTF/ntlV  SUUUEIt  Y 


905 


s  lip  IS 

■*ih1  and 
iscrt  the 
Kiiiully 
liiiil  tlu; 

as  ill  tlie 
isoly  tilt' 
\w  ^uid- 
ii!  tiii^t'i'- 
l  carrittl 
bladt'  to 
;lio  ri^ilit 
landU;  is 
its  course 
mcuvriiii? 
operation. 
,  the  other 
>s  niH!  car- 
•oximately 
■riod  more 
nore  com- 
,>sition  has 
irately  the 
;iy  require, 
al  arc  from 
.•  from  left 

|of  traction 
is  pnUinij!; 
at  a  disad- 

Itendency  is 
•n  beds  ar(> 

Inns  of  tiie 
1  too  mncli 
aijainst  tlie 
lory  tlian  it' 
uiu  is  more 
afe;j;nardi'd, 
on   is  ofteii 
10  contrary, 
plement  the 
of  coinci- 
[iijes  as  well 
,se  one,  ami 


ill  some  the  other  method,  or  even  occasionally  to  change  from  one  to  the  other 
dnrinjjj  the  (ionrse  of  the  operation. 

Symphysiotomy  {a^j/n/'ijat^,  symphysis,  ro/trj,  a  cuttiiiff)  is  an  operation 
for  division  (»f  the  piihic  symphysis.  Its  oljject  in  obstetrics  is  the  enlarge- 
mont  of  the  pelvic  cavity  to  facilitate  delivery  in  narrow  pelves. 

Ilixtorif. — The  first  symphysiotomy  of  which  we  have  any  knowledj^e  was 
performed  in  1644  by  Jean  Claude  de  la  Conrvcc,  a  Frciicli  ])hysician  jiractis- 
ing  ill  Warsaw,  Poland.  This  operation  was  performed  after  the  death  of  the 
mother  for  tiie  purpose  of  saving  the  child.  A  similar  post-mortem  section 
was  performed  in  17()G  by  Joseph  Jaccpies  Piciurk  ot  IIiiii<fary.  To  Jean 
Rene  Siganlt  of  Angers,  France,  belongs  the  credit  of  originating  the  opera- 
tion as  applied  to  the  living  subject.  The  idea  seems  to  have  lieeii  snggestccl 
to  him,  however,  by  a  work  of  Severin  Pineaud,  first  published  in  1")98. 
While  still  a  student  of  mediciin,  Siganlt  had  several  times  practised  tiie 
operation  of  symphysiotomy  on  the  bodies  of  women  who  died  in  labor,  and  in 
1768  lie  read  a  memoir  upon  the  subject  before  the  Royal  Academy  of  Surgery 
at  Paris,  jiroposing  the  divisicm  of  the  pubic  joint  as  a  substitute  for  Cesarian 
section.  His  proposal  for  a  time  met  with  little  tiivor,  since  his  first  experi- 
ments, which  were  performed  on  bodies  that  had  become  rigid  from  l)eiiig  too 
long  dead,  faileil  to  show  an  amount  of  separation  s  ifficient  to  effect  any  material 
gain  ill  the  pelvic  diameters.  The  first  operation  on  tlie  living  woman  was  per- 
formed Oct.  1,  1777,  by  Siganlt,  with  the  assistance  of  Prof.  Alphonse  Leroy, 
who  had  liecomc  interested  in  the  subject,  and  in  common  with  Siganlt  had 
studied  tiie  operation  on  the  cadaver.  Tlie  woman's  recovery  was  tedious  and 
complicated  with  a  urinary  fistula,  yet  both  mother  and  child  survived.  At 
this  time  CV-sarean  section  was  almost  uniformly  fatal,  and  the  new  operation, 
which  seemed  destined  to  replace  it,  was  received  with  enthusiasm.  In  the 
next  decade  thirty-five  symphysiotomies  were  done  in  various  jiarts  of  Europe. 
Imperfect  knowledge  of  pelvimetry  and  of  the  proper  limits  of  the  operation 
led  to  its  frequent  misapplication  ;  the  technique,  too,  was  faulty.  Urethral 
and  vesical  injuries,  sepsis  of  the  pelvic  organs,  caries  of  the  bones,  and  non- 
nnioii  of  the  joint  wen^  frequent  results  of  the  operation,  and  it  soon  began  to 
lose  favor.  Symphysiotomy  was  bitterly  denounced  by  Baudelocqiie  and 
certiiin  other  obstetric  authorities  of  the  time,  and  in  1858  it  had  fallen  into 
general  disrepute.  During  tiie  period  between  1777  and  1866  there  were, 
according  to  Harris,  one  hundred  symphysiotomies,  with  a  maternal  mortality 
of  31  per  cent,  and  a  fetal  mortality  of  65  per  cent.  From  1818  to  1801 
symphysiotomy  was  almost  exclnsivcly  confined  to  Xaples.  Though  it  at  no 
time  wholly  died  out,  it  was  practically  obsolete  from  1858  to  1866.  In  the 
latter  year  it  was  taken  up  by  Prof.  Ottavio  Morisani  of  Xajiles,  who  first 
operated  in  January,  1866,  saving  both  mother  and  child.  Fncouragcd  by 
this  success,  he  became  deeply  interested  in  the  cause  of  symjihysiotomy,  and 
to  his  labors  in  its  behalf  w(!  are  indebted  for  its  general  re-adoption.  Largely 
as  the  rosf.lt  of  Ids  ctforts  the  technique  was  improved  and  tlie  mortality  greatly 
reduced.     The  first  fifty  Neapolitan  operations  done  by  Morisani  and  his  fol- 


• 


I?     i|: 


'i 


I  ii' 


I 

•'I 

i 


fv  V  h: 


906 


AMl'UUCAA   TI'LXT-IiOOK  O/'  OliSTF/rniCS. 


hi  1 1 


H.' 


lowoM  saved  SO  per  cent,  of  the  motluTs,  and  later,  when  the  operation  eaiue 
to  be  jjerfornied  nnch-r  modern  antiseptic  nietiiods,  tiie  mortality  wa.s  still 
further  diminished.  The  residts  were  frnpiently  pid)lished,  yet  for  a  (piarter 
of  a  contnry  the  sneeessfnl  work  that  was  heiii},'  done  in  Naples  attracted  little 
or  n()  attention  outside  of  Italy.  Tntil  1H!>2  the  operation  was  almost  imi- 
versally  condemned  or  was  ij>iiored  by  obstetric  writers  in  other  parts  of  the 
world.  That  year  was  a  memorabh!  one  in  the  history  of  symphysiotoiiiv. 
In  .January,  1H!)2,  it  a^'ain  secured  a  footin<jj  in  Paris.  At  that  date  Spinolli,  a 
jmpil  of  ISIorisani,  ])ublished  in  the  AnnalcH  de  (I'l/urmloi/ic  a  memoir  with  a 
detailed  account  of  twenty-four  c-ases.  JSIoreover,  Pinard,  the  editor  of  the 
journal,  had  seen  the  oju'ration  demonstrated  upon  the  cadaver  by  Spinelli. 
Jle  at  once  became  an  earnest  champion  of  symphysit>tomy,  and  recommended 
it  in  a  paper  upon  the  subject  before  he  had  performed  it.  He  lirst  operated 
in  February,  18i)'2,  and  in  little  more  than  a  year  nineteen  symphysi- 
otonues  wore  performed  by  himself  and  his  assistants,  savinjf  nineteen  women 
and  sixteen  children.  Within  a  lew  months  after  the  pid)lication  of  his  lh*t 
successes  the  operation  had  spread  to  the  rest  of  the  Continent  and  over 
both   hemispheres. 

In  the  United  States,  Dr.  Robert  P.  Harris  of  IMiiladelphia  had  lonir 
upheld  the  cause  of  symphysiotomy,  and  had  repeatedly  brouj;ht  the  subject 
to  the  attention  of  the  Entflisli-speakin<f  ])rofession.  In  September,  1892,  lie 
presented  a  paper  to  the  American  (}ynecoloj>;ical  Society  entitled  "The 
Kemarkable  llesults  of  AntisejUic  Symphysiotomy." '  From  this  tinu^ 
dated  the  introduction  of  symphysiotomy  into  America.  On  the  30tli  of 
Septend)er,  1892,  the  operation  was  performed  by  the  writer,  and  three  days 
later  by  Prof  Barton  V.  Hirst  of  Philadelphia.  Other  operations  followid 
in  rapid  succession  in  various  parts  of  the  country. 

/iV.s»Ms  of  Si/mplii/fiiotoiiij/. — In  210  symphysiotomies  performed  since  188(), 
when  the  operation  began  to  be  done  under  Listerian  precautions,  there  were, 
aceordinj;  to  Neusjebauer,'-  27  maternal  deaths,  a  mortality  of  12.85  per  cent. 
Of  the  children  20.2  per  cent,  were  lost,  includinjij  those  that  died  shortly 
after  birth.  Under  favorable  conditions,  however,  and  at  the  hands  of  skilled 
operators,  the  death-rate  has  been  almost  nil.  Pinard  lost  but  one  mother  in 
his  first  20  operations,  and  Zweifel  none  in  his  first  2.'} — one  death  in  43  e    i -. 

In  the  first  72  operations  in  the  United  States  the  maternal  deal  ijii  was 
14  per  cent,  and  the  infantile  mortality  was  26  per  cent.     liu  residts 

cannot  be  taken  as  fairly  representing  the  capabilities  of  symphy  ^my.  The 
operations  were  done  by  a  large  nnnd)er  of  operators  of  varying  i.  gree-  (' 
skill  and  for  the  most  part  of  little  or  no  experience  in  syniphysiotoujy.  In 
many  cases  the  conditions  were  unfavorable  for  ])ubic  section,  and  most  of  the 
deaths  were  due  to  causes  wholly  independent  of  the  method  of  delivery. 

In  Italy,  at  the  hands  of  Morisani  and  his  followers,  in  55  modern  sytii- 
])hysiotonues  .3.5  per  cent,  of  the  mothers  and  5.5  per  cent,  of  the  children 

'  American  G'ynecolni/intl  Tranxnrlionit,  \\>].  xvii. 

'  Ueber  de  Rekubililalioii  der  Schamfutjenlrennuiiij  mler  Sympliyseolomii;  etc.,  18'J3. 


1 1? 


oHsTi'/rniv  sviidKii  v. 


907 


i-»l  little 
DSt  uiii- 
4   of  tllf 

siotoiny. 
|tinoHi,  11 
ir  witli  a 
»r  (»r  tlic 

Spiiit'lli. 
iniiu'iitltil 

openitcd 
lympliysi- 
I'li  Nvoincn 
)f  his  lii-t 

aiul   over 

had  h>ii<!; 
till'  subji't't 
r,  1892,  li(> 
tied   "The 

this    tinio 
u>  30th  of 

three  (Uiys 

js  Ibllowcd 

siiiee  lH8(i, 
here  were, 
;,")  per  ecnt. 
wx\  shttrtly 
llrf  of  skilled 
le  mother  in 
in  43  «     -  -. 
v'.w    was 
i-.-sults 
my.    T'l'' 

liotoiny.     1 " 
most  of  the 
ilivery. 
Iiodern  syiii- 
Ithe  chiltlreii 

I   is'.t;?. 


were  lost.  I'iiiard  of  I'aris  in  his  first  "JO  operations  had  lint  one  maternal 
death.  'V\w  total  mnnher  (»f  eases  in  the  Handeloeiine  elinie  (l8l>2-!>4)  was 
I!) ;  I'onr  women  and  live  children  died.  Zwi'il'el  of  Leipsie  operated  23 
linios,  savin*;  ail  the  mothers  and  all  lint  two  of  the  ehildren.  It  wonl  !  seem 
iliat  ill  properly  sileeted  eases  and  with  skilled  oix-rators  the  death-rate  for  the 
women  shonld  not,  at  the  most,  excreed  three  or  fonr  in  a  hnndred. 

In  the  proptirtion  of  mothers  saved  the  record  of  symphysiotomy  compares 
lavoralily  with  that  of  Cesarean  section.  In  79  Cesarean  operations  performed 
ill  the  United  States  since  the  adoption  of  the  Siintier  method,  ii').  19  per  cent, 
of  the  mothers  and  12.()9  per  cent,  of  the  children  w(!re  lost.  Zweili'l's  results 
in  23  symphysiotomies  with  no  maternal  deaths  and  Morisani's  .'jo  eases  with 
a  loss  of  .').")  per  cent,  of  tlu!  mothers  have  not  lieen  equalle<l  l»y  Cesarean  see- 
tioii.  In  the  best  Cesarean  record,  which  is  that  of  Leipsic,  three  women  were 
lust  in  54  operat  ions — a  mortality  of  5.5  per  cent.  Tin?  proportion  of  children 
lost  nn<ler  symphysiotomy  has  j^reatly  exceeded  that  of  the  (-esarean  operation. 
In  |)rematnre  artificial  labor  under  approved  modern  methods  the  maternal 
(Icatli-rate  should  not  be  more  than  2  or  3  per  cent.,  but  the  mortality  for  the 
cliildren  is  very  <i;reat.  Two-thirds  of  the  children  |)erish,  if  we  inchide  those 
who  di(!  within  a  few  days  or  weeks  after  birth. 

In  the  early  history  of  symphysiotomy  suppuration  of  the  symphysis  and 
oi'  the  saero-iliae  joints,  caries  of  the  pubic  bones,  and  non-union  were  not 
inlVecpient  results  of  the  operation  ;  but  they  were  for  the  most  j)art  faults  of  the 
crude  sur<<;ery  of  that  period,  rather  than  of  the  operation  itself.  In  several  recent 
cases  some  mobility  of  the  jiubie  bones  has  been  noted  when  the  women  betjan  to 
walk,  but  rarely  more  than  is  occasionally  observed  after  diflicult  forceps  deliv- 
eries and  even  after  spontaneous  births.  The  woman's  jiowers  of  locomotion  are 
not  necessarily  crippled  by  slijxlit  looseness  of  the  joint.  Fronimel,  however, 
recently  reported  a  case  in  which  a  se(piestruni  of  bone  an  inch  in  length 
came  away,  and  there  was  persistent  iailure  of  union  with  inability  to  walk 
alter  three  months.  As  a  ride,  under  a  rigid  asejisis,  and  with  complete  im- 
nuibilization  of  the  pelvis  during  convalescence,  the  restoration  of  the  sym- 
jiliysis  in  women  not  previously  infected  has  been  complete.  Vesical  and 
urethral  injuries  have  been  reported  in  several  instances.  They  are  liable  to 
occur  not  only  from  the  knife,  but  also  from  pinching  tiie  urethra  and  bladder 
hctween  the  bones  when  the  latter  are  brought  together.  These  accidents, 
Morisani  declares,  are  faults  of  the  operator,  and  should  be  prevented. 
Troublesome  hemorrhage  frequently  happens,  either  from  the  incision  or 
from  lacerations.  It  is  especially  liable  to  be  encountered  on  division  of 
the  subpubic  ligament,  owing  to  the  vascularity  of  the  structures  about  the 
lower  id  of  the  symjihysis.  Tiacerations  of  the  corpus  cavernosum  of  the 
clitoris,  with  more  or  less  bleeding,  not  infreipiently  occurs.  TIemorrliage, 
however,  is  controllable  by  use  of  ])ressure  and  the  hemostatic  suture.  Pack- 
iiiu  the  wound  and  the  vagina  with  iodoform  gau/e  generally  suffices.  The 
vauii  particularly  the  anterior  wall,  is  exposed  to  laceration  during  the 
extraeiion   of  the   child.     In    septic   conditions   of  the   passages   the   latter 


i 


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Ife'i  i 


li' 


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008 


AMERICAN   TEXT-BOOK    OF   OBSTETlilCS. 


1. 1' 


'  I 


I 


injuries  may  assume  no  little  importance  by  openinj;  avenues  t\»r  the  possiUIo 
infection  of  the  symphysis.  To  what  extent  these  eoniplieations  may  be  pre- 
vented future  experience  must  decide. 

Anatomical  Liinifadons. — The  piiu 
of  s])ace  attainable  in  syniphyKiotoniv 
is  mainly  deterniined  by  the  mobility 
of  the  sacro-iliac  joints  {V\^.  501). 
Experiments  on  the  cadaver  by  Wcliie 
and  numerous  other  observers  show 
that  in  non-puerperal  pelves  the  ante- 
rior sacro-iliac  ligaments  rupture  :it 
different  degrees  of  pubic  separation, 
ranging  from  about  4  to  9  centimeters 
(H  to  t\h  indies),  the  results  varying 
with  the  age  and  the  j)hysical  condition 
of  the  subject.  In  pelves  from  puei- 
peral  women  a  se|)aration  of  8,  or  even 
9,  centimeters  is  possible  without  injury 
to  the  sacro-iliac  articulations.  In  two 
operations  by  Caruso  an  intcrpiibic 
.1(11.— si|iiinii ion  or  till'  sacroiiiiic  joint  on  spacc  of  8.5  Centimeters  [IVl  ini-hes)  in 
opening  tho,,ui,ic«ym„i,>MMKarai,ouf,.  ,,,,^   .j,,^|   ,,   (rutimetcrs   (^f  inches)  in 

the  other  was  obtained  with  no  bad  results;  6.5  centimeters  (2^  inches)  may 
be  regarded  as  an  entirely  safe  limit  of  pubic  sepai  .tion.     With  an  interpubie 


Flc.  502.— Led  innominate  bono:  o,  li,  n.xis  at  the  illo-sacral  joini  upon  wliicli  llii'  lionc  rotates  \slaii  iliv 

pnliic  I'Ud  is  alxluctcil  (WcliU'). 

opening  of  6  centimeters  (2^  inches),  the  ((onjugala  vera  gains  1.2  centinieicrs 
(J  inch),  the  transverse  1.9  centimeters  {-^  inch),  and  the  oblitpie  diameti  is  i!,") 


OBSTETim '  SVRGl'Ui Y 


909 


3  possiUlo 
y  be  pi't>- 
ilccido. 
■The  p»ii» 
ivsiotoiuy 
■  mobility 
^\^.    501). 

by  AVi'lllO 

vers   show 
?  the  anti - 
rupture   tit 
separation, 
eentinieters 
Its  varyint; 
\\  comlititiM 
from  p>uM- 
[  8,  or  even 
thont  injury 
ns.     In  two 
interpubii^ 
i'^  ini'hos)  in 
i  inches)  in 
inclies)  nmy 
\n  interpuhie 


■  V.itlUOS  wlirll  \\W 


2  centiinrtt'i'- 
|iliana'tfr>  -•■ 


eentinieters  (1  inch).  With  a  separation  of  7  eentinieters  (2|  inches),  which  is 
nossiblc  under  gentU^  pressure  without  hiceration  of  the  sacro-iliac  ligaments, 
the  gain  in  the  conjugata  vera  is  1.5  centimeters  (5  inch). 


Ki<i.  MH. — Siicrum  ;  n  h,  n  h.  nxps  on  \vlii<h  the  iiitKimiimtt'  l)oiu's  hini;e.    Owinp  to  the  wadRC-slinpo  of 
IIk'  siicniin,  tliiy  run  I'miii  iiliovi'  dnwinviird  mid  inward  (Woldc). 

Wehle'  caUed  attention  to  the  fact  that  wiien  the  pul)ie  bones  are  sejtarated 
the  sacro-iliac  joints  rotate  upon  an  oblicpie  line  running  from  above  down- 
ward and  from  without  inward,  and  that  in  conscfpienee  the  ends  of  the  pubic 
iiones  move  downward  as  well  as  outward  when  tlic  joint  is  opened  (Figs.  502- 


I'h,,  ."1(11.— Moist  iinpiinitioii  of  iK'lvis  iiI'iicIumI  liy  siuTUiii  lo  a  post ;  left  iiiiioniinali' lioiii' iinniohili/.cd ; 
rif,'lit  lioiK'  alidnctcd.    Sliows  dou  iiuard  iiiovciiu'iit  of  piiliis  on  .1 1  id  act  ion  iWi'ldci. 

r)llS).  A  separation  <>f  .3  centimeters  (1  1  inches)  cau,<cs  a  descent  of  2  eenti- 
nieters (i^  incii),  wiiicii  is  still  I'urthcr  increased  by  the  downward  pressure  of 
till'  Ic'tal  head  during  delivery.     This  dcsceiil     I'  tlic  pnhic  Ixincs  ailds  matc- 

'  Arlifilcii  (tii.i  <lfr  KihiitiHcldii  l''riiiiriiUiiiiL  in  Dnsdfii,  Iliunl  i.,  lfi',11!. 


I?, 


m 


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w 

ftt 


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910  AMERICAN    TEXT-BOOK    OF    OnSTIVritlVS. 

rially  to  the  amount  of  pelvic  space  gained  (Figs.  504,  505,  507).     All  the 


Fir;.  "lO'i.— The  eflt'ot  of  di'scciit  of  tliu  imliic  Ihhu's  mi  the  fjiiin  in  K'iif.'tli  i)f  sacropiiljio  (liniiictcr.  I!y 
mere  si'piinitioii  of  bonus,  tliu  K'li"  in  fonjuKiUii  vera  would  be  .S.S';  with  udilod  ulloet  of  (k'sccnt  it  is 
y,S"'  (Wehlu). 

lines  running  from  the  promontory  to  the  anterior  half  of  the  linea  ilio-peotinea 
are  elongated  more  than  by  mere  separation  of  the  pubic  bones.     But  this  is 


Klii.  506.— DliiKrani  of  iii'lvi<'  brim,  slinwintr  friiiii  in  simcc  on  oiii'iiint,'  imbic  joint :  P  X,  coiijnt-'nti' joint 
cIosimI  ;   I'  S',  coiijUHuti.' joint  open  (i  ciii.  (Wchlr). 

not  all.    As  the  bones  recede  from  each  other  the  juiterior  parietal  bos  projects 
nearly  a  centimeter  into  the  pul)ic  interspace.     The  increase  in  the  coiijii^alt' 


OBSTETRIC  SUllUER  Y 


Dll 


All  the 


(liiimctiT.    Hy 
)f  (k'scL'Ut  it  is 

lio-peotiiioii 
But  this  is 


(•iiiij"i-'"'''  J"'"' 
hos  pmjirts 


diameter  by  opening  the  pnbio  joint  to  the  extent  of  6.5  centimeters  (2^  inches) 
amounts,  tlierefore,  in  effect,  to  about  2  centimeters  (^  inch). 

IncUcatioiis. — In  general,  symphysiotomy  is  applicable  in  obstructed  labor 
in  which  the  delivery  of  a  living,  viable  child  may  be  rendered  po.ssible  by  a 


Via.  M'. — Diftjjram  of  jielvic  lirim,  slinuiiin  f^iiiii  n(  space  on  sopiinition  of  syiii))liysis.  I'lihir  joint 
ilosi'd,  ivflvic  cavity  admits  a  fplicrc  NJ  mm.  in  iliamL'tcr;  joint  opened  (J  cm.,  the  cavity  admits  u  spliero 
;is  mm.  in  diameter  (after  Faralienf ). 

moderate  expansion  of  the  pelvis,  fn  the  simph;  flattened  pelvis  the  limits 
of  the  operation  may  be  computed  from  tlie  data  ali'oady  considered.  The 
l)iparietal  diameter  of  the  average  fetal  head  is  9.5  centimeters  (3|  inches).  It 
is  reduced  by  compression  during  the  birth  to  about  9  centimeters  (3J  inches). 


>*l  nun. 

I'lii.  "lOH.— Diasram  of  pelvic  lirini,  showing  txiuu  of  space  on  sepanition  of  sympliysis.  I'Mliic  joint 
cIiisimI,  tlie  pelvic  cavity  admits  a  sjihere  (iO  mm.  in  dianu  ter ;  joint  opened  li  em.,  the  excavation  admits 
II  spliere  M  mm.  in  diameter  (alier  Iwiriibenf  I. 

Alter  full  separation  of  the  .symphysis  the  ])arietal  l)os  jtrojeots  into  tiie  inter- 
pubic  space,  and  this  in  effect  shortens  the  biparietal  diameter  to  the  extent  of 
nearly  a  centimeter  more.  A  conjugate  of  H  centimeters  (31  inches)  will  there- 
line  be  retjiiired  for  the  pas.sage  of  the  head.  Since  a  pubic  separation  of  (5 
centimeters  (2|-  inche.<)  affords  a  gain  >>!'  1.2  centimeters  (^  inch)  in  the  antero- 


m 


i 


»;„ 


.!} 


r<. 


912 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


'\i 


posterior  diameter,  delivery  under  .symphysiotomy  may  be  done  in  simple  flat 
pelves  with  a  conjugate  not  below  6.8  centimeters  (2f  inches).  Clinically, 
liowever,  at  least  in  America,  7  centimeters  (2|  inches)  is  generally  adopted  as 
the  minimum  conjugate  for  pubic  section. 

At  its  upper  limit  the  field  of  synii)hysiotomy  begins  where  that  of  forceps 
and  version  ends.  The  latter  operations  become  dangerous  to  mother  anil 
child  in  contractions  below  9  centimeters  (3^  inches),  conjugata  vera.  Xot 
only  is  the  maternal  and  the  fetal  mortality  greatly  increased  imder  prolonged 
and  difficult  extraction  by  forceps  or  version,  but  mental  and  physical  infirm- 
ities, resulting  from  intracranial  injuries,  are  also  common  in  the  children  wlm 
survive.  With  a  nornud  heac',  then,  the  field  of  symphysiotomy  in  simple 
antero-posterii>r  contraction  lies  between  7  and  9  centimeters  (2f  and  3^ 
inches),  conjugata  vera.  In  generally-contracted  pelves  the  operation  mav 
usually  be  j)erforined  with  advantage  with  a  conjugate  between  8.2  and  10 
centimeters  (,3-^  and  4  inclies). 

The  limitations  of  symphysiotomy,  however,  cannot  yet  be  regarded  as 
absolutely  settled.  Views  dift'er  according  to  the  varying  success  of  difi'erent 
operators.  More  extended  experience  will  be  required  to  determine  fnlly 
the  jdace  which  the  operation  shall  finally  hold   in  obstetric  surgery. 

It  is  evident  that  the  safe  choice  of  procedure  nuist  depend  upon  an 
accurate  estimate  of  the  reiatis'e  size  of  the  head  and  the  pelvis,  and  this  is 
possible  oidy  for  the  exjiert  well  trained  in  pelvimetry  and  the  methods  of 
measuring  the  fetal  head.  The  capacity  of  the  jielvis  to  receive  the  head 
shotdd  be  judged  not  only  by  direct  measurements,  but  also  by  trying  whether 
the  head  can  be  crowded  into  the  excavation  or  can  be  made  to  engage  bv 
careful  traction  with  the  forceps. 

Symphysiotomy  has  been  proposed  fin*  delivery  in  impacted  and  irreducible 
mento-posterior  face  cases  and  in  occipito-posterior  positions  with  imjjaction. 
In  such  emergencies  and  in  irreducible  brow  presentations,  provided  all  other 
conditions  are  favorable  for  both  mother  and  child,  pul)ic  section  would 
seem  particularly  apjdicable,  since  the  small  extent  of  pubic  separation 
required  would  entail  a  minimum  risk  to  the  mother. 

The  symphysis  has  been  opened  to  facilitate  delivery  by  embryotomy  on 
the  dead  child  in  absolute  (jontraction  of  the  pelvis.  The  combination  of 
symi)hysiotomy  anil  premature  labor  seems  to  the  writer  of  doid)tfid  utility. 
The  object  is  to  extend  the  limits  of  the  former  procedure  into  the  higher 
grades  of  contraction,  i)Ut  the  combined  risks  of  both  operations  can  scarcely 
oH'cr  any  advantage  over  Cesarian  section,  especially  for  the  child,  Synipliys- 
iotomy  is  obviously  contra-indicated  in  aid<ylosis  of  the  sacro-iliac  joints,  and 
theretbre  in  the  Robert  and  the  Xaegele  pelvis. 

3f('tlio(l  of  ()j)cr(it!on. — The  instruments  and  materials  required  in  syni- 
])hvsiotomy  are  a  common  scalpel,  a  slightly  curved,  narrow-bladcd,  inobe- 
pointcd  bistoury,  the  Galbiati  knil'e  or  the  modified  Galbiati  knife  of  Harris, 
curved  needles,  needle-fitrceps,  catgut  and  silk  sutures,  a  few  heniostatic 
force])s,   a  metallic  catheter,  and  a  yard  or  two  of  iodoibrm  gauze.     Tlircc 


r  * 

>    ii 


obstetrh '  sunaEn  y. 


913 


iplo  flat 
inically, 
jptccl  as 

^  forceps 
hor  aiul 
ra.     Not 
roloiijfi'tl 
.1  infirni- 
Iron  who 
n  siiiiplc 
\  and  3^ 
lion  may 
,2  and  10 

iiardcd  as 
f  ditt'crent 
nine  fully 
;ery. 

[  upon  an 
and  this  is 
nethods  of 
p  the  head 
ig  wlu'tlicr 
onsiano  I'y 

irroduoiUlo 
impaction, 
-d  all  other 
Ition  wtudd 
separation 

[ryotoniy  on 
bination  of 
^tful  utility, 
the  hiu,her 
lean  searecly 
Symphys- 
|e  joints,  and 

red  in  syni- 

le.d,  probi'- 

I'o  of  Harris, 

hemostatic 

ku/o.     Thivc 


tr 


assistants  are  needed — one  to  j^ive  the  anesthetic,  two  to  hold  the  knees  and 
render  sueh  other  assistance  as  tlie  operator  may  require.  The  ])roper  time  lor 
operation  is  at  the  close  of  the  first  .stage  of  labor.  In  emer<i;eney  the  dilatation 
of  the  cervix  when  already  well  advanced  may  be  completed  by  the  hand 
or  by  the  use  of  Barnes'  bags.  In  certain  cases  advantage  may  be  gained  by 
dividing  the  symphysis  before  fidl  dilatation  in  order  to  jiromote  the  expan- 
sion of  the  cervix  by  permitting  the  head  to  sink  into  the  excavation.  Jm- 
mediately  before  tlio  operation  examination  should  be  made  for  the  ausculta- 
tory evidence  of  fetal  life  by  listening  over  the  abdomen.  liefore  finally 
deciding  upon  symphysiotomy  the  mobility  of  the  sacro-iliac  jf)ints  should  be 
te.sted  by  strongly  flexing  and  extending  the  thighs  and  by  rotating  the  knees  out- 
ward. The  ])atient  is  anesthetized  and  ])laced  upon  a  firm  table  with  her  knees 
drawn  up  and  held  apart.  The  pubes  should  be  shaved  and  tne  abdominal 
walls  shotdd  be  cleansed  and  disinfected  as  for  celiotomy,  'i'ln^  vulva  and 
the  vagina  should  be  rendered  as  nearly  aseptic  as  jiossible,  since  the  pubic 
wound  is  ex])osed  to  infection  throngh  vaginal  lacerations.  The  location  of 
the  symphysis  is  then  determined  by  searching  for  the  depression  at  its  upper 
margin.  The  slight  motion  produced  by  raising  and  lowering  the  legs  helps  in 
linding  the  joint.  It  must  be  remembere<l  that  an  exact  central  |)osition  of  the 
sym])hysis  is  exceptional  in  deformed  pelves.  The  depth  of  the  joint  is  to  be 
noted  and  the  surfaces  are  to  be  examined  carefully.  An  assistant  then  intro- 
duces a  straight  metallic  catheter  for  the  purpose  of  holding  the  nn^thra  and  th<> 
vesical  neck  backward  and  to  the  right  side  during  the  division  of  the  joint : 
this  at  the  same  time  serves  to  keep  the  bladder  empty.  Either  a  short  or  a 
long  ])riraarv  incision  may  be  adopted.  In  the  former  method,  which  is  that 
pursued  by  Morisani,  a  vertical  incision  of  from  2  to  3  centimeters  (f  to  1^ 
inches)  in  length  is  made  in  the  abdominal  wall,  terminating  below  at  a  point 
1  centimeter  {t  inch)  above  the  upper  end  of  the  symphysis.  In  the  latter, 
or  open  method,  the  incision  is  made  from  8  to  10  centimeters  (3i  to  4  inches) 
in  length,  extending  well  above  the  symphysis  and  terminating  below  at 
the  root  of  the  clitoris  or  turning  to  one  side  of  it.  The  principal  gain  in 
the  short  incision  is  the  lessened  danger  of  hemorrhage  and  of  subsequent 
infection  from  the  lochial  discharge.  The  long  incision,  however,  has  the 
advantage  that  it  enables  the  operator  to  .see  what  he  is  doing  at  each  step. 
The  former  is  generally  to  be  preferred.  The  incision  may  be  prolonged  and 
the  joint  exposed  when  foinid  necessary  for  the  control  of  hemorrhage  or  in 
consequence  of  other  complications. 

INTorisani  separates  the  attachments  of  the  recti  by  cutting  sideways  suf- 
ficiently for  the  introduction  of  the  finger.  This  practi<'e  otlers  no  a<lvantage 
:ind  unnecessarily  Aveakens  the  abdominal  wall.  The  better  practice  is  to 
make  the  o])ening  in  the  aponeurosis  between  the  recti  longitudinally,  extend- 
ing down  to  the  joint  and  large  enough  to  admit  the  linger.  The  retropubic 
stiiictures  are  separated  by  the  index  finger,  which  is  introduced  into  the 
Wiund,  carried  down  behind  the  symj>hysis,  and  hooked  under  the  inferior 
ligament.     Upon  this  finger  as  a  guiile  the  probe-pointed  bistoury  is  passed 

68 


ft 


914 


AMERICAN    TJ'LXT-nOOK    OF   OnSTF/miCS. 


If 


down  bchiiul  the  joint  to  the  lower  edge  of  the  subpubic  ligament.  The 
joint  .structures  are  then  divided,  cutting  from  behind  forward  and  from  below 
upward  until  the  bones  are  feU  to  give  way.  If  tht;  sickk;-shaped  knife  of 
Galbiati  or  of  Harris  is  used,  it  is  hooked  under  the  sul)[)ubie  ligament  and 
drawn  upward  and  forward  through  the  joint.  During  the  incision  the 
urethra  is  held  backward  away  from  the  pubic  arcli  and  to  the  right  l)y  means 
of  the  metallic  catheter  in  the  hands  of  an  assistant.  Instead  of  tlie  finger  a 
Hays  director  may  be  passed  behind  the  joint  to  guide  the  knife.  The  writer 
found  no  difficulty  in  passing  the  probe-pointed  bistoury  sal'ely  along  the 
posterior  surface  of  the  symphysis,  guided  by  a  finger  of  tlie  left  iiand  in  the 
vagina.  If  this  method  is  attempted,  the  bistoury  point  should  be  made  to 
hug  the  joint  closely  all  the  way.  It  may  happen  that  the  introduction  of 
an  ordinary  bistoury  behind  the  symphysis  may  be  found  difficult  or  impossi- 
ble, owing  to  a  petululous  abdomen.  Tiie  joint  can  tlien  be  cut  mainly  from 
above  downward.  Pinard  and  otiiers  prefer  to  incise  the  symphysis  from 
before  backward.  In  this  method  of  incision  the  retropubic  structures  should 
"be  protected  by  a  tamjion  of  iodoform  gauze  or  by  a  lead  plate  phiced  behind 
the  symphysis.  The  plan  of  cutting  from  before  backward  and  above  down- 
ward has  been  advocated,  for  the  reason  that  the  symphysis  is  wider  at  the 
upper  than  at  the  lower  margin,  and  is  wider  anteriorly  than  posteriorlv.  There 
is  usually  little  difficulty,  however,  in  engaging  the  knife  in  any  aspect  of  the 
joint.  In  rare  cases,  owing  to  the  sinuous  shape  of  the  symphysis  or  to 
ossification  of  the  joint,  it  has  been  found  necessary  to  replace  the  knife  witii 
a  chain-saw  or  a  finger-saw.  Rarely  the  head  may  be  crowded  so  firndv  into 
the  excavation  that  it  may  be  necessary  to  push  it  up  before  the  symjilivsis  can 
safely  be  divided.  As  the  joint  is  cut  through,  the  bones  usually  fall  apart 
.spontaneously  to  the  distance  of  .'i  or  4  centimeters  {\\  to  \^  inches).  The 
wound  is  protected  with  a  fold  of  iodoform  or  of  sublimate  gauze  diu'ing  the 
delivery.  If  hemorrhage  occurs,  it  should  be  controlled  by  packing  with 
iodoform  gauze  or  by  hemostatic  suture. 

An  important  improvement  in  the  technique  of  symphysiotomy  has  recently 
been  proposed  by  Dr.  J\I.  I^.  Harris  of  Chicago.'  After  dividing  the  sym- 
physis he  detaches  the  std)pubic  ligament  (whi(rh  has  been  left  uncut)  and  the 
deep  perineal  fascia  fn)m  the  pubic  arch,  using  for  the  purpose  a  blinit-poiMttil 
bistoury  under  guidance  of  the  finger  and  hugging  the  bone  closely  on  cacli 
side.  The  pubes  are  allowed  to  separate  gradually,  and  the  detachment  of  the 
fascia  from  the  bones  is  continued  until  its  fibres  are  no  longer  felt  to  be  ten^c. 
The  separation  of  the  symphysis  will  then  have  been  carried  as  far  as  can  he 
done  without  injury  to  the  sacro-iliac  joints. 

The  object  of  this  step  i^  at  once  apparent.  The  deep  perineal  fascia,  by 
reason  of  its  attachment  to  the  ischio-pubic  rami,  is  so  much  stretclied  tran>- 
ver.sely,  when  the  joint  is  opened  to  any  great  extent,  that  in  the  usual  nietliitil 
of  operating  it  is  often  ruptured.  This  fascia  is  perforated  by  the  vagina,  tlic 
urethra,  and  the  dor.sal  vein  of  the  clitoris.     It  surrounds  a  part  of  the  cor- 

'  Am.  Journal  uj  Obsletrics,  Dec,  1S94. 


OBSTETRIC  sLiiai:ii  r. 


(115 


It.     The 
iiu  Ih'Iow 
kiiiti'  of 
nout  and 
ision   the 
l)V  moans 
D  fin>j;or  a 
^'he  writer 
along  the 
luul  in  the 
i  made  to 
hictiou  of 
^v  impossi- 
ainly  from 
hysis  from 
iires  should 
iced  behind 
bove  down- 
,vider  at  the 
rly.     There 
spect  of  tlie 
ihysis  or  to 
i  knife  with 
)  firmly  into 
mphysis  ean 
\\  fall  apart 
liches).     The 
!  during  the 
lacking  witli 

has  recently 
hig  the  sym- 
licut)  and  the 
l)lnnt-pointe(l 
l)sely  on  eaeli 
Ihment  of  the 
It  to  be  tense. 

far  as  ean  be 


pal  fascia,  by 
Jetehed  traii>- 
lusnal  u\e'.lii'(l 
le  vagina,  tln' 
It  of  the  .nr- 


pora  cavernosa  of  the  clitoris,  aiul  it  contains  between  its  layers  the  cavernous 
<  bodies  about  the  vagina  and  urethra  and  the  plexus  of  veins  around  the  vesical 
neck.  Laceration  of  the  tiiscia  takes  place  in  the  direction  of  least  resistance, 
which  is  usually  through  the  line  of  perforation.  The  urethra  and  the  clitoris 
are  fre(|uently  torn.  The  vagina,  which  is  always  a  .septic  tract,  is  .sometimes 
invaded  by  the  tear.  The  venous  plexuses  and  the  cavernous  bodies  involved 
ilk  the  injury,  and  in  a  region  that  is  much  increa.sed  in  vascularity  during 
pregnancy,  are  often  the  source  of  alarming  hemorrhage.  The  bleeding,  which 
is  mainly  or  wholly  venous,  is  sometimes  extremely  diflicidt  t(t  control,  the 
veins  being  held  open  by  the  .stretched  fibres  of  the  torn  fascia,  and  it  has  even 
ended  fatally.  All  these  injuries,  too,  greatly  increase  the  risk  of  sepsis.  Afost 
(tf  the  dangers  and  complications  of  .symphysiotomy  are  prevented  by  preserv- 
ing intact  the  deep  perineal  fasciia. 

While  dividing  the  joint  and  separating  the  ftiscia  the  lateral  halves  of  the 
pelvis  nuist  firmly  be  supported.  Otherwise  they  may  prematurely  be  forced 
apart,  and  the  fa.seia  be  torn,  .should  the  fetal  head  be  suddenly  driven  down  by 
a  violent  uterine  contraction.  In  all  ca.ses  the  joint  is  to  be  oi)ened  to  the 
I'nllest  extent  permissible,  in  order  to  prevent  ])ossible  rupture  of  the  fascia 
from  imexpected  spreading  of  the  bones  during  delivery. 

To  detach  the  fii.scia  from  its  subpubic  attachment  in  the  manner  described, 
the  primary  incision  must  be  free,  extending  from  a  little  ab  .e  the  .symphysis 
nearly  down  to  the  clitoris. 

Increasing  experience  is  unfavorable  to  the  osseous  suture.  (lood  union  is 
obtained  without  it,  while  wiring  the  bones  may  lead  to  caries  and  persi.stent 
fistula. 

After  the  joint  has  been  opened  the  patient  may  be  permitted  to  deliver  her- 
self, a.ssLsted,  if  necessary,  by  expressio  fetus.  As  a  rule,  it  is  better  to  termi- 
nate the  labor  at  onco  by  forceps  or  by  version.  The  woman  is  thus  spared 
the  danger  of  long-continued  anesthesia  and  of  prolonged  exposure  of  the 
operation  wound.  In  general,  the  choice  between  forceps  and  version  should 
he  decided  in  accordance  with  the  commonly  accepted  rule  of  version  before 
and  forceps  after  engagement  of  the  head.  In  breech  presentation  the  delivery 
will  not  differ  from  the  usual  method  of  breech  extraction. 

During  the  delivery  the  lateral  halves  of  the  pelvis  .should  be  supported 
by  an  assistant  to  prevent  too  wide  separation  of  the  pubic  bones,  care  being 
taken  to  prevent  undue  strain  upon  the  anterior  .soft  parts  during  the 
extraction  of  the  child.  Some  writers  have  advised  a  ])erincal  incision  when 
neec.s.sary  to  avert  laceration  of  the  soft  structiu'cs  that  bridge  the  pubic  intcr- 
spacic.  The  same  end  would  perhaps  be  accomplished  better  by  the  usual  lateral 
opisiotomy  incisions.  The  placenta  should  be  delivered  before  the  joint  is  clo.sed. 
Afler  delivery  tne  ends  of  the  sundered  bones  are  brought  together  by 
pressure  on  the  trochanters.  As  the  lateral  halves  of  the  pelvis  are  approx- 
imated, the  retropubic  structures  are  pressed  gently  backward  to  prevent  injury 
to  the  bladder  or  the  urethra  by  pinching  between  the  bones. 

I  icopohl  sutures  the  cartilages  with  silk;  Zwcifel  unites  the  joint  surfaces 


Mi 


910 


AMEIilVAX   TEXr-nOOK    OF    OBHTETlilCS. 


¥    .V 


by  tlnw  hiiriotl  siitnros  of  catgut  or  of  silkworm  pit.  Silver  wire  irritates, 
and  is  open  to  tho  ohjoction  that  it  may  intcHbro  with  a  subsequont  operatimi. 
Most  operators  wholly  reject  the  bone  suture  as  unnecessary.  Immobilization 
of  the  joint  after  operation,  however,  by  means  of  the  usual  bandajre  is  Iron- 
blcsome  and  difficult,  and  in  certain  instances  persistent  looseness  of  the  sym- 
physis has  remained.  The  womid  in  tiie  soft  parts  is  closed  with  silk  sutiurs. 
It  is  advisable  to  include  th(!  fibrous  structures  on  the  anterior  surface  of  the 
joint  in  the  sutures  which  close  tlu;  wound  of  the  soft  parts. 

Aftcr-fredfmcnt. — Absolute  immobili/ation  of  the  pelvis  during  convales- 
cence is  essential  to  immediate  and  fii-m  union  of  tho  joint.  Many  operators 
have  trusted  to  a  strong  muslin  binder,  simple  or  starched  or  ])ainted  with 
water-glass.  A  canvas  belt  provided  with  straps  and  buckles  for  tighteninii 
makes  a  satisfactory  dressing.  The  "Itroad  part  of  an  Ksmareh  bandage  h:is 
boon  used.  An  excellent  ])lan,  which  has  been  adopted  by  several  American 
operators,  consists  in  the  use  of  adhesive  straps  of  rubber  plaster,  sui)j)Iemeiit(d 
with  the  muslin  binder.  Three  broad  strips  of  plaster  are  carried  across  the 
abdomen  from  one  wing  of  the  pelvis  to  the  other  above  the  wound.  Tiic 
muslin  binder  is  pinned  tightly  over  the  plaster  strajis.  The  adhesive  strap- 
are  ])articularly  usefid  as  a  partial  support  to  tho  pelvis  while  the  muslin 
bandage,  which  frequently  becomes  soiled,  is  being  changed.  (larrigues 
suggests  the  use  of  Martin's  roller-bandage  of  solid  rubber.  One  opei-ator 
has  used  a  wire  cuirass  to  keej)  the  bones  together.  Guoniot  proposes  an 
apjiaratus  which  he  calls  an  "  iliac  compressor,"  consisting  of  lateral  ])lat(s 
well  padded,  compression  being  applied  by  means  of  anterior  and  posterior 
straps.  Pinard  and  others  have  made  use  of  a  special  bed  with  appliances 
for  retention  of  the  bones  and  for  suspending  the  ])atient. 

Vaginal  and  vulvar  lacerations  should  be  closed  by  suture.  The  bladder 
and  the  urethra  should  bo  examined  for  possible  injuries.  An  ounce  or  two 
of  boric  acid  and  iodoform  (1  :  8)  may  be  loft  in  the  vagina  to  keep  the  dis- 
charges sweet,  and  a  large  absorbent  pad  may  be  placed  over  the  vulva.  The 
patient  is  i)Ut  in  bed  on  her  back,  with  the  knees  lightly  tied  together  and 
the  limbs  outstretched.  This  position  best  favors  the  coaptation  of  the  sun- 
dered bones,  and  should  therefore  be  maintained  until  reunion  of  the  joint 
is  established.  For  evacuation  of  the  bowels  or  the  bladder  the  patient  may  lie 
lifted  upon  the  bed-pan,  the  nurse  seizing  tho  hips  over  the  trochanters.  The 
use  of  the  catheter  is  frequently  necessary  for  the  first  few  days,  but  it  sliould 
be  avoided  if  possible.  The  dressing  of  tho  pubic  wound  may  remain  undis- 
turbed for  a  week  unless  it  becomes  soiled  by  the  lochial  discharges.  A  con- 
.stant  object  of  solicitude  is  the  pelvic  bandage.  It  should  be  examined  scveriil 
times  daily,  and  be  tightened  as  often  as  the  least  slackness  is  noted.  It  is 
exposed  to  soiling  with  urine  and  focal  discharges,  and  it  is  only  by  the  utimi-t 
vigilance  that  proper  cleanliness  can  be  maintained.  The  simple  nmslin 
binder  must  be  replaced  frequently  with  a  fresh  one.  While  it  is  being  elianircd 
the  lateral  halves  of  tho  pelvis  should  be  supported  firmly  by  an  assistant.  If 
a  water-glass  or  a  plaster  dressing  be  used,  the  parts  of  the  bandage  liable  ti 


to  lie 


OBSTETIilC  SI  RCiFJt  Y 


'J17 


iiTitatos. 
:)|)oriiti(iii. 
(bilizatiipii 
fc  is  lv()\i- 

tho  syiu- 
k  sutiins. 
'ace  of  tlif 

convnlcs- 
,'  ()])orators 
inti'd  with 

tijihtoniiiu, 

I  Aiucriciiu 
pplcincntcd 

II  across  tlir 
omul.  Till' 
osive  straps 

tlio  nmsliii 
(laiTijiiics 
)ne  (>i)orat(if 
pr()j)os(>s  an 
atcral  plates 
ml  postcrini' 
h  appliaiK'is 

The  bladder 
ounce  or  two 
■cp  the  dis- 
ulva.     Tl.e 
(liTcthor  and 
of  tlio  sun- 
of  the  joint 
itieiit  may  he 
[inters.     TIh' 
nit  it  shonlil 
•emain  nn<li>- 
es.     A  eon- 
nincd  sevend 
noted.     It  i> 
)y  the  iitniii-t 
imple    nin-hn 
)oing  ohaiiiifd 
assistant.     H 
loe  liable  tn  hr 


soiled  may  bo  protected  by  a  folded  towel  or  a  napkin  properly  placed  under 
the  buttocks  and  fre(piently  changed.  The  bowels  should  be  kept  open  as  in 
other  cases.  The  pelvic  bandage  is  to  be  worn  from  four  to  si,\  weeks.  The 
patient  may  usually  leave  her  l)ed  at  the  expiration  of  three  weeks,  and  leave 
her  room  by  the  end  of  a  month. 

Cesarean  section  is  the  operation  of  removing  the  fcti-s  from  the  mother 
by  opening  the  abdomen  and  iiicisiug  the  uterus.  Amor^-  t  areicnts  it  was 
done  immediately  after  the  death  of  the  nutther;  but  not  m  >  '  r..  rburteenth  or 
the  fifteenth  eentiny  is  there  any  record  of  the  operation  being  ])erformed  upon 
a  living  mother.  The  maternal  mortality  was  so  great  that  the  operation  was 
condennied  by  Ambroise  Pare,  ISIain'icjeau,  and  others,  and  for  a  long  time  was 
practically  abandoned.  The  cause  of  death  was  usually  hemorrhage  or  sepsis. 
The  uterine  wound  was  not  closed,  U'cause  it  was  thought  that  the  alternate 
contractions  and  relaxations  of  the  uterus  would  make  the  stitches  tear  out. 
The  uterine  wound  was  left  gaping,  and  eventually  closed  by  adhesive  inflam- 
mation to  the  abdonnnal  wall.  The  cicatrix  which  was  formed  varied  greatly 
in  depth  and  strength,  was  extremely  liable  to  subse(pietit  rupture,  and  occa- 
sionally perndtted  henna  to  take  place.  The  use  of  the  uterine  suture  was 
advocated  and  practiscnl  in  the  beginning  of  the  present  century;  nevertheless, 
the  mortality  remained  high  until  Porro  (187G)  supplemented  the  ordinaiy  sec- 
tion by  amjmtatiug  the  uterus  and  including  the  stump  in  the  abdonnnal  siitiu'e. 
r>ut  the  greatest  advance  was  made  in  1882  by  Sanger  of  Leipsii',  who  ))rojK)scd 
the  complete  closin"(!  of  the  uterine  wound  by  nudtiple  sutiu'cs  ;  to  him  is  in 
great  measure  due  the  credit  of  ])erfecting  the  modern  operation.  Its  success 
is  maiidy  attributable  to  three  causes  :  (1)  A  strict  antiseptic  technicpie  ;  (2)  com- 
plete closure  of  the  uterine  wound  by  nudtiple  sutures ;  and  (3)  the  deliberate 
selection  of  the  operation  before  the  beginning  of  labor,  and  its  performance 
before  the  patient's  strength  has  been  exhausted  or  her  i)assages  infected  by 
repeated  exandnations  and  fruitless  attempts  to  (kdiver  by  forceps  or  by  ver- 
sion. Since  the  introduction  of  the  Sanger  operation  craiuotomy  upon  the  liv- 
ing child  has  been  wellnigh  abandoned  in  France,  and  even  the  nuitilating 
Porro  operation  has  been  restricted  within  very  narrow  limits. 

Indications. — Cesarean  section  may  be  porforined  in  the  interest  of  the 
mother  or  of  the  child  when  safe  delivery  by  version  or  by  forceps  is  impossible. 
If  the  mother  is  moribund  and  the  child  is  still  alive,  its  life  will  depend  upon 
a  speedy  delivery  ;  with  the  mother's  consent  the  operation  may  k'  performed 
to  save  the  child.  But  the  cases  of  real  diiKctilty  arc  those  in  which  the  delivery 
(if  a  living  child  is  impossible  in  any  other  way  than  by  Cesarean  section,  yet 
the  mother  might  be  delivered  with  comi)arative  safety  by  perforiidng  a  crani- 
iitoniy.  Is  it  permissible  to  destroy  the  child  in  order  to  save  the  mother? 
lias  she  the  right  to  refuse  Cesarean  section  and  to  demand  craniotomy  in  her 
(iwn  interest,  or  to  insist  upon  whatever  operation  will  give  her  the  best  chance 
of  recoverv,  regardless  of  h(>r  child?  Has  th(>  obstetrician  the  right  to  weigh 
one  life  a<rainst  another,  and  decide  to  take  the  one  bv  craiuotomy  or  to  jeopard- 
ize  the  other  bv  Cesarean  section?     These  are  serious  questions,  with  import- 


tt 


f^^ 


it'      ' 


918 


AMKRIVAN   TEXT-BOOK   OF   OBSTETRICS. 


m 


^  ^ 


ant  moral  and  rdi-riuiis  lu'urinjrs,  wliioli  tlio  physician  shoultl  not  be  called  npi.ii 
to  decide.  He  should  fortily  himself  by  consultiiifj;  with  a  rmi/nVt;  and  then, 
having  laid  the  medical  aspects  of  the  case  plainly  b(  ore  the  patient  and  lier 
friends,  should  leave  the  ultimate  decision  to  them.  Undoubtedly  his  first  duty 
is  to  his  patient,  but  he  is  not  called  upon  to  over-persuade  her  or  to  override 
lu'r  wishes.  After  a  serious  accident  a  surgeon  may  recommend  the  ami>utatinii 
of  a  lind)  as  the  oidy  means  of  saving  life,  and  may  even  feel  compeUed  t(. 
retire  from  the  case  if  his  advice  is  not  taken  ;  but  he  has  neither  the  moral 
nor  the  legal  right  to  amputate  the  limb  against  the  will  of  his  patient. 
The  indications  for  Cesarean  section  are  generally  classed  as  aholnlc  and 
ndative. 

Absolute.  Jitdimtiotis, — The  indication  is  absolute  when  it  is  impossible  to 
extract  the  fetus,  either  living,  dead,  or  mutilated,  through  the  natural  i)assage. 
This  maybe  the  case  in  extreme  pelvic  contraction  from  arrested  development, 
rickets,  or  osteomalacia,  or  where  the  i)assage  is  blocked  by  tumors  of  the  pelvis 
(osseous)  or  of  the  uterus  and  the  soft  i)arts  (cantinoma,  fibroma,  etc.).  'J'he 
modern  symphysiotomy  has  narrowed  the  limits  of  Cesarean  section  somewhat, 
so  that  the  indication  is  not  now  considered  absolute  uidess  the  conjugate  is  (i 
centimeters  (2.^  inches)  or  under,  the  child  being  well-developed  and  at  full  time. 
Some  authorities  do  not  consider  even  6  centimeters  {'If^  inches)  as  an  absolute 
indication  if  the  ciiild  is  small  and  th(!  head  is  mouldable. 

After  it  has  been  decided  to  deliver  through  an  abdominal  incision,  it  nuist 
still  bo  determined  whether  it  is  better  to  remove  the  uterus  by  the  Porro  ope- 
ration, or,  by  performing  the  Siinger  o])erati()n,  to  subject  the  patient  to  the  risk 
of  a  possible  subsecpient  ]iregnancy.  In  some  cases  the  diftieulty  may  be  over- 
come by  ligaturing  the  Fallopian  tubes  or  removing  the  appendages  before^ 
closing  the  abdominal  wound.  Jn  doubtful  or  debatable  cases  individual  eir- 
(jumstances  must  decide,  but,  in  general,  it  may  be  said  that  tiie  Porro  opera- 
ti(m  is  clearly  indicated  in  preference  to  the  Sanger — (1)  if  the  uterus  is 
infected,  the  chances  of  the  motiier's  recovery  being  much  increased  by  re- 
moval of  the  infected  organ  ;  (2)  if  there  is  ])artial  or  total  obstruction  of  the 
parturient  canal  by  tumors;  (.3)  if  there  is  carcinoma  of  the  uterus,  espeeiallv 
of  the  cervix  ;  (4)  in  osteomalacia;  (5)  if  complete  inertia  of  the  uterus  occuis 
dui'ing  the  course  of  the  operation. 

Rchdive  In<Jic(tti(m)i. — The  relative  indications  are  difficult  to  formulate,  and 
must  generally  be  determined  by  the  individual  ])eculiaritics  of  the  case.  A 
<legree  of  pelvic  contraction  or  oi)struction  less  than  is  requisite  to  constitute  ;m 
absolute  indication,  but  yet  sufficient  to  make  the  safe  delivery  of  a  living  and 
viable  child  by  the  natural  passages  doubtful,  maybe  considered  a  relative  indi- 
cation. A  conjugate  of  6  to  8  centimeters  (from  2J  to  3J-  inches)  and  tunidis 
of  the  pelvis  or  of  the  soft  parts  causing  moderate  obstruction  are  the  ediii- 
raonest  relative  indications.  The  alternative  operations  arc  symphysiotomy, 
forceps,  version,  and  craniotomy  (see  p.  54.'}). 

Time  fo  Opcnitc. — TJiere  is  still  a  difTerence  of  opinion  as  to  the  best  time 
to  operate.    Some  operators  wait  until  labor  has  fairly  begun,  in  order  to  secure 


1^ 


OJhS'.  J . Til IV  .SLliUERV. 


DID 


U'll  upon 

iiul  then, 

and  her 

first  duty 

()V(M'li(l(! 

nputatioii 

IJK'llcd    til 

;he  moral 
s  patient. 
wUik:  and 

)Ortsil)lo  ti) 
id  passa>;c'. 
/cl()j)n>ont, 
'  the  pelvis 
itc).  Tlu; 
somewhat, 
jut^ate  is  () 
it  full  time, 
an  absolute 

ion,  it  nnist 
■  Porro  opt- 
;  to  the  risk 
lay  be  over- 
asres  before 
ividual  eir- 
"■orro  opcra- 
e  uterus   is 
ased  by  re- 
etion  of  the 
s,  ospeeially 
tcrus  oeeurs 

rmulate,  ami 
the  ease.  A 
constitute  an 
la  livinti'  and 
l-elative  iudi- 

aud  tuiiiiivs 
Ire  the  eoiii- 

physiotoniy. 

lie  best  time 
ller  to  seeui'c 


1: 


frop  (lraiiin<j;e  tiiroujjli  the  dihited  cervix  and  to  diininish  the  risks  of  lieinor- 
i!"i<re  ;  others  operati;  four  or  five  days  before  tiie  expected  date  of  labor.  'I'iie 
latter  method  is  preferable,  because  the  patient  can  be  prepared  as  carefully  as 
for  any  other  celiotomy,  and  the  operation  can  bo  done  deliberately,  with  all  the 
advanta<^es  of  a  good  light,  trained  assistants,  etc.  Those  who  wait  for  tlio 
onset  of  labor  may  have  to  oj)erate  hurriedly  or  at  night,  without  proper  prep- 
aration or  skilled  assistance  ;  moreover,  the  membranes  may  rupture  before  the 
ojieration,  which  is  always  a  disadvantage.  (Vsarean  section  is  an  elective  ope- 
ration whose  success  depends  in  great  measure  upon  its  being  performed  under 
the  conditions  most  favorable  to  recovery  ;  it  seems,  therefore,  more  ])rudent 
for  the  operator  to  determine  for  himself  the  time,  ])laee,  and  conditions  of  the 
ojieration  than  to  trust  to  the  uncertainties  of  a(!cident  or  of  chance. 

The  objections  commonly  urged  against  oj)eratiiig  before  labor  are  (1)  that 
hemorrhage  may  take  place  on  account  of  imperfect  uterine  contraction,  and 
("2)  that  .sepsis  may  occur  from  retention  of  the  lochia,  the  undilated  (cervical 
canal  not  permitting  free  drainage.  Experience  shows  that  the  first  objection 
is  unfounded,  because  the  uterus  does  contract  promptly  and  well  after  being 
incised  and  emptied.  The  second  objection  can  easily  be  overcome  by  dilating 
the  cervix  from  above  and  passing  a  drainage-tube  or  a  strip  of  gauze  into 
the  vagina.  That  these  objections  are  theoretical  rather  than  ju-aetical 
seems  to  be  proved  by  the  results  of  tlu^  early  o]>erati()n  in  the  riiitcd 
States,  where  in  sixteen  operations  fourteen  mothers  and  all  the  children 
were  saved. 

General  Preparation. — If  possible,  the  patient  should  be  prepared  as  care- 
fully as  for  any  other  celiotomy,  special  attention  being  paid  to  the  state  of  the 
bladder  and  the  bowels,  disinfection  of  the  vagina,  and  scrubbing  and  cleansing 
of  the  abilonien.  The  operation  slioidd  be  performed  under  an  anesthetic. 
Some  operators  prefer  chloroform  to  ether,  as  anesthesia  is  more  r'']);'l!y  ])vv.- 
duced  and  the  child  is  less  likely  to  be  asphyxiated.  The  instruments  recpiired 
are  scalpels,  strong  scissors,  hemostatic  forceps,  needles  and  a  needle-liold(>r, 
sutures,  a  hypodermatic  syringe  with  a  supply  of  ergotin  and  ether,  an  irri- 
gator, a  piece  of  elastic  cord  or  tubing,  and  occasionally  a  sliarj*  curette  and  a 
tliermo-cautery.  There  should  be  provided  also  a  plentiful  supply  of  aseptic 
towels,  sponges,  gauze,  and  boiled  water  both  hot  and  cold.  The  best  needle 
for  the  uterine  suture  is  half-curved,  round-bodied,  and  without  a  cutting  edge. 
Three  assistants  are  required — one  to  give  the  anesthetic,  another  to  take  charge 
of  the  fundus  and  the  uterine  incision,  and  a  third  to  tighten  the  rubber  band 
around  the  lower  uterine  segment. 

The  Abdominal  Incision. — Operators  differ  as  to  the  best  method  of  ileliver- 
iiig  the  child.  Some  make  a  long  abdominal  incision  and  turn  out  the  uterus 
before  they  open  It  and  extract  the  child.  Others  make  a  much  shorter  in- 
cision, open  the  uterus,  and  extract  the  child  before  they  turn  the  uterus  out  of 
tile  abdominal  cavity.  In  the  first  method  time  is  saved  and  fluids  are  easily 
prevented  from  entering  the  abdomen,  but  the  disadvantages  are  serious.  A 
very  long  incision  is  required — usually  from  a  point  4  centimeters  (1  \  inches) 


• 


i  ■/. 


I 


820 


AMHIilCAX    TKXT-nooK   OF   OliSTiyrii l(\S. 


'I 


IP' 

I. 


ii; 


f' ••  : 


3'^^ 


;.' 


*- 


) 


al)()vc  the  symphysis  piil.is  to  one  about  6  wiitinictcrs  {'I'l  iiiclics)  alxtvf  [W 
iiiul)ili('iis  ;  ail  ciioriiioiis  cicatrix  remains,  wliicli  wcaUciis  the  liiica  alba  ami 
leads  sometimes  to  lieniia,  necessitating'  snl»se(|neiit  operation.  In  tlio  seccunl 
method  the  incision  need  seldom  hv.  more  than  15  centimeters  (0  inches)  in 
len;ith,  exten<linj«;  from  a  point  4  centimeters  (1,^  inches)  above  the  svinphvsis 
to  a  point  4  centimeters  (l.V  inches)  below  tlu;  nmbilicns.  This  ii\eision  is 
usually  sullicient  for  the  introduction  of  the  hand  and  the  ('xtraetion  of  the 
child.  (Jreater  care  is  needed  to  keep  tlnitls  out  of  the  abdomen,  but  th(>  tinal 
results  are  better  and  the  abdominal  walls  are  less  liable  to  be  weakened. 
Whichever  method  is  selected,  a  small  incision  should  be  made  in  the  linea 
alba,  and  when  the  peritoneal  cavity  has  been  opened  a  finj^er  is  introdiu'cd  as 
a  j:;uide  and  the  incision  is  cnlarf^cd  upward  and  downward  by  means  of  a 
stronn'  pair  of  s(;issors.  There  will  be  less  bleeding  than  if  the  whole  incision 
is  made  with  a  knife. 

When  the  loiij;  incision  is  employed,  half  a  dozen  lonj;  wire  sutures  are 
passed  throu<ih  the  upper  portion  of  the  wound  and  left  to  be  ti<;litened  after- 
ward. The  uterus  is  then  pushed  up  into  the  incision  anil  the  abdominal  walls 
are  pressed  back  over  it.  As  it  emerifcs,  the  first  assistant  covers  it  with  towels 
wruujjj  out  of  hot  water  and  supports  it  until  a  lar<re  Hat  spon}j;o  or  a  gauze  pad, 
also  wrung  out  of  hot  water,  has  been  adjusted  behind  it,  and  the  wire  sutures 
are  tightened.  The  rubber  band  is  then  passed  around  the  lower  uterine  seg- 
ment below  the  presenting  part,  and  the  ends  are  given  to  the  second  assistant. 
The  anterior  surface  of  the  uterus  is  then  incised  in  the  niidtlle  line  without 
reference  to  the  situation  of  the  placenta.  It  is  unnecessary  to  spend  time 
detaching  the  placenta  and  pushing  it  to  one  side  when  it  is  in  the  wav,  as 
reeinnmended  by  some  operators. 

77(f  utcnnc  invlxlnn  should  be  about  10  to  12|-  centimeters  (4  to  .'j  inches)  in 
length.  An  opening  is  made,  just  abose  the  lower  uterine  segment,  large 
enough  to  admit  one  finger,  and  I'te  incision  is  enlarged  upward  by  means  of  a 
pair  of  scissors.  The  child  is  then  seized  by  the  extremity  lying  ne:  'est  the 
incision,  whether  it  be  the  head,  the  breech,  or  the  foot,  and  is  extracted  as 
quickly  as  possible.  The  cord  is  quickly  tied  and  cut,  the  elastic  ligatiu'c  is 
tightened,  the  placenta  and  the  membranes  are  carefully  peeled  off  and  removed, 
and  the  uterine  cavity  is  thoroughly  irrigated  with  hot  water  or  a  hot  antiseptic 
solution,  such  as  corrosive  sublimate  (1  :  5000).  Some  operators  dry  the  uterine 
cavity  and  dust  it  freely  with  iodoform  just  before  closing  the  uterine  wound  ; 
others  eontiinie  irrigation  with  hot  water  while  the  sutures  are  being  introduced 
and  tied.  After  the  uterine  wound  has  been  closed  the  elastic  cord  is  relaxed 
and  any  oozing  is  checked  with  a  hot  sponge.  The  uterus,  which  has  been 
kept  well  comi)ressed  by  the  first  assistant,  is  cleansed  and  returned  into  the 
abdomen.  The  pelvic  cavity  is  irrigated  and  sponged  dry,  the  toilet  of  tlio 
peritoneum  is  made,  and  the  abdominal  wound  is  sutured  as  in  an  ordinary 
celiotomy.  The  usual  antiseptic  dressings  are  applied,  and  a  hypodermatic  injec- 
tion of  ergotin  is  given  to  prevent  hemorrhage.  The  ])atient  is  put  to  bed,  hot- 
water  bottles  are  applied  to  the  limbs,  no  food  is  given  lor  twelve  hotus.  and 


iMiVr   llu> 
[0    SCt'Ulltl 

iiclics)  ill 
vmpliysis 
iicisioii   i-i 
oil  of  the 
t  tho  filial 
.vtakciK'tl, 
tlie"  liiii'a 
•odiii'cd  as 
leans  of  a 
lie  incision 

(Utiircs  arc 
ciiod  aftcr- 
iiiinal  wails 
tvitli  toWL'ls 
;^aii/e  iKul, 
virc  suturt'S 
itcrino  sog- 
\(\  assistant. 
line  without 
sjiciul  tiin(> 
the  way,  as 

5  inches)  in 
;iiient,  larj!;o 
means  of  a 
lie;  u'st  the 
xtraeted  as 
l;  lijrature  is 
itl  removed. 
|ot  antiseptic 
the  uterine 
■iiie  wound  ; 
\r  iiitrodneetl 
•d  is  relaxed 
•h  has  hceii 
■lied  into  tlic 
[toilet  of  tiie 
an  ordinary 
Irmatic  iiijec- 
to  hed,  iiiit- 
|e  hours,  and 


oiisTiyrim '  srna i:i{  v. 


921 


the  howcJH  nre  moved  within  tiie  first  twenty-four  hours.  Duriii'j;  tlie  first 
week  the  iioiirisiinieiit  should  he  ii((iiid  exclusively.  The  aluloininal  sutures 
can  generally  he  remove<l  from  the  tenth  to  the  tiiiirteenth  dav,  and  in  favor- 
able cases  tlu!  patient  may  he  ahle  to  sit  up  hy  the  middle  of  the  third  week. 

If  the  uterus  is  incised  hefore  heiii;;  turned  out,  the  technicjue  is  somewhat 
ditVerent.  The  alxlominal  incision  is  onlyahoiit  lo  i-entimeters  ((»  inches)  loiij; ; 
the  hand  is  passed  into  the  ahdoiuiual  cavity  and  swept  around  to  ascertain  the 
preseiH'c  and  situation  of  any  adhesions.  The  elastic  loop,  held  hetween  the 
ll>re  and  middle  lin^fcrs,  is  passed  over  the  fiiiuliis  and  adjusted  alioiit  the  lower 
uterine  segment ;  the  ends  are  then  given  to  the  second  assistant,  who  makes 
upward  traction  on  them,  therehy  preventing  hemorrhage  and  holding  the 
uterus  steadily  against  the  pnhes.  While  the  uterine  iiicisioii  is  being  made 
the  first  assistant  keeps  the  uterus  firmly  against  the  abdominal  incision,  and 
while  the  child  is  being  extracted  he  promotes  uterine  contraction,  makes  steady 
pressure  on  the  abdominal  walls  from  above  downward  and  it)rward,  and 
gradually  presses  the  uterus  out  through  the  abdominal  incision.  Wire  sutures 
are  not  refpiired  in  the  upper  part  of  the  wound  to  keep  the  intestines  from 
protruding.  The  subsecjueiit  ste|)s  of  the  operation  are  tin-  same  as  in  the 
method  previously  described. 

Some  ()perat(»rs  make  the  operation  comparatively  bloodless  by  tightening 
the  elastic  ligature  before  the  uterus  is  inciseil,  and  not  relaxing  it  until  the 
uterine  wouiul  is  closed;  others  do  iu)t  tighten  it  until  after  the  delivery  of  the 
child,  [f  the  ligature  is  drawn  too  tight  or  is  kept  applied  too  long,  there  is 
danger  of  jiaralyzing  the  uterine  muscle  and  producing  suhse(|iient  inertia  and 
hemorrhage.  To  overcome  this  ditlicidty  Siiiiger  proposes  the  use  of  an  anti- 
septic towel  folded  to  form  a  band.  Other  operators  use  no  band  at  all,  but 
direct  the  second  assistant  to  grasp  the  lower  uterine  segment  before  the  uterus 
is  incised,  and  to  compress  it  Hrinly  with  his  hands  until  the  child  has  been 
delivered  and  the  wound  has  been  sutured.  Hemorrhage  into  the  abdominal 
cavity  sometimes  occurs  subsequently  from  uterine  inertia  or  faulty  suturing. 
If  slight,  it  may  be  cheeked  by  an  ice-bag  over  the  uterus  and  a  hypodermatic 
injection  of  ergotin  ;  if  abundant,  the  abdomen  must  be  reopened,  the  clots 
turned  out,  and  the  bleeding  point  secured.  Before  the  uterine  wound  is  finally 
closed  some  operators  dilate  the  cervix  from  above  and  pack  a  strip  of  iodo- 
form gau/e  7.5  centiiiieters  (3  inches)  wide  and  91.5  centimeters  (3  feet)  long 
into  tifc  uterine  cavity,  passing  the  end  through  the  cervix  into  the  vagina,  to 
provide  free  drainage  and  to  guard  against  intra-uterine  hemorrhage  by  stimu- 
lating contraction.  This  practice  is  unnecessary  in  most  cases  unless  the  uterine 
iiuisele  is  flabby  and  weak  and  does  not  contract  well. 

The  rtcrinc  Siifitir. — Silver  wire,  silk,  and  catgut  sutures  are  emidoyed, 
but,  on  the  whole,  silk  or  well-jirepared  catgut  seems  to  he  preferable.  Most 
operators  use  two  sets  of  interrupted  sutures — a  deep  layer  to  ajiproximate  the 
divitled  muscular  coats,  and  a  su])erficial  layer  to  close  the  peritoneum.  The 
deep  sutures  of  \o.  2  silk  pass  from  3  to  0  millimeters  (J-  to  \  inch)  from  the 
border  of  the  incision  diagonallv  down  through  the  muscular  tissue  to,  but  do 


I  ! 


^-l  t'i 


f^ 


I   ! 


i  i 


I  I 


922 


AMERICAN    TEXT-BOOK   OE   OJiSTETJUCS. 


not  iudiulo,  the  deciclual  lininsr  (Figs.  509,  alO).  Thoy  are  about  |  inch  apart, 
and  arc  eijrlit  to  twelve  in  number,  according  to  the  Icngtli  A'  the  wound.  As 
soon  as  they  are  all  introduced  the  uterine  cavitv  is  irrigated  with  a  hot  sub- 


l"i(i.  .WJ.— Till'  deep  s\itiiro  i>lii('0(i  us  a  running  Vu;.  .Mo.— Tlio  rumiiiii;  stitches  nl'  tlio  do'ii  sii 

stitcli;  it  ini'ludi's  lu'ritdiiciil  and  inusciilar  coats,  t\iri'  cut  tn  I'onii  iiiti'i-niiilcd  sutures  (lucidilicd 
but  not  decidual  lining  ^lnodilied  from  tiraiidinl.  Iioui  (iraudin). 

limate  solution,  the  sutures  arc  tied  securely,  and  the  ends  are  cut  short.  The 
sujierficial  sutures  of  catgut  or  of  Xo.  4  silk  arc  then  put  in  to  bring  the  peri- 
toneal borders  into  close  apj)osition  (Figs,  oil,  512).  The  Ijcnibert  suture  is 
generally  employed  for  this  purpose,  though  it  is  claimed  that  ctpially  good 
restdts  may  be  obtained  by  simply  approximating  the  cut  edges.  ()iit>  super- 
ficial suture  is  introdiu'cd  over  each  deep  one,  and  another  midway  between, 


Penforical 
Suture 


Pepifo7ieiwi 


j^^^_^^j^^  ^luscularWali  ,^ 
Pccidna 


j^piscle^uiure 


//{/9c/p\fi//iire 


Km.  "dl.— Ilianniins  (d' llie  peritoneal  and  nmscle-sutnros:  A,  before  lliey  are  <ira\V"  tinlit  and  ti<'d 
(niodilied  from  Krits(dil:  It,  the  two  slitehcs  after  tyiiif;.  The  miiscle-sutnre  is  buried  and  the  upper 
suture  folds  the  |M'ritoneum  tonetlier. 

mtdving  th(!  number  of  su|»erli('ial  sutures  doid)le  that  of  the  deep  ones.  When 
they  are  ail  tied  the  knots  of  the  deep  sutures  are  completely  buried  and  the 
opposing  siirlaccs  of  peritoneum  are  in  dose  apposition  (Fig.  All,  w).  The 
action  iuid  reltit ions  of  these  two  layers  of  sutiirt's  tu'c  slio"  it  in  I'Mgure  "))  I. 
Dudley'  of  New  York  recently  adopted  a  contimioiis  (atgiit  suture  of 
three  hiyers,  which  h(>  claims  to  be  superior  to  the  ordinary  interrupted  silk 
suture  in  two  lavers.  The  tirst  row,  which  begins  tit  th(>  inner  (>dge  of  the  upper 
angle  of  the  wound,  includes  the  dtH'idua  and  the  inner  muscular  coats,  ll  is 
'  American  Journal  iif  OlmtrtrifK,  .lati.,  1S1I5,  [i.  l(i. 


OBSTtyriiir  sritoER  v. 


923 


,   II n 

1^1^  ^'> 

7-^ 

r  ' 

\ 
1 

h  apart, 
ul.  As 
lot  sub- 


till'  cU'cpsu 
L'.s  ^Illll^li^n■ll 


ort.  Tlio 
;  tlu'  poi'i- 
:  siitiuT  is 
lally  ii'ood 
)iic  supor- 
bi'tween, 


Mil 

^lil  mill  liiil 

il    tlio   Ul'pi'l' 

..      Whrll 

,h1  ami  tlic 
p.).     Tl..' 

loiirc  -'til. 

siitiirc  nl 

iipt('<l  >ill< 
llic  upper 

•ats.      It  is 


Fic.  filj.— Two  pirituiuiU  sutmcs  aro  Iuto 
shown,  oiu'  lyini;  level,  iiml  tl\>'  otluT  iis  it  is  in 
proccs.s  oC  lyintj;  luiu'iilli  tlic  liittcr  .siitiiri'  is 
seen  the  knot  of  the  tied  niuselesiiture  I'lnindin). 


contiuuc'd  to  the  lower  augle  of  the  wouiul,  and  when  tii^htened  closes  oft'  the 
uterine  cavity.  Without  cutting  or  tying  tiie  catgut,  tiie  second  row  is  car- 
ried back  to  the  upper  angle,  including 
the  rest  ot"  tiie  nniscular  tissue  and  si- 
nuses, care  being  taken  to  pass  the  needle 
through  the  cut  ends  ot"  any  sinuses 
visible.  Wiien  this  row  is  tightened 
about  three-fourths  of  the  depth  of  the 
uterine  tissues  has  been  clo,sely  approx- 
imated. Without  cutting  or  tying  the 
catgut,  the  third  row,  in'  an  over-and-  ^^ 
over  stitch,  eompletelv  buries  the  two  i 
lower  layers  and  brings  the  peritoneal 
surliices  together;  the  catgut  is  linally 
tied  at  tiie  lower  angle  of  the  incision. 
The  advantages  claimed  fortius  metliud 
are — (1)  that  it  brings  the  whole  depth 
of  the  uterine  wound  into  closer  apposi- 
tion, shortens  the  wound  considenibly, 
and  prevents  the  danger  of  leakage  be- 
tween the  sutures  and  the  formation  of  blood-clots  between  the  woiind-etlges ; 
(2)  that  the  suture  is  eomjiletely  buried  from  beginning  to  enil  e\cc])t  where  it 
c'telies  the  jieritoneum  ;  (."})  that  there  is  no  rolling  in  of  the  cut  surfaces  tuid 
no  eversiou  of  the  lips  of  the  wound,  and  catgut  is  not  more  liable  to  be  septic 
or  to  become  septic  than  silk.  It  is  urged  against  catgut  tliat  it  is  lial)Ie  to 
stretch  and  to  permit  gaping  of  the  wound,  and  that  the  knots  are  apt  to  untie; 
this  may  occur  in  the  case  of  interrupted,  but  not  with  cnntiniioiis,  sutures  ; 
moreover,  the  abdominal  siu'face  of  the  uterine  wound  is  covered  with  lynipii 
in  a  few  hours,  mm'  i;.e  peritoneal  cavity  is  .sife  .<o  far  as  the  wound  is  con- 
cerned. In  eig'ni  o''  nine  days  tiie  catgut  is  absorbed  and  the  wound  is  per- 
fectly uiiitct'  :  but  when  silk  is  used  the  suture  btvomes  encysted,  and  some 
lime  ("lapses  befo'c  it  can  be  disintegrated  and  removed.  Dudley  claims  that 
with  liis  method  there  is  le.ss  lial)ility  of  adhesion  taking  place  between  the 
uterus  and  the  abdominal  walls,  and  there  is  no  danger  of  cntliiig  down  upon 
an  encysted  suture  in  a  subsecpient  operation.  lie  performs  tlie  whole  o|)era- 
tion,  from  the  (ii'st  incision  in  the  abdominal  wall  to  its  final  closure,  under 
constant  irrigation  with  hot  water  or  with  hot  snbliniiite  sol  :*ion. 

IWairnn  Section  iiiiDifdidtcli/  affcr  flic  Pcatli  n/'  llic  Mnfhcr  or  irlicn  She  /.s- 
MnvUmntL — When  the  inolher's  life  is  extinct  there  is  no  spe-ial  teehiii(|Ue.  as 
the  main  point  is  to  extract  the  fetus  as  (jiiickly  as  po.-sible.  The  operation  is 
most  likely  to  succeed  if  death  has  been  sudden:  ii"  it  has  lu'cn  slow  or 
gradual,  the  child  is  usually  as|)liyxiated  beyond  hope  of  restoration  ix'llnv  the 
mother's  life  is  extinct.  If  she  is  living,  but  in  ciicnnis,  \\\c  operation  must 
be  done  deliberately  and  with  due  regard  to  her  safety,  fiir  one  catinot  be 
certain  that  she  must  inevital)lv  sticcumb. 


i:     >!   f 


• 


I 

\ 


•aI 


924 


AMElilCAN    TEXT-BOOK   OF    OBSTETRICS. 


M  I 


) 


% 


J'orro  Operation. — The  procccliire  in  tliis  is  pivt-isoly  the  same  as  in  tlie 
yiliiger  operation  until  the  uterus  has  been  turned  out  of  the  abdominal  cavity. 
Tlie  elastic  ligature  is  then  {)assetl  around  the  lower  uterine  segment  and  is 
tied  loosely,  and  a  large  piece  of  thin  rubber  sheeting,  a  thermo-cautery,  and 
a  Koeberle  ecraseur  are  prepared  for  use.  A  small  opening  is  maile  in  the 
rubber  sheet,  to  permit  it  to  be  ])assc'd  over  the  fundus  and  carried  down  to 
the  elastic  band.  It  serves  to  prevent  fluids  from  the  uterus  entering  the  ab- 
dominal cavity.  The  elastic  ligature  is  then  tightened,  the  uterus  is  incised,  tlie 
child  is  delivered,  the  placenta  is  detached  and  removed,  and  the  uterus  and 
appendages  are  cut  away  just  above  the  rubber  sheeting.  If  the  child  has  been 
extracted  before  the  uterus  is  turned  out  of  the  abdomen,  the  ligature  will  have 
already  been  tightened,  so  that  it  remains  only  to  slip  the  rubber  sheet  over  the 
uterus  as  soon  as  it  emerges  through  the  abdominal  incision,  and  amputate  with- 
out delay.  Many  operators  adopt  Miiller's  method  of  applying  the  clastic  lig- 
ature before  incising  the  uterus.  Fehling  passes  an  additional  ligatiu'e  beneath 
the  (irst  as  a  precautionary  measure.  After  the  uterus  is  removed  the  stump  is 
carefully  disiniocted  and  cauterized  ;  it  is  then  treated  extraperitoneally,  or  the 
entire  stump  and  cervix  are  removed  and  the  abdominal  wound  is  closed.  The 
extraperitoneal  method  is  more  rapid,  and  is  generally  preferred  if  the  patient 
is  very  weak  or  is  sutfcring  from  shock.  The  loop  of  the  ecraseiu"  is  made  to 
encircle  the  stump  just  beneath  the  rubber  ligature,  and  is  tightened  until  the 
tissues  are  blanched.  Care  nuist  betaken  not  to  enclose  the  bladder-wall  in  the 
looj)  of  the  t'craseur.  The  rubber  band  is  then  removed,  the  stiunp  is  trimmed 
and  cauterized,  and  is  ti'ansfixed  above  the  win;  loop  with  two  strong  steel  yi'ms 
passed  transversely  across  the  abdominal  wound.  The  peritoneum  is  stitched 
aroinid  the  stump  with  a  continuous  catgut  suture,  the  abdominal  cavitv  is 
cleansed  and  dried,  and  the  ab(h)niinal  incision  is  sutiu'cd.  An  iodoform  dress- 
ing is  ap[)lied,  and  left  undisturbed  for  several  days  indess  hemorrhage  occurs 
or  the  temperatiu'c  begins  to  rise.  If  the  stumj)  is  moist,  the  dressings  will 
soon  become  soaked  with  discharges;  they  nuist  be  removed  and  the  stump 
thoroughly  disinfected,  any  sloughy  pieces  being  clipped  ott'  with  scissors,  and 
fresh  dressings  applied.  If  there  is  any  bleeding  from  the  stump  during  tlie 
first  three  or  four  days,  the  bleeding  point  should  be  found  and  ligatured.  The 
stump  sloughs  away  in  from  ten  to  fifteen  days,  leaving  a  large  granulating 
surftice  which  is  sometimes  slow  to  heal.  To  hasten  this  process  various  expe- 
dients are  employed.  Sutiigin  scrapes  and  pares  the  surface  of  the  stump  to 
produce  a  raw  surface,  and  cl(»ses  the  borders  with  ligatinrs,  introducing  a  small 
tent  of  iodoform  gauz(!  into  the  lower  angle  of  the  wound  for  drainage.  Otiicis 
dilate  the  cervix  and  pass  a  strip  of  gauze  from  above  through  the  cervix  into 
the  vagina.  The  intraperitoneal  method  is  theoretically  preferable,  but  so 
far  its  residts  are  not  ideal.  The  technicpie  varies  according  fo  the  circum- 
stances of  the  case,  but  the  main  line  of  proccduri'  is  to  free  the  bladder  from 
its  attaciunents  to  the  lower  ut(>rine  segment  after  the  uterus  has  been  removed 
and  the  stump  has  been  disinfected,  secure  the  broad  ligament  on  each  side 
with  strong  silk  ligatures,  tie  the   uterine  arteries,  divide   the  vaginal  atladi- 


OBSTE  riilC  8  (  Ve  (lEli  1 '. 


925 


I  in  the 
cavity. 

;  tiiul  is 

:^ry,  uiid 

3  iu  the 

lIowu  to 
tlie  ab- 

■is(,'(l,  tlie 

>rus  and 

has  boon 

vill  luivo 
over  the 

ate  witli- 

lastic  liif- 

e  bouoatli 

!  stump  is 

Iv,  or  the 

tsod.  Tlu; 

ic  patioiit 

5  made  to 
until  tlio 

^•all  in  tlio 

s  trinnnod 
stool  piiis 

s  stitoiiod 
cavity  is 
)rm  dross- 
itjo  ocours 
•;injj;s  will 
:ho  stmiii) 
issors,  and 
lurino;  tlio 
(U-od.  The 
■anulatiiiir 
[ons  oxpo- 
stnmp  to 
Intra  small 
Othois 
K'vvix  into 
bnt   so 
cirouni- 
Lldor  iVoni 
\\  roiniivcd 
oaoh  side 
al  attaoli- 


f 


m 


meuts  of  the  cervix,  and  remove  the  stump.  Any  bleedinj;  points  are  then 
tied,  the  ends  of  the  litfaturos  being  kit  lonj;,  so  that  thoy  may  be  passed  down 
through  the  vajrinal  opening.  Strips  of  iodoform  gau/o  arc  firmly  ])aoUod  in 
the  upper  part  of  the  vagina,  and  tlie  peritoneal  cavity  is  closed  otf  bv  stitch- 
ing the  peritoneal  covering  of  the  bladder  to  the  peritoneal  layer  of  the  cul-de- 
sac  with  a  contimious  catgut  suture.  TIk;  abdominal  cavity  is  thou  ciirefnllv 
cleansed  and  (h"ied  and  the  abdonnnal  woiuid  is  sutui'cd.  The  objuet  of  this 
method  is  to  close  the  ])eritoneal  cavity  com[)lotoly,  turn  the  raw  surface  down- 
ward toward  the  vagina,  and  obviate  the  necessity  of  draining  from  above. 
Unless  the  operator  is  export  in  abdonunal  work,  it  will  be  safer  and  easier  for 
him  to  choose  the  extraperitoneal  method.  If  the  uterus  has  been  intictod,  it 
is  well  to  close  the  abdominal  wound  as  nuich  as  possible  beibre  be»riiuiin<r  to 
work  with  the  pedicle,  in  order  to  avoid  in  looting  the  ])oritoneal  cavitv. 

Laparo-elytrotomy. — This  operation  was  devised  by  Thomas  to  avoid  the 
risks  of  opeinng  the  abdonun  and  wounding  the  uterus  ;  but  since  the  perfect- 
ing of  the  kSiinger  and  Porro  operations  has  reduced  these  dangers  to  a  mini- 
mum the  necessity  for  laparo-elytrotomy  can  scarcely  be  said  to  exist.  The 
method  of  procedure  is  to  incise  the  abdominal  walls  in  the  line  of  Ponpart's 
ligament,  lift  the  poritouenm,  dissect  down  to  the  vagina,  an<l  tear  it  through 
transversely,  so  that  the  cervix  may  be  reached  and  the  child  be  delivered 
through  the  passage  thus  made.  This  oi)eration  has  been  done  thirteen  times, 
seven  of  tin  mothers  being  saved. 

7Vor/)(o.s/.s'  of  Ccn(nr<tn  .sVc/Zoji. — The  mortality  in  ]>re-antiseptic  days  ranged 
from  30  to  50  jier  cent.  It  has  been  reduced  to  about  10  per  cent,  by  doing 
the  operation  early,  and  not  as  a  <lcniicr  rri^soii,  and  by  ])ractising  a  scrupu- 
lously aseptic  techni((ue.  In  private  practice  the  jiDgnosis  for  the  mother 
depends  very  nuich  upon  the  urgency  of  the  case  and  the  jxtssibility  of  secur- 
ing favorable  conditions  f()r  the  operation.  It  is  far  more  difHcnlt  to  carry  ont 
a  pro])or  techni(pie  in  private  than  in  hospital  practice.  The  prognosis  for  the 
child  is  good  ;  from  90  to  95  percent. of  the  children  have  been  saved.  Since 
the  mother  should  not  run  nnich  more  risk  from  Cosaroan  section  than  from 
craniotomy,  while  the  child  is  almost  certainly  saved  in  the  one  ca<e  and  delib- 
erately destroyed  iu  the  other,  there  can  bo  very  little  (piestion  at  the  ])r(\soiit 
ilav  as  to  the  choice  of  operation.  In  fact,  craniotomy  upon  the  living  child 
is  justifiable  oidy  under  exceptional  circumstances.  It  must  be  admitted,  how- 
over,  that  the  results  of  the  Cesarean  section  in  Amori<'a  have  so  far  boon 
disa))pointing,  the  mortality  from  the  op(!ration  being  nmch  higher  than  in 
Kurope.  It  should  not  bo  so,  and  we  cannot  expect  that  Cesarean  section  will 
replace  craniotomy  until  oiu"  results  liav<'  been  oiinsidorably  improved. 

In  the  l*orro  operation  i!ie  maternal  mortality  ranges  higher,  owing  to  the 
more  serious  condition  of  the  mother  boi'ore  «tperation.  Notwithsianding  the 
unfavorable  circumstances  usuaUv  jircsent,  the  mortality  has  boon  reduced  to 
about  25  per  cent.  In  Italy  the  mortality  is  about  10  per  cent.,  as  the  Porro 
ojieration  is  performed  in  cases  whore  the  Siing(M'  operation  would  bo  proil'ri'od 
elsewhere.     IJreisky  performeil  11  opi.-rations,  and  Leopold  7,  without  a  death. 


• 


ife  .  •(  \ 


}  "? 


:  (         ■'? 


926 


AMEIilCAX    TEXT-BOOK    OF    OBSTETIUVS. 


I-'  '' 


i  '^ 


J    i' 


f\.  I       ( 


n 


,0  '-iii 


"■f 


Craniotomy  and  Embryotomy. — These  arc  the  terms  a{)plie(l  to  all  de- 
structive operations  by  which  the  volume  of  the  fetus  is  reduced  in  order  to 
permit  delivery  per  vUiti  nataraloi.  Althoujrh  in  a  literal  sense  all  such  opera- 
tions might  be  included  under  Kujbryotomy,  yet  general  usage  has  sanctioned  a 
more  restricted  application  of  the  term.  CnnwAomi)  is  used  to  denote  mutila- 
tion of  the  fetal  head ;  einhri/utonii/,  nuitilation  of  the  fetal  truni:.  AVhen  a 
destructive  operation  has  to  be  performed,  the  choice  of  method  is  determined 
by  the  nature  of  the  ])rcscntation.  Since  the  head  presents  in  the  great  ma- 
jority of  cases,  craniotomy  is  most  fre(piently  done,  while  embryotomy  is  com- 
paratively rare.  Whatever  may  be  the  circumstances  of  the  case,  that  operation 
should  be  chosen  which  is  likely  to  expose  tin;  mother  to  the  least  risk. 

The  operative  procedures  included  under  the  general  terms  craniotomy  aiul 
embryotomy  may  conveniently  be  classified  as  follows  : 

1.  Upon  the  /lead: 

(a)  Perforati(m  ; 
(6)  Cranioclasis  ; 
(c)  Cej)halotripsy  ; 
{d)  Basiotripsy. 

2.  Upon  the  «ec/;;  Decapitation. 

;i.   Upon  the  trunk:   Evisceration  or  eventration. 

Indications. — It  is  of  primary  imjjortance  to  determine  whether  the  fetus  is 
living  or  dead.  If  dead,  its  bulk  should  be  reduced  whenever  there  is  suffi- 
cient disproportion  to  make  delivery  difficult  or  dangerous.  It  is  far  better  to 
mutilate  a  dead  fetus  in  oriler  that  the  mother  may  be  delivered  easily  and 
safely  than  to  subject  her  to  the  risks  of  a  tedious  and  difficult  forceps  opera- 
tion. Esthetic  considerations  and  regard  for  appearances  should  not  be  allowed 
to  weigh  against  the  mother's  safety.  lint  when  the  child  is  alive  tliecjuestion 
becomes  entirely  different.  Undoubtedly,  in  recent  years  syn.physiotomv, 
Cesarean  section,  and  the  iniluction  of  j)rematin'e  labor  have  <;reatly  narrowed 
the  field  of  the  destructive  operations,  but  are  we  quite  jireprred  to  admit  that 
craniotomy  upon  the  living  child  is  never  justifiable?  Pinard  and  his  follow- 
ers boldly  take  this  ground,  so  do  a  few  operiff.rs  who  have  had  exceptionally 
good  results  from  Cesarean  sedion  ;  but  most  obstetricians  feel  that  the  results 
of  the  conservative  operations  do  not  yet  warrant  such  a  sweeping  assertion. 
Until  it  has  been  established  that  the  maternal  mortality  after  the  conservative 
operations  is  not  greater  than  that  after  embryotomy,  it  would  be  rash  to  say 
that  mutilation  of  the  living  child  is  never  justifi:ii)le.  In  the  minor  forms  of 
dystocia  the  choice  of  operation  will  probably  lie  betw<>en  craniotomy  and  syiu- 
phvsiotomv  or  the  induction  of  j)remature  labor  ;  in  tli'"  major  forms,  between 
craniot(unv  and  Cesarean  section.  The  maternal  mortality  after  basiotripsy  in 
the  Paris  lios|>itaIs  is  practically  ni/  when  (lon(>  in  selected  cases  i.nd  under 
favorable  cireumstanciN.  Leopold  and  olliers  have  had  almost  as  good  rc-iilts 
from  Cesarean  section  under  similar  conditions.  iJiit  in  private  practice,  when 
flic  skill  an<l  exiiericnce  of  I  lie  operator  are  not  iisrally  so  great,  when  lliciv  is 
lack  of  skilled  assistance  and   the  surroundinii-.  are  unfiivorable,  the  result- 


fix: 


all  (Ic- 
n'clor  to 
1  opora- 
ioiicd  a 
mutila- 
^Vliei\  a 
erminod 
cat  uui- 
■  is  com- 
ipL'ratiun 

Diuy  ami 


le  fetus  is 
;  is  siiffi- 
"  l)('tt(M'  to 

^'asily  ami 
>ps  ()]tL'ra- 
0  allowed 
le  question 
vsiot(tiuy, 
narrowed 
dmit  tiuit 
is  t'ollow- 
ptionally 
iho  results 
Assertion, 
isers'ativo 
sh  to  say 
lornis  ot" 
and  syiH- 
,  Ix'tweeu 
itripsy  in 
nd   under 
(d   re-uits 
t  ice,  when 
n  tlierc  is 
liic  results 


OBSTETIUV  SURGEJt  Y. 


927 


after  either  operation  will  be  less  favorable.  When  Cesarean  seetion  is  per- 
ibnned  as  an  eleetive  operation,  the  mortality  should  not  be  greater  than  10 
per  eent.  ;  but  wiien  done  as  a  dernier  rcNtiort,  after  ineffectual  attempts  to  de- 
liver by  forceps  or  by  version,  tlie  risk  to  the  mother  becomes  very  great  indeed. 
Craniotomy  in  suitable  cases,  done  deliberately  and  without  force,  should  be 
little  more  dangerous  than  a  forceps  operation,  but  when  done  after  repeated 
forcilde  attempts  to  deliver  with  forceps,  especially  if  the  disproportion  between 
the  fetus  and  the  maternal  passages  is  great,  it  becomes  one  of  the  gravest  and 
most  difficidt  obstetrical  (operations.  Embryotomy  on  the  living  child  involves 
such  serious  responsibility  that  it  would  rarely  be  chosen  as  an  elective  opera- 
tion. Practically,  therefore,  elective  embryotomy  is  seldom  pitted  against  elec- 
tive Cesiu'can  section.  When  the  operation  is  one  of  election.  Cesarean  section 
is  generally  the  choice  ;  when  it  is  a  <Ier)iier  re^fsorf,  embryotomy  is  usually 
safer  for  the  mother.  The  whole  ([uestion  turns  upon  an  early  and  exact  diag- 
nosis. If  the  patient  has  been  examined  carefully  before  the  onset  of  labor  to 
determine  ai)proximatcly  the  relative  size  of  the  fetus  and  the  maternal  pas- 
sages, there  should  be  very  little  difficulty  in  deciding  upon  the  best  course  to 
pursue.  Rut  if  labor  has  been  allowed  to  drag  along,  and  the  disproportion 
has  been  diagnosed  only  after  rept'atcd  failures  to  deliver  by  fori'cps  t)r  by  ver- 
sion, the  case  assumes  a  different  asjiect,  and  the  chances  of  safe  delivery  by 
any  means  are  impaired.  Such  case-<  emphasize  the  necessity  of  making  a 
careful  examination  of  the  pelvis  in  all  pregnant  women  whose  appearance  or 
history  suggests  the  possibility  of  defoi-mity  or  disproi)ortion.  There  is  really 
no  good  reason  why  an  amount  of  dispro[)ortion  calling  for  Cesarean  section  or 
end)ryotomy  should  in)t  be  made  out  long  before  the  onset  of  labor.  But  very 
often  the  physician  does  not  see  his  patient  until  labor  is  well  advanced,  and 
then  the  case  may  call  for  prompt  action,  even  though  the  surroundings  are 
unfavorable  and  skilled  assistance  camiot  be  procured.  Under  such  circum- 
stances, if  the  disproportion  is  slight  or  moderate,  a  craniotomy  could  probably 
be  done  with  far  less  risk  to  the  mother  than  a  symphysiotoniy  or  a  (*esarean 
section  ;  but  if  the  disproportion  is  extreme,  craniotomy  becomes  a  very  diffi- 
cult and  dangerous  operation,  and  Cesarean  section  will  give  the  mother  a  better 
chance  even  if  the  operator  is  inexpert.  It  is  ev'dent,  therefore,  that  no  posi- 
tive rules  can  be  laid  down,  for,  even  in  the  mother's  interest,  sometimes  one 
operation  may  be  preferable  and  sometimes  another.  At  all  events,  it  is  ])re- 
niature  as  yet  to  say  that  mutilation  of  the  living  child  is  never  justifiable. 
Under  any  circumstances  th(>  physician  should  not  assume  the  fidl  responsi- 
bility in  such  cases,  but  should  leave  the  ultimate  decision  to  the  patient  and 
her  friends,  after  having  Iai<l  the  fact-  fairly  lieforr  rhem. 

The  ordiuarv  indications  for  embryotomy  may  be  gn^nu'd  as  follows: 

(1)  Deformity  of  the  pelvis,  where  fonrps  or  version  is  either  impossible  or 
is  dangerous  for  tlie  mother. 

(2)  Disproportion  between  the  parturicMit  canal  and  the  fetus  that  cannot 
safely  be  overcome  by  a  conservative  opcniiion. 

(I])  Tumor- — utiTiuc.  ovarian,  malignant,  or  osseous. 


>:  f 


I 


« 


928 


AMERICA X    TEXT-BOOK    OF   OJiSTETIilCS. 


(:':' 


iV-', 


Fio.  51IJ.— Perforator  of  Pmellic 


Fi(i.  'jU.— IVrforiitor  (jt  sim|ps<ni. 


Flo.  M').— Perforator  of  NncRele 


Fi(,.  >>IO.-rerforator  of  I'iniii-ii. 


!)' 


>    Ai 


Fiii.  r)17.— Perforator  (jf  Harnos 


>  I 


I 


i 


Fig.  .'jUs.— Trepliiiie  of  lirauii 
(straight  anil  eiuvetli 


OBSTETRIC  SURG  EH  Y. 


929 


!,.    I 


Kro.  519.— Craniotomy  forceps  of  Meigs. 


Fiii.  MO.— Craniodnst  of  Barnes. 


.: ;  I 

\"  1  I. 

Fig.  521.— Cranioclast  of  Simpson. 


Fi(i.  522.— Cephalotribe  of  Braun. 


Fici.  .'■)23.— Cephnlotribe  of  Lusk. 


* 

I 


I'lQ.  .524.— Ccphalotribf  of  Ilicks. 


59 


§n|f^ 


980 


AMERICAN    TEXT-BOOK   OE    OJiSTETIifCK 


I'h 


I 


i; 


i   I  !^ 


(4)  Monstrosities,  such  as  hydrocephalus. 

(5)  Impaction  of  the  presenting  part,  as  in  locked  twins  or  in  some  face  nic- 
entations,  especially  it'  there  are  swelling  and  inflammation  of  the  vagina  av 
of  the  cervix  resulting  from  long  impaction. 

(G)  P]clampsia  and  other  canses  which  demand  innnediate  delivery,  if  it  can- 
not safely  be  accomplished  in  any  other  way.  It'  the  liquor  amnii  has  lo.ig  Ihcii 
drained  away,  the  uterus  sometimes  becomes  tetanically  contracted  about  tlii^ 
fetus,  and  rupture  is  imminent ;  in  such  cases  forceps,  version,  and  Cesarean 
section  are  dangerous,  and  embryotomy  aflbrds  the  best  chance  for  the  motluir. 
The  child  will  probably  have  perished  long  before  the  question  of  embryotoinv 
comes  up  for  consideration. 

Inntruinciifs. — Space  does  not  permit  a  description  of  the  numerous  innciii- 
ous  instruments  which  have  been  devised  for  the  mutilation  and  extraction  of 
the  fetus.  As  the  prime  object  of  these  operations  is  to  reduce  the  bulk  of  tin; 
fetus,  the  first  step  is  generally  to  perforate  the  presenting  part  and  evacuate  its 
contents,  and  then  to  apply  a  powerfid  instrument  to  compress  it,  so  that  it  mav 
safely  be  extracted  through  the  narroweil  passages.  When  the  fetus  caimot  be  so 
compressed,  its  bulk  must  be  reduced  by  breaking  it  up  and  removing  it  piece 
by  piece.  Perforation  is  done  by  means  of  a  i)erforator;  compression  is  made 
by  a  cei)halotribe,  a  cranioelast,  or  a  basiotribe ;  connninutiou  of  the  vault  of 
the  skull  by  a  pair  of  small  craniotomy  force])s;  decapitation  by  a  blunt  hook 
or  an  embryotome.  So  far  as  possible,  end)ryotomy  instruments  should  be 
made  of  metal  and  be  so  constructed  that  they  can  easily  be  rendered  aseptic. 

Pevforatorn. — Three  types  of  perforators  are  in  use — the  scissors,  the  ti'c- 
phine,  and  the  heavy,  spear-shaped  perforator  of  the  basiotribe.  The  scissors 
perforator  may  be  sti'aight  or  curved  on  the  flat ;  on  the  whole,  the  straight 
form  is  the  safer  and  answers  the  purpose  very  well.  The  original  model  of 
Smellie  (Fig.  51.'])  is  still  in  use,  but  Sinipson's  (Fig.  514),  Barnes's  (Fig.  517), 
or  Pinard's  modification  (Fig.  516)  is  preferable.  Oldham's  and  Xaegele's  (Fig. 
515)  are  more  jiowerful  instruments,  but  have  no  special  advantages.  Tlie 
Germans  prefer  the  trephine,  claiming  that  the  brain-sid)stance  can  more  easily 
be  broken  up,  the  skull  being  perforated  through  a  bone,  and  not  through  a 
suture  or  a  fontanelle.  The  models  most  commonly  used  are  Brau.n's  (Fig. 
518)  and  Martin's,  either  straight  or  curved.  They  are  harder  to  manipulate, 
and  an  assistant  is  required.  The  spear-shaped  perforator  of  the  basiotribe 
is  not  withdrawn  like  the  other  perforators,  but  is  pushed  through  the  brain- 
substance  and  imbedded  in  the  base  of  the  skull  to  steady  the  head  while 
crushing  is  being  done. 

The  craniodast  is  a  powerful  prehensile  craniotomy  forceps,  one  blade  of 
which  is  passed  into  the  cranial  cavity  through  the  o])ening  made  by  the  perfo- 
rator, while  the  other  grasps  the  head  outside.  When  the  blades  arc  forcibly 
pressed  together  by  means  of  a  strong  compressing  screw  at  the  end  of  tlii^ 
handle,  a  firm  grip  of  the  head  is  obtained,  and  extraction  is  easy  unless  the 
passages  are  very  small.  The  small  blade  which  is  ])assed  into  the  skull  is 
solid  and  is  grooved  on  its  convex  surface,  with  the  tenou  of  the  lock  on  tlir 


OBHTETRIC  Sir  lid  Kit  Y, 


931 


aco  prt 


if  it  can- 

O.lg  hci'll 

bout  tlic 
Cesarean 
L^  motlicr. 
Dryntoinv 

IS  injrciii- 
rac'tioii  of 
iilk  of  the 
/aouate  its 
lat  it  may 
lunot  l)eso 
n^  it  niece 
jn  is  iiuule 
e  vault  of 
blunt  h()ol< 

should  he 
!(!  aseptic. 

rs,  the  tre- 
'hc  scissors 

he  straiirht 

1  uioilel  of 

(Fi^'.  517), 
ele's  (y\'£- 
liTfs.     The 
noro  easily 
throutrh  a 
u'.u'ri  (Fit;'. 
lanipulate, 
hasiotrilx' 
the  hrain- 
lead  while 

blade  of 
|-  the  perfo- 
re  foreil)ly 
hid  of  the 
I  unless  the 
lie  skull  is 
Lclv  on  the 


liandle  ;  the  larj^er  blade,  whieh  grasps  the  outside,  is  fenestrated  and  is  grooved 
on  its  inner  coneave  aspeet.  A  moderate  pelvic  curve  is  generally  given  to  the 
instrument  to  facilitate  introduction  and  extraction.  The  tiivorite  models  are 
those  of  Barnes,  Simpson,  and  liraun  (Figs.  520,  o21).  The  cranioclast  is 
es.sentially  a  tractor,  and  is  sufficient  in  most  cases  of  craniotomy,  uidess  it  is 
found  necessary  to  crush  the  base  of  the  sUuU.  The  advantages  claimed  for 
it  are — (l)that  it  is  not  apt  to  tear  away  when  scalp  and  bone  are  seized 
together;  (2)  that  it  seldom  slips  when  once  a  firm  hold  is  obtained  ;  (li)  that 
the  head  can  be  .seized  in  any  diameter  witiiout  fear  of  slipping  ;  and  (4)  that 
when  the  parietal  bones  have  been  reuioved  tiie  base  of  the  skull  can  be  .so 
seized  as  to  bring  it  through  a  j)clvis  with  a  conjugate  of  only  4.^  centimeters 
(If  inches)  and  a  transverse  of  7i  centimeters  (3  inches)  (Harnes). 

('cphdlotribe, — This  instrument  was  invented  by  liaudelocque  to  supersede 
th(!  perforator.  It  is  essentially  a  })owerful  compressing  forceps  (Figs.  522- 
524),  made  to  crush  the  head  before  extracting  it.  Tiie  blades  are  applied 
outside  the  head,  like  tho.se  of  the  ordinary  I'orceps ;  the  instrument  therefore 
differs  essentially  from  the  cranioclast,  which  has  one  blade  inside  and  the  other 
outside  the  skull,  and  is  not  essentially  a  crusher,  but  is  simply  an  extractor. 
The  cephalotribe  is  more  bulky,  takes  up  more  room  in  the  pelvis,  docs  not 


inoniM) 


Fig.  525.— Tarnior's  basiotribe. 


Via.  r>'2ii.— TaniiiTs  luisicitribi.'  (so|iiirati'  parts). 


grasp  the  head  so  .seeui-ely,  and  is  more  liable  to  slip  than  the  cranioclast. 
The  cephalotribe  is  therefore  less  u.seful  in  ordinary  cases,  and  is  nowadays 
very  little  n.sed.  The  Hicks  model  (Fig.  524)  is  preferred  in  P^ngland,  while 
liUsk's  instrument  (Fig.  52.'5)  is  the  flivorltc  in  America. 

Rimotribe. — Tarnicr's  basiotribe  is  tlic  most  perfect  instrument  for  crani- 
otomy yet  invented,  being  at  oiu'c  a  pertbrator,  a  cranioclast,  and  a  cephalo- 


9 


!■« 


932 


AMJJh'K'A.X    TEXT-JiOOK   OF    OBSTKTIUCS. 


Mi;r»|l! 


tril)e,  iuid  is  capable  of  bciiijjf  used  in  pelves  ineasiirin<i;  no  more  than  from  I 
to  G  centimeters  (l.\  to  2';|  inelies)  in  tiio  eoiiin-rate  diameter.  The  eranioeiast 
seizes  well,  bnt  crushes  poorly ;  the  ccjpiialotrihe  crushes  well,  but  sei/.es 
|)oorIy ;  the  basiotribc  <'ombines  the  <^ood  points  of  both,  for  it  both  seizes  and 
erushes  well.  The  basiotribe  is  composed  of  a  perforator,  two  blades  of  un- 
equal lenj2;th,  and  a  powerfid  compressinjr  screw  (Fij;.  525),  The  central  piece, 
or  perforator,  consists  of  a  straij^lit  bar  of  metal,  terminatinj^  at  one  end  in  a 
fenestrated,  spear-pointed  tip,  and  at  the  other  end  in  a  small  cross-bar,  throu<rh 
which  the  compression-screw  works  (Fig.  526).  About  halfway  down  the 
handle  is  a  tenon  upon  which  the  shorter  blade  articulates.     The  shorter  blade 


'i  wi 


rc  \ 


Fi<i.  r)27.— Tiiniier's  bnsiotriltc  Kk;.  .")2H.— The  first  l)liiilo  of 

in  motion  ;  the  i)L'rt'iiriit()r  liciii^' ill        tliu  Ijiisiotrilie  has  criislu'cl  tlic 
place,  tts  is  also  the  liret  blailu.  Dccijiut,  and  thu  succinil  l>laiii' 

is  applii'd. 


,UkUU,VUX) 


Fl(i.  .V«J.— Tlio  second  liladc 
of  tin'  iHisiotriljL'  has  onisluMl  ilir 
siniipiit. 


carries  a  tenon  upon  which  the  lonjier  blade  articulates,  and  a  small  hook  to 
fasten  it  to  the  perforator  after  the  first  crushing  has  been  done.  At  the  ciki 
of  the  handle  is  a  pivot  to  which  the  compressing  screw  is  attached.  The 
longer  blade,  about  42.5  centimeters  (17  inches)  in  length,  articulates  with  tlir 
shorter  blade,  and  has  a  groove  at  the  end  of  the  handle  to  receive  tiie  coin- 
pressing  screw.  When  closed  the  instrument  measures  from  side  to  side  4 
centimeters  (IJ  inches),  from  before  backward  4 J  centimeters  (1|  inches),  ami 
weighs  a  little  less  than  1000  grams  (21  pounds).  Bar  and  Tarnier  have  iv- 
cently  modified  the  original  instrument  so  that  it  can  more  easily  be  used  in 
face  presentations.  The  blades  of  this  modified  instrument  are  made  a  iitilr 
longer  and  of  equal  length,  and  are  so  arranged  that  cither  the  right  or  tlir 
left  blade  can  be  introduced  at  will  after  the  perforator. 


ff: 


'IV 


OliS  TK  Tli  I( '  ,S'  1 7>'  (1  /■:  /,• ) ' 


933 


tVom  I 
lioclast 
,   seizes 
zcs  aiul 
of  nu- 
ll pit't'e, 
>iul  in  a 
tlin»n«rh 
)\vn  tli(( 
or  hlacic 


iiiuuuuuu^ 


SI'CdIlll    lllllll'' 

las  i:rus\u''i  tin' 


lill  hook  to 
At  tlu'  ciiu 
Lhe.1.     Th" 
Ics  with  till' 
jc  the  ooiii- 
|i>  to  sidi'  ^ 
t'h(s\  iintl 
T  iuive  n'- 
bo  nscd  ill 
luloii  lit  til' 


n<!; 


ht  or  tl 


1^ 


Ifook  and  Crotclirf. — Tliis  instrnincnt  cons  -its  ol'a  sliy-htlv  curved  metal  bar 
terniinatiiif!;  at  one  end  in  a  blunt  iiook  and  at  tlic  other  end  in  a  sharp  crotehet- 
tip  (Kif?.  530).  The  iiook  is  used  tt»  pull  down  tlie  neck  ;  the  crotchet  is  some- 
times caught  into  the  orbit  or  the  Ibr- 


"^ 


Viii. 


lliKik  mill  (Tiitclu't. 


amen  ma;j;num,  after  perforation,  and 
employed  as  an  extractor,  or  it  may  be  '"•^^ 
used  to  break  up  the  brain  after  j)ertb- 
ration.  The  blunt  hook  may  occasion- 
ally be  serviceabh;  in  extractin*:;  thi'  after-eomiiij''  head  lbllo\viiii>-  ])erl'oration. 
It  is  passed  through  the  openintr  made  by  tlu;  perforator,  and  is  hooked  over 
th(!  base  of  the  skull.  Sometimes  it  may  be  emjtloycd  with  advaiita<j,(!  in  the 
delivery  of  the  trunk  in  dillicult  eases,  if  hooked  under  the  posterior  shoulder, 
Tlie  hook  and  crotchet  is  less  used  than  Ibrmcrly,  but  is  nevertheless  very 
helpful  if  better  instruments  are  not  at  hand.  It  should  be  handled  wilh  care, 
t(>r  it  is  very  apt  to  slip  and  injure  the  maternal  scjft  parts. 

Siiudl  ('r<nuoto)nif-J'orc('p.^. — It  becomes  necicssary  sometimes  to  break  down 
the  cranial  vault  after  perforation  and  to  remove  the  bones  piecemeal.  For 
this  purpose  a  modified  bone-foree|)s  is  used.  The  best  model  is  TavUir's 
moditication  of  ^Icij^s's  instrument  (Fig.  51  it). 

JhTajiitdtin;/  Hook. — In  neglected  transverse  iiresentatioiis  decapitation  is 
sometimes  the  readiest  and  safest  means  of  etlecting  delivery.  IJraun's  hook 
is  extensively  used  for  this  purjiose  in  (jermany.  This  instrument  consists  of 
a  .steel  rotl  fitted  with  a  strong  handle  at  one  end  and  a  short  hook  tipped  with 


Fiii.  031.— Briuin's  hook. 


Kl(i.  'u','!.'  Detail  of  honks,  olil  ninl  iiupidvi'd  forms. 


a  rounded  button  at  the  other,  'i'he  hook  forms  an  acute  angle  with  the  shaft 
of  the  instrument,  the  distance  between  the  button  and  shaft  being  2  centime- 
ters (I  inch,  Fig.  532).  Zweifel  of  Leipsie  recently  modified  this  instriiiiieiit^ 
as  shown  in  Figure  531. 

Kmhryoiomoi. — Several  ingenious  but  eomi)licated  instruments  have  been 
invented  for  use  in  desperate  cases.  They  are  ex|)ensive,  easily  get  out  of 
order,  are  .«eldom  available  when  wanted,  are  dillicult  to  :>pply,  and  are  apt  to 
injure  the  maternal  .soft  parts.  However  useful  they  may  sometimes  prove  in 
large  hospitals,  they  are  practically  out  of  the  reach  of  general  practitioners. 
The  best  is  Taiv  ier's  embrvotome,  which  combines  the  blunt  hook  with  a  cut- 
ting in.struinen  .so  guarded  that  nothing  but  the  part  grasped  by  the  hook  can 
be  cut  when  *(ie  knife-blade  is  released  from  the  guard. 

Operation. — In  no  other  obstetric  ojieratiou  is  strict  attention  to  antisepsis 
more  important  than  in  craniotomy,  since  the  maternal  soft  parts  are  .so  liable 
to  be  wounded  by  the  in.struments  or  by  spicules  of  bone  from  the  mutilated 
licad,  and  most  of  the  sub.secpicnt  ill  ctlects  arc  directly  traceable  to  .sej)ti(! 
infection. 


m 


rf 


i. 


fi 


.^.^Oc- 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


1.0 


I.I 


|50     ~^^ 

^  1^    |2.2 
:!f    li£    i2.0 


II 


iiiiim 


l.25||,.4      ,.6 

^ 

6"     

► 

^  ..'^'^^ 


Photographic 

Sciences 
Corporation 


33  ^EST  MAIN  STREET 

WEBSVk:ic,K  .'    MSSO 

(716)S72-4S03 


W7) 


l/.x 


I 


6^ 


934 


AMERfCAN   TEXT- HOOK   OF   OBSTETRICS. 


Ctanioiomy  of  the  PreHvulinf)  Ilmd.—Mmv  the  bladder  has  been  emptied 
and  the  vulva  and  vagina  dij^infected,  the  patient  should  be  placed  on  a  table 
in  the  doreal  position  as  tor  the  forceps  operation,  an  anesthetic  administiuod, 
and  the  head  steadied  in  the  pelvis  by  pressure  from  above.  Full  dilatation  of 
the  cervix  is  advisable,  but  is  not  essential.  Two  fingers  of  the  left  hand  are 
passed  up  through  the  (icrvix  to  the  presenting  part,  and  held  firmly  against  it 
as  a  guide.  Throughout  the  operation  these  fingers  should  guide  the  instru- 
ments  and  guard  the  maternal  soft  parts  from  injury.  The  perforator,  held  in 
the  right  hand,  is  psissed  along  the  guide-fingers  to  a  suture  or  a  fontanelle  if 
possil)le.  The  point  should  be  I<ej)t  at  right  angles  to  the  presenting  part,  to 
prevent  slipping,  and  the  part  selected  for  perforation  should  be  nearer  the  sym- 
physis than  the  promontory  (Fig.  r);J3).    Then,  with  steady  pressure  (»r  a  careful 


V\i,.  MH.— Perforation  of  the  licftd  botjim :   tlu'  rinlit  Imiid  is  tiriispiiin  tlio  tmiicllt's  of  tlic  iiislniiMciit. 
TliL'  lips  sliouUl  not  l>i'  scpiiriitcd  until  iifliT  tliey  Imvo  outoroil  the  foiitaiu'lle. 


boring  movement,  the  point  is  made  tocnter  the  cranial  cavity,  and  the  perforator  is 
pushed  home  as  far  as  the  shoulder-guard  will  permit.  The  opening  is  enlarged 
by  compressing  the  handles  so  tis  to  separate  the  blades.  The  instrinnent  is  then 
closed  and  witlulrawn  slightly  to  jierinit  its  being  introduced  again  at  rigiit 
angles  to  the  first  incision.  The  blades  arv  tigtiin  separated,  then  finally  closed 
and  withdrawn.  By  this  means  a  crucial  incision  is  made,  through  which  a 
metal  noz/le  or  crotchet  can  be  introduced  to  break  up  the  brain-substance. 
The  remaining  steps  of  the  operation  will  be  more  cleanly  if  a  syringe  is 
attached  to  the  nozzle  and  the  broken-down  brain-matter  is  washed  out  with 
sterilized  water.  When  the  fetal  skull  is  completely  emptied  of  brain-matter, 
it  can  more  easily  be  com])ressed  and  extracted  than  if  it  is  only  slightly  or 
partially  emptied.  If  a  suture  or  a  fontanelle  cannot  easily  be  reached,a  gniMJ 
perforator  with  a  sharp  point  can  readily  be  pushed  through  the  substance  <il' 
any  cranial  bone.  In  face  presentations  tlu'  perforator  should  be  passcnl  tliroiioli 
tiie  orbit  or  one  of  tiie  frontal  bones  if  possible,  or,  failing  in  that,  through  the 
roof  of  the  mouth,  behind  the  nasal  fossa;.     When  the  bonv  landmarks  are 


J; 


oiiSTF/rniv  sriiOEii  v. 


936 


unrecognizable,  j)erforation  may  he  made  wherever  most  convenient,  hut  should 
then  be  carried  very  deep. 

Cramotomif  of  the  Aftev-cnming  lleorl. — T\m  is  always  a  difficult  oi)eration, 
since  the  trunk  interferes  with  the  neccssarv  manipulations.  Moreover,  tlu; 
trephine  can  mrely  be  used,  the  scissors  perforator  is  apt  to  slij),  the  thin  cranial 
vaidt  is  out  of  reach,  and  only  the  thicker,  denser  ])ortions  of  the  >kull  are 
accessible.  It  is  usually  recommended  to  perforate  throntih  a  lateral  fontanelle 
or  at  the  articulation  of  the  occiput  and  atlas.  The  ixKly  (tf  the  fetus  may 
require  to  be  drawn  upward  or  downward,  to  the  right  or  to  the  left,  to  bring 
the  desired  point  within  reach  of  the  guide- fingers.  Practically,  the  operator 
must  generally  be  content  to  ])erforate  at  any  point  behind  the  ear  that  he 
can  reach,  without  troubling  to  find  a  fontanelle  or  a  sutiur.  If  the  occiput 
is  behind  the  pubes,  the  operator  passes  tluve  or  four  finy;ers  under  the  sym- 
physis to  the  occipito-atlantal  articulation,  while  assistiUits  steady  the  head 
in  the  pelvis  and  draw  the  bcnly  downward  and  backward.  The  perforator, 
guarded  by  the  fingeix,  is  inserted  between  the  occiput  and  the  atlas,  and  a 
crucial  incision  is  made.  A  fertile  brain-substance  has  been  broken  u\)  and 
washed  away  the  head  can  usually  be  delivered  without  ditticulty  ;  occasionally, 
however,  the  cranioclast  is  required.  When  jierforation  of  the  occiput  inider 
the  symphysis  is  difficult  or  dangerous,  the  body  may  be  drawn  upward  and  the 
perforator  intnMluced  through  the  mouth  or  the  orbit.  If  theoccijHit  is  poste- 
rior, the  IxkIv  is  raised  until  the  perforator  can  be  pushed  into  the  occiput 
posteriorly.  If  the  head  lies  transveively  in  tin;  pelvis  and  cannot  be  rotated 
into  the  antero-posterior  diameter,  tlu?  body  may  be  drawn  upward  or  down- 
ward and  the  side  of  the  head  be  jwrforated  near  the  car.  Strassmann  of  Ber- 
lin recently  proposed  perforating  between  the  chin  and  the  neck  (Fig.  S-'U), 


Kin.  .".34.— rrnnlotomy  on  tin-  afliT-coiniiig  lieail ;  one  method  of  [HTforf  ting. 

passing  the  instrument  through  the  base  of  the  tongue  until  its  point  is  felt  by 
the  fingers  in  the  mouth,  then  pushing  it  through  the  posterior  nares  into  the 
firamen  magnum,  when  the  blades  are  separated  and  the  base  is  broken  up. 


r 


m 


4  I 


936 


AMKRICAX   TEXT-BOOK   OF   OBSTETRICS. 


m 


471 


A  nozzle  is  pass-ed  through  tlie  opening,  and  the  cranial  contents  are  broken 
up  and  removed. 

After  iKjrfomtion  and  excerebration  some  openitors  allow  lalM)r  to  terminate 
by  the  natural  efforts,  while  others  deliver  by  means  of  forcejts,  cranioclast, 
cephalotribe,  or  veraion.  In  most  (Sises  there  is  nothing  to  Imj  gained  by  wait- 
ing, and  it  is  generally  safer  and  better  to  deliver  without  any  unnecessary 
delay. 

With  the  strong  French  forceps,  which  is  a  powerful  compressor,  it  is  some- 
times possible  to  deliver  the  perforated  head  ;  but  the  ordinary  forceps  is  too  feel)l(> 
an  instrument,  and  is  apt  to  slip  unless  the  disproportion  is  very  slight.  When 
no  other  extractor  is  available,  forceps  delivery  can  be  made  less  difficult  bv 
washing  away  the  brain-substance  completely  and  removing  jM)rtions  of  the 
cranial  bon&s  with  short  craniotomy  forceps.  Care  should  always  be  taken  to 
protect  the  passjiges  from  injury  by  sharp  spicules  of  bone  during  extraction. 
The  forceps  proves  more  ust^ful  in  the  delivery  of  the  |)erforated  after-coming 
head ;  there  is  then  far  less  risk  of  slij)ping  or  of  wounding  the  soft  parts. 

Notwithstanding  the  warm  commendatit)ns  of  Tarnier,  Taylor,  and  others, 
version  after  craniotomy  must  be  regardetl  as  a  dangerous  operation  in  most 
cases.  When  labor  is  protracted  the  uterus  tends  to  retract  about  the  body  of 
the  child  and  the  lower  uterine  segiucnt  becomes  distendetl.  Attempts  to  tin-ii 
under  such  circumstances,  especially  if  any  spicules  of  bone  protrude  from  tiie 
opening  in  the  skull,  must  expose  the  mother  to  serious  risks. 

Crauiocta.si'i. — The  cranioclast  is  a  tractor,  not  a  comminutor,  and  the  ope- 
ration of  cranioclasis  consists  in  getting  a  firm  hold  of  the  mutilatal  head  witii 
the  cranioclast  and  delivering  it  through  the  narrowed  passages,  not  in  crushing 
or  breaking  up  the  cranial  bones.  Tiie  solid  blade,  held  in  the  right  hand,  is 
guided  through  the  opening  made  by  the  perforator  and  is  pushed  well  down 
to  the  base  of  the  skull.  The  fenestrated  blade  is  then  applied  to  the  otitside 
of  the  skull,  <lireetly  opposite  the  blade  which  is  inside;  the  blades  are  locked, 
and  the  compression-screw  is  tightened  mitil  the  head  is  firndy  grasped  between 
them.  The  blades  will  be  less  liable  to  slip  if  tiie  outer  one  is  applied  to  the 
face  rather  than  to  the  occiput.  Before  locking,  the  handles  should  not  be  iicid 
horizontally,  but  should  be  depressed,  so  as  to  make  sure  of  including  the  cliiri 
in  tiie  bite.  Before  beginning  to  extract,  the  cranioclast  should  be  so  turned  as 
to  bring  the  longest  diameter  of  the  head  into  the  transverse  diameter  of  the 
pelvis.  During  extraction  the  left  hand  should  be  kept  in  the  vagina  to  guard 
the  perforation  and  to  protect  the  maternal  soft  parts  from  being  injured  by 
projecting  edges  of  bone.  The  line  of  traction  should  be  in  the  axis  of  the 
pelvis,  the  same  as  in  the  forceps  operation.  Tf  any  pieces  of  bone  ])r()tnid(>, 
they  should  carefully  be  removed  before  traction  is  continued.  In  difliciill 
cases  it  may  be  net^cssary  to  strip  back  the  scalp  and  remove  the  parietal  bones 
by  means  of  small  craniotomy  forceps ;  the  blades  of  the  cranioclast  can  tluii 
be  so  adjusted  as  to  get  a  good  grasp  of  the  frontal  bones  and  the  lace,  and 
extraction  will  be  easy.  Occasionally  it  will  be  found  easier  to  introduce  the 
fenestrated  bhule  first  and  to  adjust  it  carefully  before  passing  the  solid  blade 


OBSTETltIV  SriiGEU  W 


937 


the  upo- 
1(1  with 
UHliiiiii 
mml,  is 
1  down 
outsido 
lockctl, 

M'tWCH'll 

oil  to  tlio 
Im'  1i(>1«1 
the  tliiii 

turned  us 
er  of  tlio 
to  ifuard 
ijurcd  l)y 
Lis  of  tlic 
protn\d<', 
ditticnlt 
tal  Uoiits 
can  tlu'ii 
i'ticf,  aiid 
(dui'c  tli<' 
|)lid  blade 


1;^ 


J 

V 


into  the  cranial  cavity.  In  most  cases  the  bmly  comes  tlironi^li  easily  after  the 
head  has  been  extracted.  If  the  body  is  so  larjre  that  it  cannot  be  delivered 
with  a  moderate  amount  of  traction,  it  should  be  perforated  U^twoen  the  clavicle 
and  tlie  scapula,  and  the  cranioclast  so  adjusted  that  the  fenestrated  blade  is 
applicnl  over  the  back.  Tiie  cases  are  extremely  rare  in  which  delivery  cannot 
be  aceomplishwl  by  perforation  and  cranioclasis. 

Cephdlotripsi/. — Occasionally  the  fetal  head  is  too  large  or  too  nuich  ossifiotl 
to  be  delivered  safely  with  the  cranioclast,  anil  it  becomes  necessary  to  crush 
it  in  order  to  reihice  its  bulk.  CeplialofiijMy  is  the  name  given  to  this 
crushing  and  extraction  of  the  fetal  head.  When  the  operation  was  first  pro- 
posed, it  was  iioped  that  it  wovdil  supersede  perforation  ;  but  this  hope  has  not 
been  realizwl,  and  at  the  present  day,  whin  the  head  is  presenting,  it  is  almost 
invariably  perforated  before  being  crushed.  The  cephalotribe  in  general  use 
is  a  powerful  forceps  with  slight  cephalic  curve,  fitted  with  a  strong  com- 
pression-screw at  the  end  of  the  handles.  The  blades  are  intriKluced  like  those 
of  the  forceps,  and  when  the  head  has  fiiirly  been  grasped  the  compression- 
screw  is  slowly  tightened.  The  opening  made  by  the  perforator  should  care- 
fully be  watchiil  for  pieces  of  extruiling  bone  while  compression  is  being  made, 
and  the  maternal  passages  should  be  protected  during  extraction.  When  the 
cephalotribe  gets  a  good  grasp  of  the  head,  it  crushes  satisfactorily  ;  but  the 
difficulty  is  to  get  and  keep  a  good  hold,  for  the  head  is  apt  to  slip  away 
when  the  compression-screw  is  tigiitened.  As  Piuard  remarks,  it  is  one  thing 
to  seize  the  head  with  the  blatles  of  the  cephalotribe,  but  i|uite  another  to  hold 
it  while  being  crusheil.  Cephalotripsy  is  indicated  when  the  pelvic  con- 
traction is  only  moderate  or  slight ;  but  when  the  contraction  is  extreme  the 
instrument  takes  up  too  much  room  and  the  tractile  force  re(juired  to  effect 
delivery  is  dangerous  for  the  mother.  When  the  conjugate  of  the  brim  meas- 
ures less  than  7  centimeters  (2|  inches),  the  (>j)eration  becomes  difficult ;  when 
less  than  6.3  centimeters  (2^  inches),  it  is  highly  dangerous. 

In  difficidt  breech  cases,  when  the  aflor-coming  head  cannot  be  delivered  by 
manipulati<m  or  by  forceps  on  account  of  slight  pelvic  contraction,  its  bulk  may 
be  reduced  sufficiently  by  cephahttripsy  even  without  ])orforation.  Or  if  per- 
foration has  been  done  and  the  forceps  does  not  hold,  or  if  it  is  found  neces- 
sary to  reduce  the  bulk  by  crushing  the  base  of  the  skull,  the  cephalotribe  will 
be  useful.  Or  if  the  body  has  been  delivered  and  the  head,  which  is  free  in 
the  uterine  cavity,  cannot  be  seized  and  delivered  with  forceps,  it  is  sometimes 
necessary  to  steady  the  head  in  the  pelvis,  fix  it  by  means  of  a  crotchet  j)assed 
into  the  cranial  cavity,  and  then  apply  the  cephalotribe  to  crush  the  skull 
before  it  can  be  extracted.  In  all  such  eases  the  maternal  tissues  should  be 
carefully  guarded  against  injury. 

At  the  present  day  ce|)halotripsy  is  seldom  done;  when  craniotomy  is  in- 
dicated and  the  pelvic  contraction  is  only  moderate  or  slight,  perforation  and 
cranioclasis  usually  suffice;  when  the  pelvic  contraction  is  extreme,  basiotripsy 
or  Cesarean  section  is  preferable. 

Bmiotrijjxy. — Basiotripsy  is  an  improved  cephalotripsy  that  in  France  has 


i:    1 


Ml 


938 


AMERICAN   TEXT-BOOK   OF    OBSTETRICS. 


ill  ' 


If:; 


completely  taken  the  place  of*  the  latter  operation  whenever  plvic  oontrnc- 
tion  is  nKMlerate  or  extreme.  The  steps  of  the  oiK'ration  are  jwrforatioii,  the 
small  crushin}^,  the  j^reat  crushing,  and,  fins.lly,  extraction.  The  jM-rforator, 
held  in  the  right  hand,  is  guided  along  tiie  fingers  of  thr  left  hand  to  the  point 
selected  for  i)erforatioii ;  kept  at  right  angles  to  the  skull,  it  is  then  thrust 
through  the  cranial  bone  and  pushe<l  along  until  its  point  is  imbechUHl  in  the 
base.  The  short  blade,  which  corresponds  with  the  left  or  lower  blade  of  the 
forceps,  is  introduced  like  the  forceps-blade,  and  is  articulated  with  the  tenon 
on  the  handle  of  the  perforator.  The  compression-screw  is  then  adju8t(>d  and 
tightened  until  the  short  blade  is  force<l  close  to  the  ]>erforator ;  tiie  hook  is 
closed  down,  which  sectu'ely  fastens  the  short  blade  to  the  j)erforator.  Tliis 
])roce(hire  is  the  small  crushing.  The  compression-screw  is  remove<l,  and  tiic 
long  blade  is  applied  like  the  right  or  upper  blade  of  the  forceps  and  articu- 
lated witii  the  tenon  on  the  handle  of  the  short  blade.  Tjie  compression-screw 
is  again  applied,  and  slowly  tightened  until  the  long  bhuu^  is  brought  close  to 
the  perforator.  This  operation  is  the  great  crushing.  If  the  instrument  has 
been  properly  applie<l,  the  vault  and  base  of  the  skull  will  have  been  crushed 
and  flattened  by  the  o|'oration  to  a  little  less  than  2  inches,  and  extraction  is 
comparatively  easy.  Tarnier  and  his  followers  set  4  centimeters  (1^  inches) 
of  the  conjugate  as  the  lowest  limit  for  basiotripsy.  Below  this  limit  the 
mother  is  exposed  to  risks  as  great  as  from  (Vsareau  se<'tion,  but  above  6  cen- 
tinieters  (2f  inches)  tlie  maternal  mortality  is  pra(  tically  nil.  Pinard  operatecl 
fifteen  times  consecutively  without  a  death,  the  conjugate  in  one  case  njeasiu  ing 
only  6  centimeters  ("1^  inches).  This  optn-ation  was  done  forty-nine  timis 
without  a  death  in  the  practice  of  Pinard  and  his  coUeagJies,  and  in  all  the 
cases  the  puerperiui'i  was  normal. 

Decapitation  and  EriHceration. — These  operations  are  indicated  (1)  in  neg- 
lected transverse  presentations  with  impaction,  where  version  is  dangerous  or 
impossible  and  the  head  cannot  be  brought  down  far  enough  for  craniotomy  ; 
(2)  whcMi  a  monster  or  some  ])athologieal  enlargement  of  the  fetal  struetin-es 
renders  delivery  oiierwise  impossible.  Decapitation  is  indicated  when  the 
neck  of  the  fetus  !S  within  reach  and  a  hook  can  be  passed  over  it ;  eviscera- 
tion is  indicat(Hl  in  all  other  cases.  These  operations  are  always  difficult  and 
dangerous.  The  <ri;  aeti'»n  of  the  fetus  interferes  with  manipulation,  while 
the  uterine  tissues  are  thinned  and  liable  to  be  injured  or  be  ruptured  l)y 
the  hands  or  instruments. 

For  (Iccnpitation  Braun's  hook  (Fig.  S^H)  is  the  simplest  and  most  efficient  in- 
strument ;  it  is  less  liable  to  injure  the  mother  than  the  more  complicated  contriv- 
ances. Before  operating  the  bladder  should  be  euiptied  and  the  parts  thoroughly 
disinfected.  An  arm  is  then  brought  <lown  and  a  tape  is  attached  to  it,  so  that 
an  assistant  may  make  traction  when  required.  The  whole  hand  is  then  passed 
into  the  vagina,  palm  upward,  with  the  ihiunb  close  to  the  symphysis  and  four 
fingers  in  the  hollow  of  the  sacrum,  until  the  neck  is  clasped  between  the  thiuiil> 
and  the  middle  finger.  If  the  head  is  lying  toward  the  mother's  lef>  side,  \ho 
left  hand  is  introduced  into  the  vagina  ;  if  the  head  points  to  the  mother's  right 


ii;^ 


F'VU 


onsTKTnic  suita  i:ii  v. 


9.'{9 


timos 
all  the 

ill  no<i- 
•ous  or 
otoniv  ; 
•iK'turcs 
WW   tlic 

•ult  mill 
n,  while 
uml  1>V 


'11  passt'tl 
and  four 
10  thumh 
side,  ll»> 
pr'rt  rii^ht 


side,  tlio  right  hand  is  introdiu'cd.  The  hook,  wiih  its  concavitv  pointing 
away  from  the  head  toward  tin  Ix  dy,  is  grasj)e<l  in  tiio  other  hand,  palm  down- 
ward, is  passetl  along  the  thumb  of  the 
inside  hand,  and  is  giiidwl  over  the 
ehihrs  neck  until  the  tip  touehes  the 
operator's  middle  finger.  During  the 
passage  of  the  hook  it  should  lie  all 
the  time  beneath  the  thumb  and  the 
fingers,  v/hich  should  not  be  separated. 
The  neek  is  put  on  the  stretch  by  pull- 
ing the  handle  of  the  hook  firmly 
downward  (Fig.  535)  while  an  assist- 
ant draws  down  the  arm  by  means  of 
the  tape.  While  strong  traction  is 
being  made  the  handle  is  quickly 
raise<l  as  far  as  possible,  and  twisted 
forcibly /ro/u  head  toward  breech,  turn- 
ing the  palm  of  the  hand  upward. 
Three  or  four  twists  (Figs.  536,  537) 
are  generally  suflicient  to  sever  the  head 
from  the  body.  Throughout  the  opera- 
tion the  insi<lo  hand  must  protect  th(( 
maternal  tissues  from  injury.  Twisting 
should  never  be  done  unless  the  hook 
is  clasped  between  the  thumb  and  the 
finger  of  th(>  guiding  hand.     As  soon 

as  the  neck  is  divided  the  head  reredcs,  and  the  body  is  casilv  delivered  bv 
pulling  upon  the  prolapsed  arm  ;  the  head  is  subsequently  extracted  with  for- 


Fui.  ■>;!.■).— Dornpitntiiiti  with  r.nniir.--  Imok. 


Flo.  636.— Braiin's  hook  seizliit;  the  ciTViPHl  vitU--        Km.  M?.— Urmm'H  lionk  rntntcd  in  the  niiimsiti' ili- 
bra>  ami  rotiUed.  ri'ctioii:  tlii' spina!  cnlmmi  tjivliiK  «ii.v. 

ceps  or  the  ceplialotribe.     During  the  extraction  of  trunk  and  head  the  mater- 
nal j)assages  should  be  guarded  against  injury  from  the  ragged  ends  of  the 


940 


AMERICAN    TEXT- HOOK    OF   OBSTETItlCS. 


several  vertebrte.  If  Brauii's  Ijook  ih  not  available,  a  strong  cord  may  ho 
carrietl  arounil  tiie  neek  by  means  of  a  gum-elastie  catheter,  and  the  soft  parts 
Ik;  sawn  through  by  pulling  upon  the  ends  of  the  cord ;  or  a  long,  bliuit- 
pointetl  scissors  may  be  used  to  snip  through  the  tissues,  always  taking  care 
to  guard  the  points. 

EpiscemUon  may  be  accomplishetl  byojK'ning  either  the  thorax  or  thealxlo- 
men  with  blunt-pointed  scissors,  and  breaking  up  the  internal  organs  and  remov- 
ing them  by  means  of  a  volsella  ;  or  the  scissors-perforator  may  be  carried  up 
to  the  most  accessible  portion  of  the  trunk,  and  an  opening  l)e  made  througli 
wiiich  a  crotchet  or  a  metal  nozzle  can  be  intro<luced  to  break  up  the  internal 
organs.  The  operation  is  very  tedious,  and  great  care  must  be  taken  not  to 
itijure  the  uterus  or  the  passages.  After  any  pieces  of  loose  bone  have  been 
removcil  the  blunt  hook  may  be  introduced,  and  an  attempt  may  be  made  to 
extract  the  trunk  by  pulling  it  down  and  bending  it  upon  itself.  If  this 
maneuvre  fails,  nothing  remains  but  to  dismember  the  fetus  and  deliver  it 
piece  by  piece.  Chain-saws  and  enjbryotomes  of  more  or  less  complicated 
pattern  have  been  devised  for  use  in  difficult  cases ;  but  they  are  seldom  avail- 
able when  wanted,  are  difficult  to  apply,  and  are  apt  seriously  to  injure  the 
maternal  passages.  Symphysiotomy  has  been  odvise<l  in  these  difficult  cases, 
to  give  more  room  for  manipulation  and  extraction.  Pinard,  however,  protests 
strongly  against  the  use  of  symphysiotomy  for  the  delivery  of  a  dead  or  muti- 
lated fetus,  maintaining  that  the  mother's  chances  of  recovery  are  thereb}  much 
impaired.  Cases  are  occasionally  met  with  where  the  ordinary  methods  of 
decapitation  and  evisceration  are  not  feasible.  Spencer'  of  University  College, 
London,  has  recently  drawn  attention  to  two  such  classes  of  cases:  (1)  When 
it  is  impossible  to  deliver  the  body  after  the  head  has  been  extracte<l,  on  account 
of  unusual  size  of  the  l)ody  or  of  pathological  conditions  in  the  serous  cavities 
or  the  viscera ;  (2)  when  the  back  of  the  fetus  presents,  rendering  decapitation 
impossible.  In  the  first  class,  when  traction  fails  to  deliver,  he  suggests  snip- 
])ing  through  the  clavicles  (clcidotomy)  and  introdu(!ing  a  blunt  hook  into 
the  axilla  to  bring  down  the  arms,  or  decapitating  and  then  passing  the  hand 
over  the  thorax  and  opening  the  abdomen.  Care  must  be  taken  to  seize  the 
neck  with  a  volsella  before  decapitating,  to  prevent  the  trunk  from  receding 
out  of  reach  after  the  head  is  remove<l.  In  the  second  class  he  suggests  snip- 
ping through  the  spinal  column  with  a  pair  of  scissors,  seizing  the  trunk  with 
a  craiiioclast,  and  so  drawing  it  down  that  it  can  be  snipped  through.  The 
two  halves  of  the  body  can  then  readily  be  delivered. 

After-treaiment. — After  the  mutilated  fetus  has  been  delivered  and  the  pla- 
centa has  come  away,  a  hot  antiseptic  uterine  douche  should  be  given,  and  the 
parturient  canal  examined  for  traumatisms,  which  should  be  repairetl  imme- 
diately. During  the  puerperium  the  chief  danger  is  sepsis,  and  the  treat- 
ment should  be  regulated  accordingly. 

Prof/nosis. — The  prognosis  of  embryotomy  depends  in  great  measure  upon 
the  degree  of  disproportion  present,  the  condition  of  the  patient,  the  stage  of 
'  British  Medical  Journal,  April  13,  1895,  p.  808. 


I- 


oiiSTiyntic  sriidKit  v. 


U41 


lalK»r,  tlie  nature  of  previous  attempts  to  deliver,  tlie  amount  of  injury  done  to 
the  maternal  tissues,  und,  above  all,  upon  the  presenee  or  absence  of  sepsis. 
When  the  disproportion  is  not  extreme,  and  the  operation  is  done  early,  before 
the  patient  has  beeome  exhausted  by  a  pr()tra(!ted  labor  or  by  futile  attempts  to 
deliver,  when  the  maternal  soft  parts  have  not  lu-en  bruise<l  and  lacerated,  and 
when  all  the  manipulations  have  been  done  with  strict  antiseptic  jH'ccautions, 
the  mortality  shotdd  be  very  low.  Craniotomy  may  be  a  verv  easy  or  a  very 
ditTieult  operation,  according  to  the  degree  of  disproportion  and  the  stage  of 
labor  at  which  it  is  done.  Other  things  being  equal,  embryotomy  is  more  dan- 
gerous than  <'raniotomy.  In  private  practice  there  are  many  difticidtics  and  dis- 
advantages to  overcome,  which  are  not  encounteretl  in  well-arranged  maternities  ; 
consecpiently  the  mortality  may  reasonably  be  expecttKl  to  be  higher;  but,  unfor- 
tunately, it  is  far  higher  than  it  ought  to  be,  owing  in  great  measure  to  the  want 
of  early  and  exact  diagnosis,  and  to  the  )>revailing  tendency  on  the  part  oi'  the 
general  practitioner  to  postpone  operation  until  forceps  and  version  have  repeat- 
e<lly  been  trial  and  have  failed.  The  brilliant  results  in  Paris  of  basiotripsy 
show  the  possibilities  of  the  operation  when  done  early  in  suitable  eases.  There 
can  l)e  very  little  doubt  that  early  oj^ration  and  strict  antisepsis  would  minim- 
ize the  chief  immediate  dangers,  rupture  and  sepsis,  as  well  as  the  risks  of 
subsequent  pressure-complications,  such  as  tistuln;.  But  we  can  scarcely  look 
for  much  improvement  in  our  results  initil  the  profession  as  a  whole  comes 
to  have  clearer  ideas  respecting  the  limitations  as  well  as  the  indications  of 
the  destructive  operations,  and  is  more  generally  possessed  of  a  sensitive 
"  antiseptic  conscience." 


s  snip- 
k  with 
.     Tl 


le 


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land  til 


imme- 
le  treat- 


Ire  upon 
)f 


Itage 


n.  Manual  Operations. 
Varieties  and  jMethods  of  Version. 

Version  is  a  manual  operation,  designed  to  bring  about  a  ])artial  or  a  com- 
plete change  in  the  relation  (»f  the  long  axis  of  the  child  to  the  long  axis  of 
the  mother,  whereby  a  longitudinal  is  substituted  for  a  transverse  presentation, 
or  one  end  of  the  child  is  substituted  for  the  other.  The  object  attained  is  the 
exchange  of  a  less  favorable  presentation  which  nature  cannot  deliver,  such  as 
a  shotilder,  for  a  presentation  that  is  favorable  for  expulsion,  such  as  a  head,  a 
breech,  or  a  footling ;  or,  in  such  an  emergency  as  placenta  ])ra?via  or  a  con- 
tracted pelvis,  a  change  of  the  presenting  part  from  head  to  foot  in  order  to 
secure  speed  or  ease  in  delivery. 

Omitting  the  study  of  the  infrequent  cases  in  which  nature  can  compass 
version,  and  which  have  been  considered  under  the  heati  of  Mechanism  of 
Labor  (p.  489),  we  find  three  varieties  of  version :  (A)  cephalic,  (B)  pelvic, 
and  (C)  podalic,  and  three  methods  oi'  version:  (1)  external,  (2)  bipolar,  and 
(3)  internal. 

Varieties. — Cephalic  version  causes  the  head  to  present ;  pelvic  version, 
the  breech  ;  and  jiodalic  version,  one  or  both  feet. 

Choice  of  Variety. — For  cephalic  version  an  easy  case,  an  ample  pelvis,  and 


%rl  I 


2H 


942 


AMERICAN   TEXT-BOOK   OF   OJiSTtyriilCH. 


labor  not  under  way  are  the  ordinary  conditiotis ;  pelvic  version  is  an  oeca- 
sional  early  prei)aratit>n  for  labor  with  placenta  praevia ;  while  potlalic  version 
is  our  chief  reliance  in  urgent  or  difficult  cases. 

Methods. — External  version  is  accomplished  by  manipulation  through  the 
abtlominal  wall.  Bipolar  versi*  n  is  ett'ecteil  by  passing  two  fingers  througli 
the  cervix  and  tossing  along  the  successively  presenting  parts  of  the  child 
until  the  leg  can  be  seized,  while  the  exterind  hand  docs  its  part  through  the 
abdominal  wall.  For  internal  version  one  hand  is  pushed  freely  into  the 
uterine  cavity  to  grasp  the  foot  or  the  knee,  on  which  traction  is  made  while 
the  other  hand  assists  from  without. 

Choice  of  Method. — In  a  typical  case  we  should  attempt  the  correction  of 
tlie  presentation  by  the  three  methods  in  the  order  named.  The  indications 
for  each  method  will  be  given  in  its  proper  section,  but  they  may  be  sum- 
marixed  here : 

1.  The  exteniul  method  is  not  often  employed,  because  its  success  depends 
on  a  c>onibination  of  conditions  that  is  seldom  found.  It  is  the  simplest  and 
safest  procethire,  and  will  be  more  often  required  as  early  I'ecognition  of  the 
position  of  the  child  by  abdominal  palpation  becomes  more  common.  It 
demands  the  presence  of  the  liquor  amnii,  or  at  least  a  relaxed  uterus  and 
abdominal  wall,  with  free  mobility  of  the  child,  and  is  usually  available  only 
beiore  labor  or  early  in  its  course. 

2.  The  bipolar  methoil  has  the  advantage  over  the  internal  method  in  that  "  it 
can  be  performed  at  the  commencement  of  labor,  long  before  the  os  is  com- 
pletely dilated,  and  that  it  obviates  the  necessity  of  introducing  the  whole 
hand  into  the  uterus,  which  is  not  without  danger  to  the  parturient  and  the 
child."     But  it  is  not  always  easy  or  feasible. 

3.  The  internal  method  is  the  obstetrician's  chief  reliance,  especially  in  urgent 
or  difficult  cases,  but  it  is  many  times  an  operation  of  no  little  moment. 

Indications  for  the  Operation :  A.  Indications  for  Cephalic  Version. — 
Breech  presentation  calls  for  cephalic  version  when  all  conditions  are  favor- 
able— such  as  a  sufficiently  roomy  pelvis — and  when  it  can  readily  be  accom- 
plished by  the  external  method  before  labor  by  a  practised  hand.  Under 
such  circumstances  shoulder  cases  will  also  be  amenable  to  this  variety  of 
turning. 

B.  Indications  for  Pelvic  Version. — As  this  maneuvre  is  rarely  employed, 
its  consideration  may  be  brief.  It  is  only  undertaken  by  the  method  of 
external  version,  as  by  other  methods  we  bring  down  one  or  both  feet.  It 
is  indicated  for  placenta  prsevia  and  for  a  slightly-contracted  pelvis  before 
labor  or  early  in  labor. 

C.  Indications  for  Podalic  Version. — Stated  in  the  order  of  their  import- 
ance, the  conditions  under  which  version  should  be  chosen  are : 

1.  In  transverse  presentations,  which  are  chiefly  shoulder  cases.  This  indi- 
cation is  the  most  frequent,  and  includes  all  except  small  or  macerated  fetuses, 
and  the  few  instances  in  which  cephalic  version  is  preferred. 

2.  In  normal  pelves  and  head  presentations,  when  the  life  of  the  child  or 


UliSTETIiJl  •  SI  RUKIt  Y 


i)43 


that  of  the  mother  is  threutt'iied,  if  the  heail  cannot  be  inihieed  to  enj^age 
and  tlie  cervix  i.s  not  dilateil  «o  that  forceps  can  be  applied.  This  indica- 
tion inchides  phicenta  prievia,  exwpt  in  the  sinipk'r  marginal  variety  with 
the  head  K)w  in  tiie  pelvis,  and  scant  bleeding.  It  also  covers  cases  of  pro- 
lapse of  the  cord  not  otherwise  manageable.  In  certain  instances  with  pro- 
lapse of  one  or  more  extremities,  and  chicHy  when  the  foot  presents,  podalic 
version  is  our  resource,  as  also  in  the  most  troublesome  face  or  brow  presenta- 
tions with  the  head  at  the  inlet,  when  the  posture  of  the  head  cannot  be  recti- 
fied manually,  and  particularly  in  i)osterior  positions.  Lastly,  in  certain  other 
emergencies,  should  the  case  call  for  rapid  extraction,  we  employ  version,  as 
in  eclampsia  and  in  accidental  hemorrhage. 

3.  In  contracted  jwlves.  Version  is  called  for  in  flat  pelves  where  the  true 
conjugate  is  not  below  8  centimeters  (31  inches),  where  there  is  a  relative  dis- 
proportion between  passage  and  passenger  c(]uivalent  to  the  above-nanied  con- 
traction, when;  the  head  does  not  engage  and  changes  its  |)ositi()n  frequently 
above  the  brim,  or  where  previous  breech  deliveries  have  been  more  favor- 
able than  vertex  presentations,  and  also  "  in  obli(piely-contractcd  pelves  and 
unsuccessful  or  unfavorable  engagement  of  the  head  with  the  occiput  over  the 
contracted  side." 

Contra-indications  to  Version. — Rigid  and  permanent  contraction  of  the 
wall  of  the  uterus,  especially  in  dry  labors;  high  position  of  the  retraction- 
ring  (5  to  7.5  centimeters — 2  to  3  inches — above  the  symphysis — Winckcl) ; 
engagement  of  the  head  ;  impaction  of  the  presenting  part  which  would  recjuire 
dangerous  pressure  to  dislodge, — all  contra-indicate  version. 

Dangrers  of  Version. — Rupture  of  the  uterus,  shock,  increased  risk  of  sep- 
sis, hemorrhage,  and  laceration  are  the  hazards  for  the  mother.  In  external 
and  bipolar  version  these  dangers  are  usually  insignificant,  because  we  I'arely  use 
nnich  force  in  these  procedures,  but  in  internal  version  there  is  risk  of  uterine 
rupture.  It  is  for  this  class  of  eases  that  we  urge  the  necessity  of  firm  gen- 
tleness and  the  avoidance  of  t)peration  in  the  presence  of  pronounced  tension 
or  thinning  of  the  uterine  wall.  There  is,  of  course,  no  obstetric  operation 
more  likely  than  version  to  infect  the  mother  if  the  operator  does  not  carry 
out  aseptic  measures,  except,  perhaps,  that  of  Cesarean  section.  The  danger 
of  laceration  and  of  shock  is  proportionate  to  the  rapidity  with  which  the 
child  is  turned  and  extracted,  aiid  to  the  lack  of  skill  of  the  operator.  To  the 
child  the  dangers  are  fracture  of  the  femur  or  the  humerus,  together  with  the 
usual  risks  of  breech  labors. 

Cephalic  Version. — "As  head  presentation  is  the  tyi^e  of  natural  labor, 
it  follows,"  says  Barnes,  "  that  to  obtain  a  head  presentation  is  the  great  end 
to  be  contemplated  by  art,  but  practically  head-turning  is  little  known.  De- 
livery by  the  feet  is  almost  universally  practised  when  the  substitution  of  a 
i'avorable  for  an  unfavorable  presentation  has  to  bo  accomplished.  AVhy  is 
this?  The  answer  rests  chiefly  upon  the  undoubted  fact  that  in  the  great 
majority  of  instances,  at  the  time  when  the  mal-prosentation  conies  before  us, 
tiu'uing  by  the  feet  is  the  only  moileof  turning  which  is  practicable."     It  may 


!  \       < 


fill 


944 


AMHIilCAN   TKXT-nOOK    OF    OliSrKTlUrS. 


also  Ik'  iiotod  that  lai-k  of  certainty  coiuH'i'niiit;  presentation  and  |)Osition,  due 
to  detective  traininj^  in  abdominal  palpation,  leaves  the  patient  withont  help 
until  the  time  has  passed  for  the  milder  manipidation. 

Omditiomfor  ('f/Jtolir  Wrfiion. — For  a  favoral)l(!  outcome  hv  this  method, 
labor  should  not  yet  be  under  way,  or  should  not  be  so  far  advanced  that  there 
is  any  marked  tension  of  the  uterine  walls.  The  liquor  aninii  should  he 
present,  and  the  alMlominal  walls  neither  tense,  tender,  nor  thickly  padded 
with  fat.  Amoufij  transverse  conditions  we  prefer  an  obliquity  that  is  nuxl- 
erate,  with  the  shoulder  not  yet  driven  down  into  the  jH'lvis.  To  convert  a 
breech  into  a  vertex  presentation,  not  only  nuist  these  favoring  circumstances 
Ih^  present,  but  the  operator  should  also  Im  endowed  with  skill  in  version  and 
experience  in  abdominal  palpation,  so  that  his  maneuvre  shall  not  be  arrested 
halfway  and  a  breech  ca.se  be  converted  into  a  transvei-so  presentation. 

The  ailcantaf/es  of  cephalic  version  are  evident,  and  in  the  ])resenee  of  a 
sufficiently  capacious  pelvis  should  induce  skilled  oj)erators  t<>  undertake  this 
measure.  Tlw  (Imtdvautaf/ex  consist  in  the  limited  scope  of  the  procedun>an(l 
the  experien(!e  recpiired. 

Strps  nf  the  Oprnitiou. — Cejihalic  version  is  practically  c*>nfined  to  the 
external  and  bipolar  methods,  uid  the  steps  are  the  same  as  in  these  metho<ls, 
which  are  described  on  another  paj^c,  excejrt  that  the  fetus  is  to  be  moved  in 
the  opposite  direction  from  that  describe*!  under  jwdalic  version.  If  the  oper- 
ator prefers  to  do  version  with  the  woman  lyinj;  on  her  side,  she  should  be  on 
the  same  side  as  that  on  which  the  head  i>  found.  Supposing  the  case  to  be 
one  in  M'hich  the  head  is  in  the  left  iliac  fossa,  and  the  fundus,  with  the  breecii, 
is  to  the  right  of  the  mother's  s})inal  column,  the  woman  is  to  be  placed  on 
her  left  side.  In  this  j)osture  the  fundus  of  the  uterus,  loaded  with  tlu; 
breech  and  being  movable,  will  tend  to  fall  toward  the  dependent  side. 

1.  External  Version. — This  method,  the  simplest  and  safest  of  the  three 
methods  of  turin'ng,  will  become  more  comm<mly  employed  as  the  general 
practitioner  adopts  the  habit  of  a  thorough  examination  by  abdominal  palpa- 
tion a  month  before  labor  for  each  pregmuu  ..oman  under  his  care.  When- 
ever possible,  it  should  be  attempted  before  the  other  methods  are  begun. 
As  Fritsch  well  says:  "Even  to-day,  when  the  danger  from  sepsis  is  small, 
a  successful  external  version  means  the  achievement  of  large  results  through 
little  means." 

ImUcatiouH  for  Externnl  Version, — The  indications,  in  general,  are  the  same 
as  those  that  aj)ply  to  all  versions,  the  special  contHfioun  required  being  the 
])resence  of  the  liquor  anniii  or  its  recent  loss,  leaving  a  relaxed  and  insensi- 
tive uterus  with  free  mobility  of  the  child.  External  vereion  shoidd  be  un- 
dertaken oidy  when  it  can  l)e  performed  without  violence;  this  period,  as  a 
rule,  is  before  labor  is  actually  established,  or  at  any  rate  before  rupture  of 
the  mend)ranes.  It  may  be  performed  with  advantage  for  a  high  transverse 
position  of  the  second  child  in  twin  labors. 

Contrn-hnUcations. — External  version  cannot  be  effected  when  there  is  m 
macerated  fetus,  or  in  case  of  twins,  or  where  the  presenting  part  has  sunk 


and 


I  tho  same 
1)01111;;  the 
insoiisi- 
\i\  he  uii- 
1,  as  a 


(•KM 


ro 


liptii 
Iraiisvorso 


hioro  is  a 


ojis  Ti<:  TR  ic  s  I  wf  a  ku  y. 


Mh 


<leop  ill  tlio  pelvis,  or  wiicrc  tiio  uinuiotii^  fluid  is  sinall  in  (|iiaiitity  ;  uoitlier  is 
it  practicable,  as  a  rule,  where  an  excess  of  fluid  (;aiises  marked  tension  of 
the  uterine  wall,  as  in  such  cases  the  fetus  cann<u  lie  retained  in  its  new  posi- 
tion. It  is  seldom  adapted  to  cases  where  a  rapid  termination  of  tli((  delivery 
is  iiulispensalile.  Malformations  of  the  uterus  and  tumors  are  rare  contra- 
indications. 

There  is  no  (lanf/er  connected  with  this  operation.  Its  manifest  advantages 
are  that  neither  sepsis  nor  shocU  can  result  from  its  use. 

The  Ixjst  time  for  npemtion  is  at  the  end  of  prefjiiancy,  just  before  the  onset 
of  labor,  because,  later,  uterine  contractions  impede  the  nianeuvre.  Earlier, 
as  at  the  seventh  month,  one  sees  transverse  presentations  in  the  multipara 
that  rectify  themselves,  but  version  may  be  undertaken  early,  or,  indeed,  at 
any  time  during  the  first  stage  when  the  conditions  above  mentioned  exist. 
If  begun  during  labor,  the  manipulations  should  nu  !>e  persisted  in  so  long 
that  the  uterine  wall  takes  on  firm  and  persistent  coi, traction — a  condition 
which  renders  the  other  methods  very  ditfieult. 

Preparation  for  External  Version. — The  bla'''  r  and  the  rei  .urn  should  lie 

emptied,  and  the  woman  placed  in  the  horizontal  dorsal  decubitus,  the  head 

and  sh  ^'Vl'rs  moderately  elevated,  and  the  lower  limbs  .slij;htly  flexed  with 

the  knees  apart.     Anesthesia  is  not  rtquired  unless  the  patient  is  extremely 

'.nsitive. 

Hteps  of  the  Operation. — The  hands  are  applied  to  the  bare  alHlomen  and  the 
diagnosis  is  carefully  confirmed.  A  hand  is  then  placed  on  each  end  of  the 
fetal  ovoid.  In  transverse  cases 
the  liead  is  lifted  toward  the  fun- 
dus and  the  breech  is  driven  down 
toward  the  inlet  by  a  succession 
of  moderate  impulses  which  are 
checked  as  soon  as  a  nterine  con- 
traction is  produced,  while  what- 
ever gain  has  been  made  is  care- 
fully held  until  the  uterine  wall 
amiin  relaxes.  A  method  that  has 
merit  is  the  following:  The  opera- 
tor seizes  the  opposite  ends  of  the 
fetus  with  the  palms  of  his  hands 
(iicing  each  other,  the  fingers  of 
Diie  hand  opposite  the  wrist  of  the 
other,  the  hands  lying  parallel. 
The  power  is  exertv'  by  simple 
flexion  of  the  fingers  moving  in  unison,  and  although  the  position  of  the  hands 
may  .seem  forced,  they  will  be  found  to  work  easily  (Fig.  538).  Alternating 
pushes,  first  ou  the  liead  and  then  on  the  breech,  most  readily  dislodge  and 
turn  the  child.  These  strokes  are  made  in  rapid  succession  upon  the  two 
extremities,  one  hand  giving  a  movement  of  ascent  and  the  other  a  movement 

60 


Fio,  '-38.— External  version :  arrows  show  the  directioii 
in  which  the  ends  of  tlie  fetus  should  move. 


.  ! 


• 


liii 

m 


i-i 4  II 


946 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


of  descent.  CVplialic  vei-sion  should  first  be  tried  in  transverse  presentations 
wherever  the  pelvis  i;  sufficiently  large  and  it  is  not  likely  that  hasty  extrac- 
tion will  be  required,  or  the  tampon  action  of  the  leg  will  become  necessarv 
as  in  placenta  prujvia. 

If  it  is  attempted  to  replace  a  breech  by  a  vertex  presentation,  the  first 
step  of  the  <»peratit)n  consists  in  lifting  the  breech  into  one  iliac  fossa  while 
at  the  same  time  the  head  is  driven  to  one  side.  As  in  all  other  methods,  the 
end  of  the  child  to  be  brought  down  is  made  to  ft)ll()w  the  shortest  possil)lc 
arc  that  will  bring  al)out  the  desired  result.  This  will  be  accomplisheil  by 
pushing  the  head  in  the  direction  of  the  occiput  and  the  breedi  in  the  direc- 
tion of  the  feet.  Patient  and  repeated  atiempts  should  be  made,  but  tiie 
woman  should  not  suffer  pain,  though  she  nuiy  be  subjected  to  some  dis- 
comfort. Wiien  the  turning  is  effected,  a  vaginal  examination  is  to  be  made 
to  make  sure  that  the  tlesired  fetal  pole  has  been  brought  to  the  inlet. 

JidentioH  after  Version. — JIaving  succeeded  in  altering  the  presentation,  it 
will  be  found  that  the  causes  which  produced  the  tbrmer  presentation  will 
tend  to  reproduce  it;  therefore  we  either  bandage  the  abilomen  to  retain  what 
we  have  gained,  or,  if  labor  is  under  way,  we  make  sure  that  the  presenting 
part  becomes  well  engaged.  The  bandage  may  be  one  of  two  kinds — either 
an  impromptu  afliiir  of  flannel  or  of  unbleached  muslin,  like  the  ordinary 
binder,  to  which  a  longitmlinal  pad  on  each  side  is  carefully  fitted  and  fas- 
tened, or  one  of  the  abdominal  bandages  to  be  found  in  any  large  instrument- 
store,  reinforced,  if  ne<!essary,  by  lateral  splints  or  padding.  Pinard's  bandage^ 
has  long  inflatable  pads  on  the  sides  and  straps  under  the  thighs.  If  labor  is 
under  way  and  the  new  presenting  part  do(>s  not  engage  well,  the  ])atiei'.t  mav 
remain  on  her  back,  watched  by  the  ol)stetrician  or  the  mu'se,  or  on  that  side 
from  which  the  presenting  part  was  dislodged,  with  a  firm  pillow  under  the 
uterus  to  prevent  undue  sinking.  In  certain  cases  it  is  advisable  to  rupture 
the  membranes  to  make  sure  that  the  child  remains  in  the  desired  position. 

2.  Bipolar  Version. — liKlicdtiovK. — The  foregoing  general  rules  apply  also 
to  the  bij)()lar  method  of  version.  The  special  conditions  necessary  are  that 
the  liquor  amnii  be  wholly  present  or  so  recently  present  that  the  child  is  still 
movable  in  a  liur  degree,  and  that  the  cervix  admit  two  fingei-s,  while  the 
vagina  must  tolerate  the  preseiuie  of  the  rest  of  the  hand  if  necessary.  "  It 
is  one  of  the  natural  (umsecpiences  of  a  s'oulder  prcsentaiion  that  the  cervix- 
is  but  rarely  found  dilated  enough  for  turning  and  delivery  until  after,  per- 
haps long  after,  the  indication  for  turning  has  clearly  been  present.  The 
shoulder  does  not  dilate  the  cervix  \vell." 

The  admntar/cs  of  the  bipolar  method  over  the  internal  method  are  that 
there  is  less  danger  of  infecting  the  uterine  cavity  in  its  deej)er  parts,  and 
that  it  permits  the  operation  to  be  done  when  the  dilatation  of  the  cervix  is 
but  slight.  Its  disadmntagvH  are  that  the  finger-tips  have  but  a  limited  con- 
trol over  the  parts  of  the  child  that  successiyely  come  within  reach,  and  the 
niethod  is  therefore  usually  restricted  by  its  limitations  to  those  transverse 
cases  in  which  one  has  not  far  to  reach  or  far  to  turn  in  order  to  brin<^'.  the 


OBSTETRIC  SURGERY. 


947 


ations 
xtviu;- 
:essiu'y 

le  fii'st 
I  while 
lis,  the 
)ossihle 
heel  by 
B  Uirec- 
but  the 
nie  ilis- 
ue  intitle 

[ution,  it 

ion  will 

[lin  what 

i-ertontinii 

s — either 

oriliiuiry 
aiul  ia>- 

■^tnunent- 

s  hanclajie 
f  labor  is 
lent  iiniy 
that  side 
\iinler  the 
)  rupture 
lositioii. 
ipply  also 
y  are  that 
lihl  is  still 
while  the 

lary.  "  It 
he  eervix 
after,  per- 
ent.     'Hie 

|m1  are  that 
I  parts,  aii.l 
ie  eervix  is 
Inited  eoii- 
|h,  anil  tlie 
transverse 

brini',  tlie 


child's  knee  into  tlie  cervix ;  nevertheless  this  resource  should  always  l)e 
kept  in  mind. 

The  preferred  time  of  operation  is  early  in  the  dilatation  stage  when  the 
cervix  is  passable  for  two  fingers. 

Preparation  for  lllpolar  Version. — Anesthesia  is  not  necessary  nor  usual, 
but  it  should  be  a  preliminary  procedure  with  an  excessively  sensitive  or  rest- 
less patient.  The  parturient  lies  on  her  back  across  the  bed,  with  her  hips 
near  the  edge,  and  her  feet  on  the  edge  of  the  bed  or  supported  by  assistants 
or  on  chairs.  Working  short-handed,  one  nuiy  pass  a  rolleil  sheet  under  the 
patient's  neck  and  tie  the  ends  about  the  knees,  to  keep  them  flexed.  The 
forceps  is  wraj)peil  in  a  towel  and  boiled,  t(»  be  at  hand  in  case  arrest  of  the 
after-coming  head  should  suddenly  demand  it  lltr  a  dillicult  extraction.  AVith 
the  forceps,  scissors,  episiotomy  knife,  needles,  needle-holder,  catch-forceps  for 
quick  seizure  of  the  cord,  douche-bag  and  tube,  tape;,  and  silk  or  silkworm 
gut  are  sterilized  by  heat.  The  douche-bag  is  filled.  Towels,  steamed,  fresh- 
laundered,  or  wrung  out  of  solution,  gauze,  iodoform  or  zinc-oxide  gauze  for 
tampon,  basins,  and  solutions  are  ready  for  use.  The  diagnosis  is  coufn'med  ; 
the  hands  of  the  operator  are  rendered  sterile,  the  vulvar  hair  is  clipped  close, 
and  the  vulva  and  its  vicinity,  th(!  lower  abdomen,  the  Imier  sides  of  the 
thighs,  and  the  vagina  and  cervix  are  lathered  and  douched. 

Steps  of  the  Operation. — The  fingers  of  the  hand  that  correspond  in  name 
with  the  side  of  tlie  mother  to  which  the  presenting  part  is  to  be  pushed — the 
left  hand  if  the  shoulder  is  to  be  pushed  to  the  left — are  sli|)ped  through  the 
cervix  into  the  uterus,  the  remainder  of  the  hand  being  inserted  into  the 
vagina  only  when  the  presenting  part  is  at  such  distance  as  not  otherwise  to 
be  reached.  The  outer  hand  grasps  that  end  of  the  child  which  is  to  be 
brought  into  the  cervix.  A  simj)le  and  efficient  way  to  keep  this  hand  liom 
contamination  is  to  wrap  it  in  a  sterile  towel  or  to  lay-across  the  abdomen  of 
the  mother  a  towel  wrung  out  of  a  warm  disinfectant  solution. 

Let  us  suppose  that  we  have  a  vertex  presentation,  the  occiput  to  the  left 
and  front,  to  be  changed  to  a  breech  presentation.  The  head  nuist  be  sent 
in  the  direction  in  which  the  occiput  points — in  tiiis  case  to  the  left.  AVe 
now  begin  "the  simultaneous  action  on  the  two  ends  of  the  fetal  ovoid, 
the  fingers  of  the  internal  hand  pressing  the  head-gU>be  across  the  pelvic 
brim  and  lifting  it  upward  toward  the  left  iliac  fossa  ;  the  hand  outside 
])ressing  the  breech  across  to  the  right  and  downward  toward  the  right  ilium 
(Figs.  0,39,  540).  The  movements  by  which  this  is  eiVected  are  a  combination 
of  continuous  pressure  and  gentle  taps  with  the  finger-tips  on  the  head,  and 
a  series  of  half-sliding,  half-pushing  impulses  with  the  curved  hand  on  the 
breech  "  (Barnes).  As  tiie  head  is  lifted  out  of  the  brim  on  to  the  shelf  of  the 
iliac  fossa  and  is  passed  on,  the  shoulder  nun-es  along  into  its  ])laee.  Then  the 
chest,  elbow,  or  knee  com<>s  witliin  reach,  but  further  away  and  at  times  almost 
too  high  for  touching.  When  the  arms  and  legs  are  completely  flexed  the 
knees  of  the  child  are  found  about  the  h"ight  of  its  navel  or  against  its  chest. 
Meanwhile  the  outer  hand  crow«ls  the  breech  well  downward  to  bring  the 


M 


!  \f  I 


i   !ii 


hi 


948 


AMERICAN   TEXT-BOOK  OP   OBSTETRICS. 


or 


if 


knee  within  the  grasp  of  the  fingers  passed  into  the  uterus,  and  the  nurse 
assistant  is  requested  to  lift  the  liead  upward.     As  soon  as  a  knee  comes 
within  reach  it  should  be  seized.     When  a  choice  can  be  made,  the  lower  or 
near  knee  should  be  chosen  in  a  dorso-anterior  position  of  the  child  (Fig. 
543),  and  the  remote  knee  in  a  dorso-posterior  position  ;  that  is  to  say,  the 
lower  of  the  two  in  the  case  we  are  considering.     Often  one  cannot  choose, 
but  breaks  through  the  membranes  (if  they  are  intact)  and  gets  down  either 
leg  or  both  legs  without  ado,  as  the  finger-touches  cannot  determine  the  mat- 
ter so  readily  as  does  the  full  hand-grasp  of  internal  version.     [A  full  con- 
sideration as  to  the  choice  of  foot  is  found  on  page  950.]    Still  applying  power 
to  the  ends  of  the  fetal  ovoid,  the  version  is  completed  by  drawing  the  leg 
down  into  the  vagina  to  secure  the  engagement  of  the  breech.     If  tlie  arm  is 
prolapsed,  Braxton  Hicks  advises  that 
it  be  flexed  and  pushed  up  over  the 
anterior   surface   of   the   thorax,    first 
noosing  a  fillet  about  the  wrist.    In  ap- 
plying the  above  method  to  a  transverse 
presentation  (Figs.  540,  541)  the  steps 
we  have  described  are  undertaken  so 
far  as  they  apply — that  is,  one  begins 
by  tossing  along  whichever  part  first 
comes  within  reach  of  the  inner  fingers. 
Moreover,  while  we  have  described  po- 
dalic  version    because  it  is   the    more 
common,  cephalic  version  can   be  ac- 
complished by  the  same  procedure. 

3.  Internal  Version.  —  By  this 
method,  which  is  the  most  effective  and 
the  most  commonly  employed,  as  well 
as  the  most  dangerous,  the  hand  is 
passed  into  the  uterus  deeply  enough 
to  seize  one  or  both  feet  and  to  bring 
them  through  the  cervix.  The  indications  are  those  already  described  on 
page  942,  and  the  same  may  be  said  of  the  contra-indications,  with  emphasis 
on  the  fact  that  the  reasons  there  given  apply  with  their  fullest  vigor  to  this 
method,  which  in  neglected  cases  may  constitute  a  difficult  and  hazardous 
operation. 

The  conditions  necessary  for  the  performance  of  internal  j)odalic  version — 
and  podalic  version  is  practically  the  only  variety  undertaken  by  this  method — 
are  rather  numerous : 

1.  The  mother  must  not  be  in  gravest  danger,  for  in  such  case  v(>rsi()ii 
cannot  save  her.  The  child  is  likely  to  be  so  weak  as  certainly  to  die  diirinir 
the  process  of  turning  and  extraction  ;  and  the  fetal  life  could  only  be  saved 
by  Cesarean  section  immediately  following  the  mother's  death. 

2.  The  pelvis  nmst  be  sufficiently  ample  to  allow  free  passage  of  the  hand, 


Fi(i.  r)39.— The  first  stei  of  bipolar  pmlnlic 
version:  two  lingers  witliiii  tlie  cervix  lift  tlu' 
hoiid  toward  tlio  iliac  fossa,  while  the  breech  is 
crowded  over  toward  the  other  ilium. 


li 


OBSTETRIC  SURGERY. 


949 


rse  or 

1 

monies 

w 

ver  or 

W 

y,  the 
hoose, 

1 

either 

1 

e  niat- 

§ 

1  con- 

1 

power 
the  h% 

arm  is 

N> 


|)liir  pcM\ii\io 
:vix  lift  llH' 
he  brocih  is 


jribed  on 
lempliasis 
lor  to  this 
imzardoiis 

.-ersioii — 
knethwl — 

\v,  version 

lie  (hiriiV-!! 

bo  saved 

Ithe  haiul, 


so  tliat  the  fetal  part  can  be  grasped  securely  and  the  living  fetus  extracted. 
For  the  live  child  a  true  conjugate  of  not  less  than  8  centimeters  (3J  inches) 
will  be  desirable  with  a  fetus  of  ordinary  dimensions. 

3.  The  cervix  should  be  completely  dilated,  or  in  a  nuiltipara  almost  com- 
pletely dilated,  and  at  the  least  be  freely  dilatable  and  easily  passable  for  the 
hand  without  injury ;  for  if  rapid  (jxtraction  is  necessary  the  cervix  nuist 
permit  ready  passage  of  the  head,  and  to  secure  this  it  should  be  large  enough 
to  allow  the  closed  fist  to  j)ass.  A  note  must  always  be  made  in  passing  of 
the  size  and  dilatability  of  the  orifice,  for  there  is  no  more  annoying  obstruc- 
tion than  to  find  the  after-coming  head  firmly  retained  by  a  jwiwerful  india- 
rubber-like  band  applied  about  the  neck.*  Where  the  dilation  is  not  complete 
version  is  not  forbidden,  for  we  resort  to  it  in  oases  of  placenta  praevia  in 


Fio.  MO.— Bipolar  version :  the  shoulder  ami 
arm  are  pushed  along;  the  breech  is  pushed  down- 
ward. 


Fio.  ."i-ll.— Bipolar  version:   the  knee  is  almost 
within  reach,  tlie  head  is  pressed  upward. 


order  to  plug  the  bleeding  canal  by  the  thigh  or  the  breech  and  wait  for  dila- 
tation, and  we  are  not  deterred  by  the  case  wherein  the  elastic  tube  fits  the 
head  snugly,  because  incisions  will  permit  us  to  extract  rapidly  if  this  become 
imperative. 

4.  The  uterus  must  not  be  tetanica'.ly  contracted  about  the  child,  for  under 
such  conditions  there  is  imminent  danger  of  rujiture;  therefore  the  ob.stet- 
rician  tries  to  ascertain  whether  there  is  a  transveive  ridge,  the  retraction-ring, 
between  the  symphysis  and  navel,  and  how  high  up  it  has  been  drawn. 

5.  The  child  should  not  be  crowded  too  deeply  into  the  pelvis,  but  should 

*The  circumferenpe  of  tlie  oone-shapcil  Imnd  is  from  'JO  to  24  centimeters  (M  to  !t.\  inchesl, 
that  of  the  dosed  list  from  25  to  28  centimeters  (10  to  11  inches),  while  that  of  the  flexed  head 
is  from  80  to  33  centimeters  (12  to  13)  inches),  so  thiit  the  closed  list  should  imss  loosely  to 
ensure  rapid  extraction  of  the  after-coming  head. 


1 
1 

it 

. 
i 

950 


AMERICAN   TEXl-BOOK   OF   OBSTETRICS. 


be  siifficlontly   movable  to   allow  the  preseiitinj;  part  to   be  pushed  back. 
Neitiier  must  the   fetus  be  too  large.     If  premature   (before   tweuty-uiglit 

weeks)  and   dead,  and  macerated,  no 
^'enr flint ^^jTiJ^^SM^  operation  is  likely  to  be  needed.     Most 

favorable  will  be  the  case  wherein  the 
child  is  relatively  small,  the  uterus  lax, 
the  cervix  open,  the  membranes  intact, 
and  the  mother  insensitive. 

Dangers  of  Internal  Vermon. — The 
dangers,  as  has  been  said,  are  ruptir'e 
of  the  uterus  from  the  employment 
of  undue  force,  and  sepsis  caused  by 
uncleanlincss,  together  with  laceration, 
hemorrhage,  and  shock. 

The  adrantages  of  this  method  are 
the  complete  control  of  the  fetus  and 
its  evolutions  which  it  affords. 
Choice  oj  Foot. — Before  proceeding  to  operate,  we  must  have  a  clear  idea  of 


Fig.  ril'-'.— Dorso-antorior  position:  tlii'  hand 
is  passed  diroctly  across  tlie  cliild  to  soizt'  tlie 
near  foot. 


Fi(i.  .m;).— Tractiiin  iin  tlic  near  Ic^  is  niadi-  ill- 
aRiinally  ai'Hiss  tlu-  niotluT's  pelvis  to  pull  tlio 
child's  breech  into  the  inlet. 


Fl(i.  rill.— Traction  made  directly  downwiinl 
leaves  the  lireech  seateil  on  the  iliac  fossa  ami 
reiinires  nseless  force. 


the  mechanism  we  desire  to  institute,  and  we  shall  diverge  from  oui-  practical 
study  to  consider  confiicting  theories  and  teachings,  since  there  is  much  diflcr- 


^m 


OBSrETRIC  SCRGERV. 


951 


Idownwiinl 

I'llSSH    iiiwl 


hractu'iu 


ence  of  opinion  as  to  the  most  advisable,  expoditious,  and  successful  method. 
The  question  at  issue  is  whether  to  seize  one  or  both  feet,  the  near  or  the  re- 
mote foot,  or  the  remote  foot  in  certain  casi's  and  the  near  foot  in  certain  other 
cases.  We  state,  theoretically,  the  most  advisable  method,  but  we  do  not  pre- 
tend to  make  hard-and-fast  rules.  In  practice  we  often  do — not  what  w(^ 
would,  but  what  we  may.  We  may  summarize  the  discussion  by  sr.ying  that 
traction  on  either  foot  will  rightly  effect  the  version,  but  that  it  is  preferable 
to  bring  down  the  remote  foot  in  dorso-posterior  positions  of  the  child,  and 
the  near  foot  in  dorso-anterior  positions. 

The  simplest  metluxl  is  to  seize  either  foot  indifferently.  Some  operators 
(Nagel,  Grandin,  Fritsch)  endorse  this  practice.  In  the  most  difficult  cases 
where  the  pressure  of  quick-recurring  uterine  contractions  or  the  emergency 
during  a  hemorrhage  is  such  that  one  is  happy  to  be  able  to  reach  either  lower 
extremity  ;  or  in  case  only  out;  vaw  be  found  ;  or  with  an  operator  who  has  not 
been  thoroughlv  trained  bv  manikin  teaching  or  who  is  without  sufficient  ex- 
perience  and  possesses  cloudy  ideas  of  position  and  meclianisni, — tiiis  course 
is  a  sensible  one  to  advise.  Traction  on  either  leg  will  l)ring  about  version. 
It  is  merely  a  question  which  leg  will  most  efficiently  produce  the  desired 


Vm.  Ma— Till'  hrccch  oiitiTS  tin."  lu'lvis  with  triic- 
tiiiii  ill  till'  rijilit  I'.iri'ilidii. 


Kiii 


Vlfi.— Ni'W  sfizurt'  nil 


tlu' tliiuli;  tlic  li'BOii 


wliicli  tructidii  is  iiiii 
till'  ju'lvis. 


lie  li.'ilit.'  Ilif  iiiitcTiiir  Iff,'  ill 


|1  ( 


lilVer- 


result;  therefore,  for  the  novice  let  us  say 
if  he  is  unable  to  get  both. 


that  either  loot  should  be  seized 


"(r  i 


952 


AMERTVAN    TEXT-BOOK   OF   OliSTKTRICS. 


The   near  foot  nhrays   is  chosen  by  certain   operators   (Winckel,   Lusk, 

Remote  i 


/Jearfoot 


Fig.  547.— Dorso-antcrior  position;  suizurc  of  tlie       Fkj.  .MS.— Tlio  rcmoti'  fipot  drawn  in  a  ilia^^onul 
rrmotr  fdcit.  direction  tliroiiuli  tlii'  inotluT's  i)t'lvi.'*. 

Schroeder,  (lalabiu),  except  with  a  freely  movable  child,  because  it  i,s  .simpler 


i 
Is 


Fig.  54U.— TIk'  uiipiT  Imttock  i.s  movin^r  down,  ird  Fi(i.  .'i.V).— Tlio  l)r(U'o)i  i-ntors  tlio  pelvis,  tlic  Ice 

and  tlio  lower  shonlder  rif'    i;;.  on  which  traction  is  made  lieint;  the  i)()sterior  lej; 

in  the  pelvi.s. 

aud  less  difficult,  and  l)ecau.se  "  only  a  revolution  (Figs.  542-546)  about  the 


m 


OBSTETRIC  SURGERY. 


953 


cliild's  sagittal  axis  occurs,  to  which  is  added  later  one  about  its  long  axis, 
when  the  hip  which  has  been  brought  down  engages  under  tiie  symphysis." 
In  pulling  on  the  upper  foot  "a  revolution  (Figs.  547-552)  about  the  long 
axis,  and  then  one  about  the  sagittal  axis,  and  finally  a  short  revolution  about 
the  long  axis  of  the  chii<l  occur,  and  a  disastrous  lifting  of  the  arms  is  pro- 
duced." This  objection  to  tract'on  on  the  remote  leg  has  force  in  dorso- 
auterior  cases  only. 

The  remote  foot  always  is  sought  by  certain  teachers  (Simpson,  Kristellar, 
Barnes).  "The  proper  knee  to  seize  is  that  which  is  farthest.  We  have,  for 
example,  a  right  dorso-anterior  position  (Fig.  547) ;  the  right  arm  and  shoulder 
are  dowumost,  and  these  jjarts  have  to  be  lifted  out  of  the  brim.  How  can 
this  be  done  ?  Clearly,  by  pulling  down  the  opposite  knee,  which,  representing 
the  opposite  pole,  must  cause  the  shoulder  to  rise,  the  movements  running 
parallel  in  opposite  directions  like  the  two  ends  of  a  rope  around  a  pulley  " 
(Fig.  549).  "  If  only  the  foot  of  the  same  side  as  the  presenting  arm  is 
seized,  the  effect  is  to  increase  the  wedge  and  the  impaction."  In  Figure 
543  it  will  be  seen  that  traction  on  the  leg  is  like  pulling  on  the  stalk  of  a  T, 
of  which  the  horizontal  bar  is  represented  by  the  body.  Moreover,  in  trans- 
verse cases  the  breech  is  usually  further  from  the  median  bno  than  the  head, 
and  the  near  leg  may  pull  in  the  long  axis  of  the  child  at  a  disadvantage. 

The  inadvisability  and  the  bad  mechanics  of  traction  on  the  posterior 
leg,  as  compared  with  traction  on  the  anterior  leg,  are  well  shown  in  Figure 
560,  (a-c).    It  needs  but  a  glance  to  see  that  the  pull  in  the  direction  of  the 


'^^, 


Fig.  551.— The  Ior  on  which  Inu'lion  is  iiuide 
hi:s  pp.ssed  ovor  from  tlie  left  to  tlu'  rinht  .siilo  of 
the  mother's  pelvis. 


Km.  552.— Tlie  Iok  which  was  posterior  in  Fifjiire 
551)  is  now  unterior. 


arrow  of  Figure  560,  a  is  at  an  angle  which  in  no  way  coincides  with  the 


'I 


ill 

1                           i 

1' 

^         1 

'i               1 

954 


AMERICAN   TEXT-BOOK   OF   OBSTETRICS. 


axis  of  the  inlet  of  the  pelvis,  whereas  the  pull  indicated  by  the  arrow  in 
Figure  560,  c,  is  at  a  much  more  favorable  angle.  Figure  560,  n,  shows  rota- 
tion under  way.  Nagel  demonstrated  elinically  that  the  leg  swings  the  long 
way  round  the  mother's  pelvis. 

The  Near  Foot  in  Dorm-nnterior  PosUiom — The  Remote  Foot  in  Dorm-poste- 
rioi'  Positions. — In  dorso-anterior  positions  the  near  leg  should  generally  be 
brought  down.     A  strong  argument  in  favor  of  this  method  may  be  drawn 


If 


Fi(i.  ."i3. — Porso-postiTidr  iHisiticiii :   tlii'  hand        Fio.  rw^l.— The  fodt  is  dniwii  down;  assistiincu  by 
is  passed  in  dm-ctly  to  seize  the  remote  foot,  the  means  of  tlie  hands  without  is  sliown. 

mother  in  the  d  irsal  posture  (see  Fig.  562). 

from  these  two  facts — first,  that  in  pulling  the  breech  through  the  brim  after 
turning,  it  is  of  great  advantage  to  make  traction  on  the  leg  which  will  come 
at  once  to  the  front  behind  the  .symphysi.s,  and  .secondly,  by  this  means  the 
fetus  never  lo.ses  its  dorso-anterior  position.  But  in  bringing  down  the  upper 
foot  the  child's  face  is  turned  to  the  front,  requiring  a  subsetiuent  rotation  of 
the  trunk  to  bring  about  a  dorso-anterior  condition,  which  is  rcfjuired  at  a 
further  stage  of  the  extraction  in  order  readily  to  deliver  the  shoulders  and 
head.  This  will  best  bo  demon.strated  by  consulting  the  two  series  of  fig- 
ures (Figs.  547-551)  illustrating  the  stages  oi'  the  procedures  here  .set  in 
order.  It  will  be  .seen  that  one  evolution  is  simple  and  that  the  other  is  com- 
plicated ;  that  in  one  case  the  rotation  of  the  body  on  its  long  axis  is  entirely 
avoided  ;  and  that  a  very  im[)()rtant  consideration  argues  for  the  simpler  pro- 
cedure— namely,  that  the  chances  of  throwing  the  arms  above  the  head  are 
materially  lessened  by  the  method  of  traction  on  the  near  foot.  When  there 
is  firm  contraction  of  the  uterus  it  is  rightly  objected  that  pulling  on  the  near 
foot  will  more  tightly  wedge  the  parts,  and  that  it  will  be  necessary  to  push 
the  head  higher  up  in  the  iliac  Ibs.sa  in  order  to  loosen  the  obstruction,     iJiit 


;4i 


m 


\  ' 


oBsrjyritw  surgku  y. 


955 


in  the  presence  of . such  relaxation  as  would  justify  version  the  simpler  method 

is  advisable. 

In  dorso-posterior  transverse  positions  the  remote  leg  should  be  brought 

down.     Here  the  back  of  the  child  is  at  the  rear,  and  traction  on  the  upper 

leg  after  the  change  in  the  long  axis  has  been  ett'ected  will  bring  about  an 

anterior  position  of  the  dorsum  of 
the  child.  To  secure  this  condition 
promptly,  the  upper  leg  is  the  one  to 
seize,  as  shown  by  our  graphic  argu- 


Kio,  riri'i.— Traotidii  is  iiiaiU'  iliiiKoiiHlly  iicniss 
till'  iiKJtliiT's  pi'lvis  to  ilislod^f  till'  liri'ech  ;  tho  li'(f 
brought  down  is  now  thu  iiuturior  Itx. 


Kio.  nrifi.— The  chiUl  slips  fartlior  down. 


inents  (Figs.  55.'i-55G).  As  one  i)ulls  on  the  remote  foot  the  body  rolls  over, 
the  uj)per  buttock  follows  over  a  <'oui*se  toward  the  front  and  becomes  lower 
than  its  fellow,  while  the  spine  is  strongly  curved.  Imagining  tlie  tetal  trunk 
to  be  a  flat  block  of  wood,  the  traction  on  the  upper  or  sacral  corner  of  the 
block  forces  the  diagonal,  or  opposite,  corner — the  impacted  shoulder — to  rise. 
-.1  S!n(/le  Foot. — The  advantage  of  bringing  down  one  foot  instead  of  both 
feet  is  that  the  second  leg  applied  along  the  fetal  trunk  ensures  a  larger  mass 
(made  up  of  the  breech  and  the  flexed  thigh)  by  wliieli  the  cervix  will  be 
wedged  more  fully  open  for  the  benefit  of  the  larger  after-coming  siioidders 
and  head,  than  will  be  the  case  where  this  wedge  is  decomposed  and  l»oth  legs 
are  brought  down,  leaving  a  dilating  mass  of  the  cal'bre  only  of  the  child's 
hips.  The  circumference  of  the  hips,  with  both  legs  down,  is  somewhat  over 
25  centimeters  (10  inches),  while  that  of  the  breech,  witii  one  leg  up,  is  28  to 
;iO  centimeters  (11  to  12  inches). 


■Ifc  ^ 


906 


A  Mi:  It  I(  AX    TKXT-nOOK    OF   OBSTETRICS. 


fi' 


Both  Fid. — Wlioii  the  cervix  is  widely  dilated,  when  tiie  most  nipid  ox- 
traetion  is  called  for,  or  when  the  uterus  is  not  well  relaxed,  both  feet  may  he 
brougjjt  down.  The  middle  finger  is  passed  between  the  child's  ankles  when 
seizing  both  feet,  and  the  other  fingers  surround  the  ankles.  U  seizure  of 
the  foot  is  diftieult  or  if  straightening  of  the  leg  is  impeded,  the  leg  may  Ixj 
brought  down  l)y  making  pressure  in  the  popliteal  space,  thus  flexing  the 
thigh  alongside  the  trunk  toward  the 
back  and  side  of  the  child  and  giving 
more  space  in  which  to  pull  down  the 
foot  (Fig.  561).  In  some  cases  the 
finger  may  be  hooked  over  the  knee, 
and  the    knee   drawn    downward  in  a    jj 


Fio.  G'>7.— Oorso-postcrior  position :    tiR'  rear  Icr 
has  lioeii  brought  down. 


Kio.  55S.— The  child's  l)recch  enters  the  pelvic 
cavity. 


flexed  condition,  extensijm  of  the  foot  being  effected  farther  down  in  the  birth- 
canal,  but  usually  this  method  is  troublesome. 

In  all  the  above  difficulties  the  outer  hand  supplements  the  work  of  the 
imier  hand,  pushing  or  feeding  the  desired  ])art  within  reach  of  the  fingers 
working  in  the  uterus. 

Choice  of  Hand. — Xo  stress  is  laid  on  the  choice  of  hand,  because  the 
feet  of  the  child  usually  lie  within  equally  ea.sy  reach  of  either  baud,  near  the 
center  of  the  uterus.  The  hand  that  is  most  readily  u.sed  depends  somewhat 
on  the  position  in  which  the  ])atient  is  to  be  delivered.  In  general  oneclioosos 
that  hand  which,  in  a  given  case,  will  most  conveniently  pass  in  to  the  leg  to 
be  brought  down,  in  such  a  way  that  the  .sensitive  surface  of  the  fingers  will 
be  turned  toward  the  jiart  to  be  examined  and  grasped — the  palm  toward 
the  child's  abdomen.      Thus  in  the  case  shown  in  Figure   542,  the  patient 


-  m 


onsTETjiii  •  suiidEii  y 


957 


1  birth- 

ol"  tho 
tiugcrs 

luse  the 
liiear  i\w 
Iniewhat 
!  chooses 
lie  lofi;  to 
tors  will 
toward 
patioiit 


I: 


ill  the  dorsal  posture  with  tlie  fetal  alKloiuen  to  the  rear  and  the  feet  to  the 
mother's  left,  the  lelt  iiaiul  works  more  easily  into  the  deep  hollow  behind 
the  ehild.  In  dorso-posterior  positions,  or  in  cases  <tf  peiidnlons  alKlonien, 
there  is  often  diflienlty  in  passing  the  hand  into  the  cavern  above  the  syni- 
jihysis  because  of  the  troublesome  backward  bend  at  the  wrist-joint  (Fig.  553). 
In  such  coiulitions  the  latero-prone  posture  is  of  value,  in  combination  with 
the  expedient  of  passing  the  hand  along  the  lower  lateral  wall  of  tlm  uterus, 
the  patient  lying  on  that  side  on  which  the  child's  teet  are  situated  (Fig.  562). 
PreparatioHH  for  the  Operation. — Internal  version  may  be  undertaken  in 
an  emergency  with  no  assistant  except  a  nurse,  but  oik;  works  at  a  great  dis- 
advantage, and  would  prefer  to  have  one  medical  man  as  anestheti/er,  and  a 

second  to  assist,  besides  the  nurse,  who 
will  have  enough  to  do  in  carrying  out 
directions  that  may  be  given  her. 
Whenever  possible  the  operation  should 
be  performed  on  a  table.  A  large  ene- 
ma should  always  be  given.  The  cath- 
eter should  be  used  if  sitting  on  the 
chamber  and  the  application  of  hot 
cloths  to  the  vulva  fail  to  induce  an 
evacuation  of  the  bladder. 

To  prevent  undue  soiling  of  the  bo<1, 
the  floor,  or  the  operator's  person — for 
this  is  one  of  the  bloody  operations — 
some  ample  receptacle,  such  as  a  pail, 
dish-pan,  or  child's  bath-tub,  should  be 
jilaced  on  the  floor,  and  to  guide  the 
fluids  into  the  vessel  a  Kelly  pad,  or 
a  waterproof,  or  table  cover,  or  some 

Fio.  r,r,9.-The  ihUd-s  trunk  is  fully  within  newspapers  under  sheets  should  be 
the  pelvis,  but  further  rcitution  is  neeossary  to     spread  beneath  the  hips.     Over  these 

bring  the  U'K  to  the  front*  .  ,,  , 

and  next  to  the  jiatient  a  sterile  towel 
or  one  wrung  out  of  an  antiseptic  solution  should  be  laid.  The  operator  pro- 
tects his  clothing  with  a  rubber  apron  or  by  a  sheet  tied  under  the  arms. 

A  well-equipped  instrument-table  will  contain  a  large  basin  of  hot  water 
for  the  scrubbing  or  to  resuscitate  the  child,  a  basin  of  antiseptic  solution  in 
which  the  uterine  douche-tube,  connected  v  ith  a  filled  douche-bag,  may  con- 
veniently lie ;  green  soap  and  brushes ;  gauze  or  towels  to  be  used  as  sponges 
and  in  seizing  the  child  ;  a  bandage  or  strip  of  gauze  ;  a  fillet ;  scissors  ;  silk 
or  silkworm  gut  for  tying  the  cord ;  an  episiotomy  knifli'  for  the  cervix  or 
vulva,  and  forceps  for  the  after-coming  head.  The  assistant  who  administers 
the  ether  is  at  hand  with  restoratives,  a  hypodermic  syringe,  and  ergot. 

*  I  am  indebted  to  tlie  beautiful  work  of  I'arabeuf  and  Varnier  for  the  suggestions  from 
which  many  of  the  illustrations  to  tills  article  were  made.  For  all  of  my  cuts  jihotogniphs 
of  the  pelvis  and  fetus  were  taken  and  painted  over  (Kobert  L.  Dickinson). 


J    4:H 


i, 


I 


958 


AM /:/,'/( 'AN    Ti:XT-UO()K   OF   OJiSTF/ntTCS. 


AuvHthvHin  is  ic(|uin'(l  lor  all  sensitive  patients  in  most  of  tlic  diffieiilt  one- 
rations  and  wiienever  complete  relaxation  of  the  alulominal  and  uterine  walls 
is  essential,  Weeause  tlie  walls  of  the  cavity  l>e<'onie  ten^e  as  the  hand  pushes  in, 
and  may  take  on  a  more  or  less  eontinuons  form  of  eontraetioii.  Xantosis  is 
nsnnlly  desirahle  to  relieve  the  pain  of  the  operation  and  t(»  prevent  striijrjrlin); 
on  the  part  of  the  patient.  It  is  to  bo  omitted  where  siieh  favoralde  conditions 
as  the  open  vulva  of  tiie  multipara,  a  fully  dilated  cervix,  and  Hahhyand  insen- 


Klci.  .".til.— Tci  hriii);  dnwii  ii  font  when  It  l.«  iitraliist 
tlic  lilcc  llu'  klicc  liMiy  111'  li"ii|  l.y  |ilcssiin'  ill  llic 
|io|ilitciil  spncc  iiiiiHliUccI  I'niiii  I'liriilicul'  mihI  Viir- 
iiior). 


Flo.  560.— A,  trnt'tion  iin  the  ptistcriiir  leg:  ilie 
IdWiT  urrdw  slidw.s  tlu'  iixis  of  tlu'  inlet,  tlii'  arrows 
to  the  rlulit,  the  axis  of  traction:  the  Imttoek  is 
cauKlit  on  tlie  tiriiii.  H,  coiitinueil  traetion  is  ro- 
taliiiK  tlie  le^;  to  the  iMwilion  of  ('.  r,  traction  on 
anterior  leu:  the  arrows  show  that  the  pull  is 
nearly  in  the  a.\is  of  the  brim  (moUilied  froiu 
I'arabeuf  and  Varnior). 


Ftu.  .WJ.— Iiorso-posterior  position:  the  liaml 
passes  easily  aloni;  the  side  wall  of  the  uterus 
to  seize  the  feet. 


sitive  uterine  and  abdominal  walls  are  present,  or  when  serious  heart  disea.><e 
forbids  its  use.  It  may  be  discontinued  as  soon  as  turning  is  accomplished. 
Ether  produces  less  complete  relaxation  than  chloroform. 

In  no  obstetric  operation  is  thorough  antisepsis  more  urgently  demanded. 
The  operator's  sleeves  are  rolled  up  nearly  to  the  shoulder  and  ]>inne»l,  a  rubber 
apron  or  a  sheet  is  fastened  about  him,  and  his  hands  and  forearms  are  thor- 


oiiSTF/ntw  smann  y. 


9r)9 


?*" 


ouf^hly  scnihlKil.  Tlicii  tlio  liuir  is  <>Ii|)|>e<l,  aiul  the  vulva,  tlio  itisido  (»t'  the 
thighs,  uikI  tlie  alHlotniiial  wall  ari>  latlicriKl  with  ^aii/o,  soap,  and  hot  water. 
S('riihl)iii}r  should  1>»'  done  with  a  brush  after  auestliesia  is  unch-r  way.  This 
cU'aiisin^'  i.-.  eminently  desirable,  because  (xrasional  eontaet  with  the  skin-siir- 
f'aee  is  hardly  avoi<lable.  In  eases  of  haste  or  in  an  einerjieney  there  uiav  onlv 
1m'  tinieenoii^rh  t(t  send)  ofV  the  vidva  and  to  wrap  the  out«'r  nianipidatin^  hand 
in  a  clean  towel.  The  desirability  of  keeping;  that  hand  aseptic  is  evident  from 
the  fre(|uent  necessity  for  a  change  of  hands  by  which  the  outer  becomes  the 
inner  hand  at  a  time  when  valuable  minutes  would  be  lost  in  <'leanin^  a  con- 
taminated outer  hand. 

Next,  the  vagina  is  well  lathered  with  a  wad  of  jjan/eand  jrreen  soap,  everv 
fold  being  stretehe<l  and  scrubbed.  The  douche  is  then  given.  If  time  and 
material  serve,  each  leg  should  be  ndled  in  a  separate  sheet  and  the  covering 
secured  with  safety-pins.  In  our  hospital  work  the  patient  wears  a  pair  of 
combination  stocking-drawers  tied  about  the  waist.  The  shcet-sling  (I'^ig.  56.'$) 
is  employed  when  working  short-handed.  A  clean  towel,  or  one  wrung  out 
of  an  antis  r'tic,  on  a  chair  or  table,  holds  the  instruments,  which  have  been 
wrapped  in  another  towel,  and  which  have  been  boiling  ten  mimitcs  while  the 
j)atient  was  being  shaved  and  anesthetized. 

J'oNfiiir  of  the  Patient:  Ihrml  Poatuve. — Usually  the  patient  is  laid  with 
buttocks  close  to  tiie  lower  end  of  the  tabic-  or  across  the  bed,  her  thighs 
flexed  and  supported  by  assistants  or,  in  cases  in  which  the  operator  works  very 
short-handed,  by  the  sheet-sling  (Fig.  5G.'}).     The  shoulders  may  be  low;  a 


Kellii  imd 


Fio.  rifiS.— The  shet't-sling :  a  sheet  caught  by  diasonally  opposite  eorners  aiirl  roUed  is  passed  under 
the  neek  and  flexeil  knees.  To  keep  tlie  legs  well  apart  the  knees  should  he  widely  sepnrnted  holbre  the 
feet  are  allowed  to  drop  into  this  position. 

pillow  under  the  hips  covered  with  water-shedding  material  will  lift  the  pelvis 
advantageously,  and  a  light  blanket  protects  the  body  frohi  chilling.  This 
po.sturc  is  mo.st  commonly  em])loyed,  because  it  is  the  only  one  that  allows  free 
play  to  the  outer  liand  ;  the  chances  of  infecting  the  outer  hand  are  les.sened  ; 
if  working  alone,  one  can  better  direct  the  anesthetic  and  watch  the  breathing ; 


960 


AMERICAN    TEXT-BOOK   OF   OBSTETRICS. 


and  extraction  can  bo  completed  in  th-  position  in  which  version  has  been  ac- 
complished.    The  accompanying  illustrations  (Figs.  564-5G6)  show  that  with 


i! 


Fic.  .Vil.— Dorsal  posture  with  tliiRlis  flat  on  the  bed :  the  heavy  black  line  iiuhcates  the  conjugate  of  tlic 

brim  and  its  relation  to  the  horizon. 


i 


Fio.  565.— Dorsal  posture  with  moderate  flexion  of  the  thighs  when  the  feet  rest  on  the  edge  of  the  table. 


m 


Sit 


Fia.  Ofifi.— Dorsal  posture  with  strong  flexion  of  the  thighs  against  the  abdomen;  most  ready  access  to 

the  fun<lus. 

well-flexed  thighs  the  operation  will  be  easiest.     Wl.i-n  extracting  the  after- 
coming  head,  or  whenever  additional  space  in  the  conjugate  diamcier  of  the 


'■'*%   , 


i 


in  ac- 
;  with 


the  aftcr- 
a>r  of  thi 


OBSTETRIC  SUIIGER  Y 


961 


brim  is  demarKled — 6  to  9  millinu'tcrs  {\  t(»  f  inch) — the  thighs  may  bo  cx- 
tentled  to  their  utmost  over  the  edge  ot'tlie  tabic  or  bed.  This  is  the  Wah'hev 
posture  (Fig.  567).  It  will  be  seen  that  the  axis  of  traction  at  the  inlet  in 
this  posture  must  be  almost  directly  downward. 

Latero-prone  Posture, — If  tiie  patient  is  placed  on  her  side,  as  is  advisable 


*'''-~^'\.^ 


Via.  5G7.— Walohcr  posture  :  the  ('(injugate  of  the  brim  is  a  hlnek  line,  nnd  the  amount  of  space  gained  is 

a  (lotted  eontinuation  of  this  line. 

in  dorso-posterior  positions,  it  should  be  on  the  side  ttn  which  lies  that  end  of 
the  fetus  which  it  is  desired  to  bring  down  ;  that  is,  when  the  breech  is  to  the 
right  the  mother  should  be  placed  on  the  right  side.  By  this  method  the 
operator  stands  behind  or  in 
front  of  the  patient  in  such  a 
way  that  he  faces  in  the  same 
direction  as  the  child.  The  ne- 
cessity for  the  operator  to  assume 
these  positions  is  somewhat  less 
im[)erati  ,'0  if  he  proceeds  by 
slipping  his  iiand  beneath  the 
child  along  the  lateral  aspect  of 
the  uterus,  since  he  can  then 
easily  pass  his  hand  in  either 
direction  (Fig.  5G8).  This 
method  is  particidarly  availal)lc 
in  dorso-posterittr  ])()sitions  and 
in  cases  of  pendulous  abdomen, 
liccauso  in  tlicse  one  can  reach  into  tlie  bay-wiudow-likc  uterine  cavity  above 
the  i)ubes  to  sci/e  the  feet  without  that  distressing  backward  heud  caused  by 
tiie  over-extension  of  the  wrist-joint  ahout  the  symphysis  that  is  recpiired  in 
operating  in  the  tlorsal  jMisition  (Fig.  5.5;J).  The  right  hand  would  uatin-ally 
61 


Kiel,  fiiw.— '.nteriil  jiiisliire  for  version;  the  hand  is 
liassed  aloMf;  the  side  wall  of  tlie  lilenis  to  the  feet.  Het- 
ter  ad«|ited  to  dorso-posterlor  positions. 


I  :' 


[1.    S'  -  ^ 


f^-t'i 


m 


IHIiH 


962 


AMEltlVAN    TEXT-BOOK    OF   OBSTETRICS. 


beomploved  with  the  ])ati(Mit  on  hor  right  side,  and  vice  versd.     liUter,  when 
the  feet  have  been  drawn  well  down  into  tiie  vagina,  the  patient  may  be  turned 

over  on   the  bark   to  facilitate  tlu; 


!^-^»cx 


external  manipulations  necessary  to 
complete  the  turning. 

Kncc-clhow  Posture. — This  atti- 
tude should  be  chosen  in  difficult 
cases  when  the  presenting  parts  are 
sniijrlv  fitted  into  the  inlet.  It  oc- 
casionally  yields  brilliant  results, 
rendering  version  possil)le  when  tiie 
fetus  could  not  be  dislodged  in  any 
other  ])osture  of  the  mother  (Fig. 
569).  One  of  the  disadvantages  of 
tiiis  posture  is  that  unless  the  mother 
be  sup|)orted  anesthesia  is  not  avail- 
able. The  writer  has  been  able  to 
m-DiiiKrani  of  kuot-wiMiw  |,..sii.ro  f.,r  iii-     \^^^\^\    p.,tit'nts    ill    tliis   position   bv 

swinging  a  sheet  between  the  backs 


'^'^^i^CT*,^^ 


Tlif  liiwur  |iiiil  of  tlu'  IioIIdw  i>1' the 


tcniiil  \ 

uterus  is  lifted  out  of  the  pelvis. 


of  chairs  placed  on  eitlier  side  of  the 
bed,  directing  the  patient  to  bend  herself  double  over  this  hammock,  and  ope- 
rating over  the  foot  of  the  bed  near  whicli  she  knelt. 

Trenthhnbiuy  Posfiire. — Tiiis  posture  is  available  for  anesthesia,  for  which 


Via.  .'iTil— Iiiiiirovisi'il  'fifuileleiiliurf!  appnriitiis  fur  externiil  version  by  ineiiiis  of  ii  clmir  laid  on  its 
fiu'c  on  tlu'  lii'il.  I'lir  internal  version  a  chair  without  runes  is  useil,  the  lesjs  of  the  patient  liein^  tied  lo 
the  hind  Ick's  of  the  chair.    'I'liis  is  availalile  in  Cesureau  section. 

the  knce-ciie.'^t  attitude;  is  almost  out  of  the  (pie.stion.  The  necessary  incliiud 
))lane  is  easily  improvised  by  turning  a  chair  on  its  face,  as  shown  in  Figure 
570.     If  internal  version  is  to  be  ilouc  in  this  attitude,  a  chair  without  rungs 


I     i: 


OBSTETlilC  SinaERY. 


963 


must  he  used,  tlio  buttocks  must  He  against  the  hack  edge  of  the  chuir- 
seat,  and  the  thighs  be  tied  to  the  baek  legs  to  allow  working  space  be- 
tween the  thighs. 

As  a  general  rule,  it  is  wise  for  the  operator  to  use  that  position  with  which 
he  is  most  familiar. 

The  squatting  position  in  its  most  extreme  form,  when  the  thighs  ure 
strongly  applied  to  the  sides  of  the  abdomen,  is  said  to  have  some  effect  in 
diminishing  the  transverse  diameter  and  increasing  the  longitudinal  diameter 
of  the  uterus,  and  might  be  tried  before  other  measures. 

Examination. — Whenever  external  examination  has  left  any  doubt  as  to 
the  exact  position  of  the  child,  the  fingers,  or  even  the  whole  hand,  passed 
into  the  uterus  will  yield  the  desired  information.  Diu'iug  this  search  the 
rate  of  pulsation  of  the  cord  may  cautiously  be  determined  and  a  low  Im- 
plantaticm  of  the  placenta  be  recognized. 

l^U'ps  of  the  Operation. — Tiie  stcj)s  of  the  operation  are  four  in  number : 
(1)  The  introduction  of  the  hand  ;  (2)  recognition  and  seizure  of  one  or  both 
feet ;  (3)  turning  of  the  child  ;  (4)  extraction  of  the  child. 

After  completing  the  preparations  just  described  and  having  confirmed  the 
diagnosis  of  position,  the  obstetrician  determines  which  hand  to  use  and  which 
foot  to  seize,  and  whether  to  ))ass  the  hand  along  the  back  or  front  or  along- 
side of  the  fetus.  He  nooses  a  fillet  on  the  child's  wrist  if  the  arm  is  in  the 
cervix,  and  he  proceeds  with  the  first  step  of  the  operation,  which  is  the — 

Introduction  of  the  Hand. — The  sterile  hand  is  anointed  on  its  external  sur- 
face with  vaselin,  mdess  a  lubricating  antisej)tie  solution  is  used,  such  as  1  per 
cent,  ereolin  or  lysol  ;  the  tips  of  the  fingers  and  thumb  of  one  hand  are  so 
placed  together  as  to  form  a  cone  ;  the  vulva  is  drawn  wide  open  with  the  fin- 
gers of  the  other  hand,  the  op  M-ating  hand  being  slowly  |)ressed  through  the 
vulva  by  a  rotary  motion.  To  pass  the  hand  in  front  of  the  fetus  the  elbow 
should  be  brought  down  low,  even  if  it  is  necessary  to  kneel  to  do  so.  To 
pass  the  hand  in  behind  the  child,  the  fingers  should  be  slipped  up  to  one  side 
of  the  promontory,  which  may  seem  to  jut  further  forward  than  normal  be- 
(uuse  it  can  be  so  plainly  felt.  The  operator  should  ])ush  steadily  but  gently 
through  the  cervix,  and  having  jwssed  that  opening  sliuuld  fiatten  out  the  hand 
and  "slowly  slip  it  along  without  violence,  without  hesitation,  steadily  upward 
to  the  fundus,  interrupting  its  ju'ogrcss  only  if  a  contraction  commences,  and 
([uietly  awaiting  its  passing  away  before  further  advance." 

If  the  membranes  are  inirnpturcti,  it  is  advisaltle  to  break  through  them  a 
sliort  distance  within  the  cervix,  unless  jHilsating  Ioop«;  of  curd  arc  detected. 
In  the  latter  ease  a  new  and  more  circuitous  path  toward  the  foot  may  be 
chosen  before  rupture.  One  is  loath  to  let  part  of  the  waters  drain  away,  with 
the  possibility  of  bringing  the  cord  down,  but  when  the  hand  is  passed  deep 
Ixtween  the  membrane  and  the  uterine  wall,  it  is  ditticidt  or  impossible  to 
determine  quickly  what  part  one  seizes  through  distended  mend)ranes.  Work- 
ing within  the  amniotic  sat-  leaves  an  important  natm-al  covering  on  the  uter- 
ine wall  and  protects  the  titerus  against  contact  and  infection. 


I 


\  ■}!  ■ 


if-  ■  ■     f 

ri 

Hi-..  . 


t'ii* 


I 


I 


1:V  ^ 


•■m\ 


964 


AMERICAN    TEXT-BOOK   OF    OBSTETRICS. 


m 


The  oporator'.s  fiDgors  aro  held  together  to  prevent  the  cord  from  slipping 
in  between  them.  The  hand  may  keep  to  the  side  of  the  child's  body  (Fig. 
562),  particnlarly  in  oblique  cases,  to  avoid  the  cord,  as  the  latter  is  easily 
compressed  if  the  hand  is  passed  roughly  across  the  child's  belly.  Compres- 
sion of  the  cord  is  avoided  Avhenever  possible;  if  unavoidable,  the  remainder 
of  the  operation  is  hastjued.  "From  the  time  one  conuuences  to  penetrate 
into  the  uterus,  happy  to  Ix;  able  to  push  aside  the  engaging  part,  always 
watciiing  to  employ  a  force  that  is  moderate,  but  continued  and  real — the 
other  hand,  free  to  act  without,  is  applied  over  the  fundus  to  slide  the  breech 
downward  and  to  bring  it  to  meet  the  hand  within.  Without  this  support 
the  upward  pressure  of  the  inner  hand  might  rupture  the  uterus  or  tear  it 
from  the  vagina  "  (Farabeu^'  and  Varnier.)  When  the  hand  has  been  intro- 
duced along  the  child  as  far  as  tlie  navel  the  knees  will  be  encountered.  The 
feet  are  usually  found  near  ♦^he  fundus,  ajjplied  to  the  child's  breech.  In  a 
few  instances  the  feet  of  the  v^hild  are  against  its  face,  or  its  knees  are  witiiin 
easy  reach  of  the  entering  hand  ;  under  such  conditions  the  fingei*s  need  make 
but  a  short  excursion  inio  the  uterine  cavity.  In  most  cases,  however,  one 
nuist  push  on  frankly  and  fearlessly  to  the  fundus,  and  need  not  hesitate  to 
.slip  the  arm  into  the  vulva  up  to  the  elbow,  in  order  that  the  finger-tips  may 
reach  well  beyond  the  fetus  (Fig.  542),  and  readily  curved  backward  to  secure 
a  firm  hold  on  the  feet ;  "  lacking  this  there  is  no  easy  going.  One  wauders 
vaguely  below  the  level  of  the  feet,  hesitating.  Deep  in  the  uterus,  on  the 
contrary,  one  readily  seizes  the  feet,  and  from  that  moment  is  master  of  the 
situation"  (Didx»is;  see  Figs.  547,  562).  The  early  mistake  of  students  and 
practitioners  on  the  manikin,  and  of  internes  in  the  wards,  according  to  the; 
writer's  experience,  is  to  waste  time  in  half-hearted  and  fruitless  attemjjts  to 
seize  parts  of  the  infant  out  of  reach. 

Seizure  of  the  Foot. — At  this  stage  the  operator  should  pause  to  examine  the 
largt!  number  of  limbs  that  seem  to  be  crossed  in  front  of  the  child,  in  order 
to  distinguish  the  hand  from  the  foot,  and,  if  desired,  between  the  near  and  the 
remote  foot.  The  foot  is  readily  recognized  by  the  large  knob  of  the  heel. 
The  flexed  knee  points  toward  the  head,  the  flexed  elbow  toward  the  breech. 
Nothing  need  hurry  one  except  the  numbing  of  the  operator's  hand  under 
})ressure.  It  is  embarrassing  to  ])ull  down  an  arm.  If  but  one  foot  is  found, 
it  should  be  seized  ;  if  both  feet  can  be  had  and  the  cervix  is  wide,  both  may 
be  brought  down.  The  foot  is  to  be  seized  between  the  bent  index  and  the 
middle  finger,  one  over  the  projecting  heel,  the  other  over  the  arch  (Fig.  541>), 
itv,  indeed,  in  any  possible  manner  (Fig.  554). 

Tarnhu/. — The  operator  now  draws  the  leg  downward  to  the  sacral  hollow 
and  across  the  patient's  body  in  the  direi'tion  of  the  child's  head  (Fig.  5")4). 
If  the  breech  is  to  enter  the  pelvis  on  tlic!  mother's  left  side  (Fig.  54.")),  lie 
should  pull  across  to  the  right,  while  at  the  same  time  the  extei'iial  hand  is 
pushing  the  head  up  toward  the  fundus  with  considerable  vigor  (Fig.  545). 
The  assistant's  hand  may  well  be  em|)loyed,  meanwhile,  in  pressing  the 
breech  downward.     After  the  toot  has  been  drawn  well  downward  and  ver- 


f 

I? 


OBSrETIilC   SURGERY. 


965 


H  ■)     I.I 


(Fig. 
easily 
iipres- 
aiiulor 
iietratc 
always 
il— the 
breech 
support 
tear  it 
w  intro- 
1.     The 
1.     In  a 
e  within 
led  make 
ever,  one 
esitate  to 
-tii)S  may 
ti)  secnve 
B  wauders 
u^,  on  the 
pter  of  the 
idents  anil 
ng  to  tlu! 
ttenii>ts  to 

;amine  the 
in  order 
yar  and  the 
the  heel, 
[he  breeeh. 
and  under 
l)t  is  found, 
I  both  may 
Ilex  and  the 
l(Fig.  541»), 


sion  cannot  yet  be  effected,  before  attempting  to  grasp  the  other  foot  one 
should  secure  the  first  foot  with  a  fillet  passed  by  means  of  a  catcli-fijreeps 
(Fig.  571)  up  over  the  wrist  of  that  hand  of  the  operator  which  holds  the 
foot,  and  fastened  about  the  ankle.  Failing  still,  the  inner  hand  lets  go  the 
foot;  the  outer  liand,  steadying  the  breech  and  pushing  downward,  slips  alonj^ 
to  the  shoulder  and  head  and  ])ushes  up  between  the  pains,  returning  to  pull 
wpon  the  leg.     Or,  better,  a  fillet  made  fast  to  the  foot  is  seized  by  the  outer 

hand,  which  draws  the  foot  down 
through  the  vulva,  while  the  inner 
hand  is  pushed  deej)  in  to  lift  up  the 
shoulder  and  head,  the  assistant  mean- 
while helping  as  he  may  externally ; 
but  all  the  precautions  wo  have  men- 
tioned should  carefully  be  observed  to 
avoid  injury  to  the  uterine  wall. 

If,  in  any  of  these  procedures,  an 
arm  slips  down  or  a  hand  is  brought 
down  by  niistake,  a  noose  is  made  fast 
to  the  wrist  in  order  to  prevent  the 
extension  of  this  arm  and  its  elevation 
above  the  head  during  extraction.  In 
some  cases  when  the  child  is  in  the 
transverse  position  the  humerus  may 
be  used  as  a  lever  to  siiove  the  shoul- 
der up  and  along.  The  hand  inva- 
Fio.57i.-A-:.oii-forceps  seizes  the  loop  oi  band-     riably  becouics  uumb  in  a  short  time, 

age  to  Blip  it  up  ovor  tlie  iiulile.  ,  i     j.  i 

and  must  be  changed  for  tiie  otiier 
hand.  The  operation  is  complete  when  the  child's  breech  is  engaged  in  the 
pelvic  inlet.  To  bring  the  feet  through  the  vagina  and  out  of  the  vulva,  one 
will  have  to  resort  to  seizure  with  a  towel,  or  to  the  noose  about  the  ankle, 
the  slippery  skin  of  which  not  affording  a  good  hold  to  tlie  tired  hand. 

Immediate  Extradlon  verum  Dvlaij. — Having  completed  the  version,  one 
carefully  examines  the  fetal  heart  and  considers  the  mother's  general  (!ondi- 
tion,  to  decide  whether  the  child  shall  be  delivered  at  once  or  whether  its 
expulsion  shall  be  left  to  nature.  In  any  condition  threatening  grave  danger, 
such  as  excessive  loss  of  blood  from  placenta  jMWvia,  threatened  rupture  of  the 
uterus,  slow  or  very  rapid  fetal  heart  (near  100  or  close  to  200),  immediate  ex- 
traction is  advisable.  When  the  cervix  is  not  sufficiently  dilated,  when  mother 
and  child  are  in  good  condition,  and  when  there  are  no  indications  for  imme- 
diate extraction,  the  patient  may  be  allowed  to  pass  out  of  anesthesia,  and  the 
uterus  may  be  expected  to  expel  its  contents  with  its  ordinary  jtromplness, 

Extrnction. — In  the  section  on  breech  delivery  (p.  470)  will  be  found  a 
full  description  of  the  different  methods  of  extracting  the  child  when  once 
the  child's  breech  has  been  brought  within  the  cervix.  After  a  troublesome 
vereiou,  and  in  any  case  where  much  traction  on  the  breech  has  been  required, 


k 

\<^; 

-*-^"- 

'"^^m^^ 

w^ 

%i,\t. 

• '  ■  ■ 

), 


966 


AMKIiJVAN   TEXT-JiOOK   OF   OliSTETJilCS. 


{j.i 


^'4 


[III 


1 

I; 

(■. 

it 


the  arms  are  likely  to  be  fbuiul  in  the  most  difficult  position  to  extract- 
namely,  above  llie  bead.  The  frozen  section  (Fijjj.  572)  of  a  patient  who  died 
with  a  rnptnred  uterus  shows  the  distin-bed  relations  of  the  arms. 

In  the  ordinary  method  of  extraction  the  trunk  is  carried  sharply  to  one 
side,  the  jjosterior  shoulder  is  brought  as  nearly  as  possible  into  the  sacral  hol- 


Kk;.  r)7'_'.— Kni/cn  section  of  a  piiticnt  who  died  of  rupture  of  tlie  uterus  (Zweifel) :  tlie  nnterior  lep  is 
piivlly  delivered,  llie  Inink  lills  tlie  pelvic  cavity  snugly,  and  tlio  arms  and  head  are  located  in  the  elon- 
gated \iterus  liiKli  in  the  motlicr's  alidonieu. 

low,  and  the  hands  are  slipped  along  the  back  of  this  posterior  shoulder  until 
the  operator's  finger-tip  can  reach  up  near  the  elbow  to  swing  the  iirm  across 
the  chest  c*'  the  child.  This  manipulation,  as  will  be  seen  in  Figure  578,  is 
etfective  when  the  elbow  can  be  brought 
below  the  inlet,  and,  as  a  rule,  only 
then.  It  is  the  procedure  usually  ad- 
visect  in  text-books.  The  writer  suc- 
ceeded in  unlocking  some  very  diffi- 
cult cases  by  the  method  advised  by 
Barnes.  He  swings  the  rear  shoulder 
well  backward,  pas.ses  that  hand  whose 


i'Ki.  57:'  —The  usual  method  (d  swiiiKint;  an  ex- 
tenclcd  arm  across  llie  child's  chest  to  extract  it. 


rRi.  .'iT  I.— Rotation  of  the  trunk  lo  lirinsoue  shoul 
der  to\var<l  the  sacrum. 


palm  most  conveniently  lies  against  the  child's  back,  forward  under  the  ])iil(ic 
arch  into  tlit;  vulvti,  along  the  child's  back  and  shoulder,  Ibllowiiig  down  tiic 
liumerus  as  near  to  the  el!)ow  as  jjossiblc  (Fig.  575).  I*rc.-Jsmv  with  the  finger- 
tips now  swings  the  elbow  across  the  face  in  front  of  the  promontory  and  toward 


OBSTETRIC  SURd KR  Y 


907 


the  upper  chest  of  tlie  cliild.  The  writer  slips  in  the  otlier  Imnd  ah)ng  tlie 
child's  abdomen  to  extract  the  arm.  The  hands  are  tlien  applied  flatly  against 
the  sides  of  the  tniid<  and  the  body  is  rotated    in  order  to  bring  the  other 


Fio.  o"5.— The  littiul  passed  in  under  the  jmhie  iirch  aloiiM;  ttie  arm  swoops  the  elbow  aeross  the  child's 

fiiee  (not  on  the  same  scale  as  the  preceding). 

shoulder  toward  the  promontory  (Fig.  574).  This  maneuvre  is  repeated  on 
the  remaining  arm,  the  operator  using  the  other  hand  ;  but  usually  a  deadloek 
is  caused  by  the  jamming  of  the  elbow  of  the  child  between  its  tlice  and  the 


h;  ^ 


% 


Flu.  .W).— To  enable  the  elliow  to  pass  over  the  promontory  the  face  must  get  out  of  the  way.    The  left 
hand  of  the  oiierator  therefore  rotates  the  licail  to  free  the  elhciW. 

promontory.  This  difliculty  may  be  overcome  by  firm  j)re.ssur('  with  the  inner 
fingers  at  the  same  time  that  the  outer  htind  seizes  the  occiput  (Fig.  HTG), 
shoving  the  latter  in  the  opposite  direction  from  that  in  which  the  inner  fin- 
gers are  pushing.     This  manipulation  causes  rotation  of  the  head  and  an  ex- 


968 


AMF.IUCAX    TEXT  HOOK    OF   onsTETIUVS. 


Ifi   t 


r! 


ciirsion  of  tlic  fidvlioiid  in  tlic  (lirccfidii  in  wliicli  the  (■ll)(>\v  is  attetiiptiiiji'  to 
move;  bosidi's,  there  is  an  iipprecial)!*-  (liniiniition  of  tlie  resistance  to  tlie 
flexiiis;  of  the  arm. 

Siiould  tliis  nuinenvre  fail,  the  child  nnist  he  rotated  throii<;h  threi'-(niar- 
ters  of  a  circle,  so  that  the  arm  shall  he  left  hehiiul,  as  it  were,  as  the  body  is 
swept  around,  thus  hrinuinjr  the  arm  across  the  chest.  A  deep  reach  will 
secnrc  the  elhow.  One  must  ex|)ect,  in  this  procedure,  to  have  the  child  run 
considerable  risk,  on  account  of  the  dangerous  torsion  to  which  the  necU  is 
subjected  if  the  head  does  not  freely  follow  the  body-rotation. 

It  is  claimed  that  an  additional  leniith  of  true  conjugate  can  be  obtained 
by  the  Wulchor  posture,  whereby  the  thighs  are  drawn  as  far  backward  as 
possible,  the  patient   lying  on  the  edge  of  the  table  or  the  l)e(l  (Fig.  5(j7). 

Xff/lccfcd  or  IiiijKictcfl  ()i,srs. — Considerable  judgment  will  be  rcipiired  in 
determining  how  far  we  dare  proceeil,  and  much  tact  nmst  be  exercised  in  our 
mani])ulations,  in  cases  where  the  uterus  has  fitted  itseli'  firmly  about  the  child. 
A  uterine  wall  in  apparently  tonic  spasm  will  sometimes  relax.  'I'he  knee- 
diest  posture  or  anesthesia  to  the  surgical  degree  with  the  patient  in  the  lateral 
or  the  Trendelenburg  posture  is  necessaiy  to  secure  the  utmost  relaxation. 
The  feet  of  the  child  are  drawn  <lown  while  its  head  is  pushed  uj)  by  one  (»1" 
the  methods  previously  described.  In  case  of  iiiilnre,  or  in  tiiosc  cases  whert; 
im|)aetion  of  a  dead  <'liild  with  |)ermanent  contraction  of  the  uterus  renders 
further  attempts  dangerous  to  the  mother's  Hie,  embryotomy  is  in  order.  De- 
capitation is  the  easie-it  procedure.  Symphysiotomy  or  Cesarean  section  mav 
bo  considered  where  the  pelvis  is  narrow  and  the  child  is  living. 

in.  Celiotomy  for  Sepsis  in  the  Child-bearing  Period. 

Since  the  first  jHM'fornianee  by  Tait  of  abdominal  section  for  purulent  i)eri- 
tonitis  there  has  been  an  extremely  important  develo])ment,  especially  in  the 
last  decade,  in  the  scope  of  pelvic  and  abdominal  surgery  for  septic  iuHamma- 
tions  during  the  child-bearing  period. 

Regarded  at  first  as  a  ])rocedure  analogous  to  opening  an  abscess  anywhere 
on  the  body,  the  whole  abdominal  cavity  being  looked  upon  as  an  abscess- 
eavity  and  the  abdominal  walls  as  its  ca|>side,  abdominal  section  for  ])uer|)eral 
sepsis  has  become  a  generic  term  of  wide  sigit";'canee,  including  hystenH-tomy, 
salpingo-oophorectomy,  evacuation  of  abscesses  in  the  peritoneal  cavity  and  in 
the  pelvic  coiuieetivc  tissue,  removal  of  gangrenous  or  infected  neoplasms  of 
or  in  the  neighborhood  of  the  parturient  tract,  and  ex|)loratory  incisions. 

I)i<}i('(ifio)i.s  for  Ah(Joinhi<il  Sccdoti  in  flic  Traifinciif  of  Piirrjicni/  .Syw/.v. — 
It  is  more  convenient  to  deal  gencrically  with  tlu."  indications  for  abdominal 
section  in  the  course  of  puerperal  sepsis,  for  the  operation  is  usually  decided 
upon  in  practice  without  reference  to  what  may  be  retpiired  after  the  abdomen  i- 
opened,  the  ])rudent  and  experienced  obstetrician  holding  himself  in  readiness  to 
perform  any  of  the  ])elvic  or  abdominal  operations  detailed  above  that  may 
be  found  necessary  when  the  abdominal  cavity  is  exposed  to  view  and  to  touch. 

In  order  properly  to  decide  the  extremely  important  and  anxious  (juestioii 


J 


<  Kl.loToMY. 


l'i.\Ti;    l!>. 


lo-   to 

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<  rt'iulcrs 

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lout  iii'ri- 
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[inywlioiv 

alisccss- 
Duorju'ral 
Mvctoiiiy. 

Ity  and  i" 
llasnis  i>t" 
Ions. 

|l)(loiiiinal 
Iv  (kridi'il 
Ixlonu'ii  is 

dint'ss  to 
Itliat   may 

to  toiu'li. 

S  (UU'StifMl 


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S    I 


niiSTKTlilC   SI  11(1  Kll  Y. 


960 


for  or  against  celiotomy  in  tiie  conrso  of  pnorporal  soptic  fcvor,  tlio  nio«lical 
attendant  must  Im;  familiar  with  the  (litU'tvnt  forms  of  sepsis  after  labor,  and 
should  know  whioh  of  them  arc  most,  whieh  are  least,  ameiial>le  to  surj^ieal 
treatment.  In  u  general  way  it  may  be  stated  that  the  opisration  is  demanded 
most  frequently  for  localized  suppurative  ])eritonitis ;  it  may  be  indicated,  and 
often  is,  for  diffuse  suppurative  peritonitis;  for  suppurative  salpingitis  and 
ovaritis;  for  suppurative  metritis,  if  the  inflammation  extends  outward  toward 
the  peritoneal  investment  of  the  womb  or  into  the  connective  tissue  of  the  broad 
ligament ;  for  abscesses  in  the  pelvic  coinieetlve  tissue;  for  infected  abdominal 
or  pelvic  tumors.  On  the  contrary,  abdominal  section  is  contra-indicated  or 
is  not  recpiired  in  simple  sapremia ;  in  septic  endometritis  of  all  forms — diph- 
theritic,* ulcerative,  suj)purativc  ;  in  dissecting  metritis,  sloughing  intra-uterine 
myomata,  or  in  suppurative  metritis  with  the  abscess  pointing  into  the  uterine 
cavity;  in  phlebitis,  lymphangitis,  and  in  direct  infection  of  the  blood-current. 
One  is  most  likely  to  perform  an  unnecessary  operation  in  diphtheritic  endo- 
metritis (PI.  49).  The  writer  has  thus  erred  several  times.  By  the  time  that 
symptoms  justify  surgical  intervention  in  this  condition  it  is  always  too  late. 

It  is  extremely  difficult  to  lay  down  correct  rules  for  the  guidance  of  a 
physician  in  any  situation  involving  so  much  responsibility,  and  of  necessity  so 
dependent  u]>on  many  circiunstances,  as  that  seeming  to  recjuire  a  very  serit)us 
surgical  operation  in  the  midst  of  an  adynamic  fever  with,  very  likely,  pro- 
found depression,  rapid  pulse,  high  temperature — in  short,  with  everything  a 
surgeon  least  desires  in  the  face  of  a  major  operation. 

First  and  foremost,  then,  the  attendant  should  avoid  the  operative  treat- 
ment of  puerperal  sepsis  if  ])ossible,  and  should  not  seek  an  excuse  for  siu'gi- 
cal  intervention  merely  in  the  cardinal  symptoms  of  septic;  infection — high 
temperature,  rapid  i)ulse,  and  general  depression.  He  sho\dd  demand  some 
tangible  evidence  of  those  forms  of  sepsis  that  are  amenable  to  surgical  treat- 
ment. But  the  physician  of  to-day,  while  reluctant  to  operate  upon  a  jjatient 
under  the  least  favorable  circumstances  and  on  his  guard  against  unnecessary 
or  harmful  surgery,  must  be  prepared  in  the  event  of  certain  symptoms  or 
complications  to  o|)erate  with  the  least  possible  delay. 

Thus,  on  the  very  first  appearance  of  symptoms  that  will  justif\'  the  diag- 
nosis of  diffuse  suppurative  peritonitis,  the  abdonien  must  be  opened  without 
a  moment's  more  delay  than  is  necessary  for  an  aseptic  operation.  Even  with 
the  utmost  promptness  the  operation  will  almost  always  be  too  late,  for  the 
inflammation  extends  so  rapidly  and  at  first  insidiously  that  by  the  time  a 
diagnosis  is  possible  the  progress  of  the  disease  cannot  be  stayed.  The  writer 
must  admit,  however,  contrary  to  his  former  belief  and  declaration,  that  an 
occasional  success  is  possible  by  timely  surgical  interference.t 

*  By  diphtheritic  enifometritis  is  meant  a  dirty,  grayisli-  or  greenish-brown  exudate  on 
the  endometrium,  containing  mixed  micro  organisms,  and  not  necessarily  tlie  Klebs-Loeiilet 
bacillus  (see  PI.  4i)). 

t  Hirst:  "A  diffuse,  imlimited  snpimrative  peritonitis  in  a  child-hearing  woman  cured  by 
abdominal  section;"  Medical  iVeuvs,  18i)4.    A  unique  case,  in  the  writer's  experience. 


1 


B 


1       ' 


»?  h 


^H   : 


i-  m 


r 


B.-  Hci<;K!! 

^Mt'l'F' 

Iflfl 

|| 

ii 

ill 

II 

970  AJ/hJilCAA-    TKXT-IIOOK   OF   OUSTET/trCS. 

Af-aiii,  ill  tli(>  prcsonro  of  exudate,  ailliesioiis,  or  Miiuatural  oiilargcmunt  of 
any  pelvic  .stnietiire,  sii|)piiratiou  may  l)e  suspected  if  the  piiysieal  sijrns  do 
not  inijmn-e  and  if  the  temperature,  pnlse,  and  jrenoral  condition  indicate  a  con- 
tinuance of  septic  inflai'imation.  Jt  is  hardly  necessary  to  state  tiiat  if  pus 
forms  it  nuist  he  reached  and  evacuated  irrespective  of  its  situation.  Just  how 
long  to  wait,  however,  is  a  (piestion  re(|uiring  experience,  good  judgment,  and 
a  special  study  of  each  in<lividual  ease  for  its  correct  answer. 

Knormous  pelvic  and  aiidominal  exudates  may  disappear  ;  adhesions  may 
melt  away  ;  enlarged  and  inflamed  tul)es,  ovaries,  and  uterus  may  resume  tiieir 
proper  size,  functions,  and  condition  on  the  subsidence  of  the  inflammation  ; 
hut  in  these  favorable  cases  distinct  signs  of  im|)roveinent  manifest  themselves 
in  a  few  days,  and  the  course  of  the  disease  is  comparatively  short.  A  mere 
protraction  of  septic  symptoms  is  in  itself  suspicious,  <(loii(/  irith  /ocaf  .tu/HK  o/ 
hiflammaCiou.  Without  the  latter,  the  same  general  symptoms,  sometimes  last- 
ing for  mouths,  mean  phlebitis  and  infection  of  the  blood-current.  In  this 
form  of  sepsis  an  operation  can  do  no  good  and  may  do  the  greatest  harm. 

In  infected  tiunors  in  and  near  the  genital  tract  the  indication  for  operation 
should  be  plain  and  the  decision  easy.  The  presence  of  the  tumor  should  of 
course  be  known.  On  the  first  sign  of  inflammation  in  it,  or  in  the  event  of 
an  elevated  temperature  for  which  there  is  no  good  explanation,  the  tumor 
should  be  removed.  Early  operations  in  these  eases  have  fnrni-ihed  the  best 
results,  delayed  operations  the  reverse."^'  In  cystic  tinnors  the  likelihood  of 
twisted  pedicle  should  be  remembered,  and  in  every  case  of  childbirth  com- 
plicated by  a  new  growth  the  woman  should  be  watched  with  extraordinary 
care  to  detect  the  first  indication   of  trouble. 

An  exploratory  abdoirdnal  incision  should  be  made,  as  a  rule,  only  when  it 
is  desired  to  determine  if  a  pelvic  mass,  [)resumably  containing  pus,  is  situated 
within  or  without  the  peritoneal  cavity,  and  if  the  abscess  had  better  be  evacu- 
ated through  the  abdominal  cavity  or  extra-peritoneally.  The  writer,  in  the 
early  period  of  experimentation  with  abdominal  section  for  puerperal  sepsis, 
made  exploratory  incisions  in  obscure  cases  without  any  local  symptoms  of 
iuHammation  in  the  jK'lvis  or  the  abdomen,  iMtl  he  has  seen  a  number  of  such 
operations  in  the  hands  of  others.  None  «»i"  (lie-c  operations  yielded  informa- 
tion of  value,  nor  did  they  benefit  the  pati  Mit-.  Consequently,  he  adheres  to 
the  general  rule  not  to  o])en  the  abdomen  of  a  puerpera  for  sepsis  unless  there 
are  physical  signs  of  iuHamnuition  in  the  abdomen  or  the  j)elvis. 

Following  these  general  statements  in  regard  to  abdominal  section  for 
puerperal  se])sis,  it  is  ijow  more  convenient  to  describe  in  detail  the  different 
kinds  of  operations  recpiired  for  the  various  forms  of  intra-abdominal  septic 
inflammations. 

Alxloiniudl  Section  for  Iiifraperitoiiral  Almu'xKcs  and  DIJf'nse  Si(j)j)ur(ttirr 
Pa'itonilifi. — The  situation   and  extent   of  localized   suppuration  within   the 

*  The  most  desperate  cases,  however,  need  not  l)e  despaired  of.  Tlie  writer  successfully 
removed  a  gangrenous  ovarian  cyst  from  a  pncrpcra  who  was  so  weak  that  compli'tc  anesthesia 
was  not  attcnpted.     'I'lie  hitu  I)r.  (ioudcll  had  dfclincd  tlie  operation  as  necessarily  fatal. 


Iliii, 
...     ._,|j. 

Ill;:, 


oitsTiyriiK '  SI  ltd  Eli  y. 


971 


uIhIdiiuiiuI  cavity  vary  j^rcatly.  Tlic  writer  lias  seen  a  quarter  of  the  al)- 
iloiuiiial  eavity  tilled  with  pus,  the  iiiij^e  alxscess-eavity  beiiij;  thoroughly  walled 
otr  by  dense  exudate  froiu  the  rest  of  the  abdonuiial  eavity.  A  smaller  eol- 
leetiou  of  |)us  about  the  oriliee  of  the  tube  is  not  uneoiuiuou.  in  one  eas(>  two 
or  three  abscesses  the  size  of  an  orauj^e  were  found  in  coils  of  iiitcstino  (juite 
far  removed  from  one  another  and  without  apparent  connection  with  the  genital 
tract.  In  three  cases  abscesses  were  found  between  the  fundus  uteri  and  ad- 
joining structures — the  abdominal  wall  near  the  uiubilieus  in  one,  the  caput 
coli  in  the  second,  and  the  sigmoid  flexure  in  the  third.  In  these  cases  infce- 
ti<»n  had  travelled  through  a  sharply-delincd  area  of  uterine  wall  and  had  ap- 
j)cared  in  the  same  limits  on  its  peritoneal  investment.  Exudate  and  adhesions 
immediately  walled  off  the  infected  area,  with  the  result  of  an  encapsulated 
abscess  between  the  uterine  wall  and  the  structure  nearest  to  it  at  the  time  of 
inHammation.  The  treatment  of  these  abscesses  consists  in  their  thorough 
evacuation,  the  cleansing  of  i\\v  eavity,  and  drainage.  The  cleansing  may  be 
effected  by  Hushing  with  hot  sterilized  water,  if  the  rest  of  the  abdominal  cavity 
can  be  guarded  from  contamination.  In  some  cases  the  writer  has  avoided  irii- 
gation  and  in  its  place  has  thoroughly  dried  the  cavities  with  gauze  with  good 
results.  For  drainage,  as  a  rule,  iodoform  gauze  will  usiudly  be  found  best. 
In  certain  cases  of  ab.  esses  near  the  abdominal  walls  a  rubber  tube  answers 
better  than  the  gauze,  and  in  deep-seated  abscesses  on  the  base  and  the  back 
of  broad  ligaments  vaginal  drainage  by  means  of  gauze  or  rubber  tube  is  nnich 
to  be  preferred.  If  the  work  during  the  operation  is  well  doiM',  there  n)ay  be 
little  or  no  subsequent  discharge,  and  douching  of  the  abscess-cavities  during 
convalescence  is  uncalled  for.  Occasionally,  however,  if  the  absecss-eavity  is 
very  large  and  well  isolated,  daily  douching  with  sterile  lu)t  water  is  an  advan- 
tage. In  diffuse  sujipurative  peritonitis  the  remote  chance  of  success  depends 
greatly  upon  the  earliest  possible  operation,  though  there  are  many  vindeut 
cases  in  which  nothing  could  stop  the  spread  of  the  inHammation  and  the 
deadly  effect  of  septic  absorption. 

This  is  not  the  plac(:  to  discuss  the  symptoms  of  diffuse  suppurative  \tm- 
tonitis,  but  one  fact  should  be  insisted  upon  from  the  operator's  point  of  view. 
It  is  usually  supposed  that  true  diffuse  suppurative  peritonitis  appears  early 
after  delivery;  it  nuiy,  however,  develop  at  any  time.  The  writer  has  seen  it 
as  late  as  four  weeks  after  eontinement.  The  woman,  who  had  been  up  and 
about  for  some  time,  lifted  an  older  child  down  a  tew  steps.  The  effort  siiutezcd 
a  few  drops  of  pus  out  of  one  of  the  tubes.  The  abdomen  was  opened  within 
twenty  hours,  but  to  no  purpose.  The  teehni(pie  of  the  operatiou  is  simple: 
A  small  incision  is  made,  and  the  finger  is  ra])idly  swei)t  about  the  ])elvis  and 
abdomen  to  determine  the  condition  of  the  organs  ;  then  the  irrigating  tube  is 
passed  into  the  eavity  at  the  lowest  angle  of  the  wound  and  is  swe|>t  about  in 
all  directions,  while  the  return-How  is  ]irovided  fi)r  by  two  fingers  of  the  left 
liand  distending  the  sides  of  the  wound,  which  l)y  the  fingers  and  the  irri- 
gating tube  IS  kept  gaping  as  though  by  a  trivalve  speculum.  (lauze 
drainage  into  the  [touch  of  Douglas  and   the   Hiud<s   is    provided  for,   and 


\- 


'^H 


972 


AJfKIUCAN   TEXT-JiOOK   OF    OliSTr/riiTCS. 


the  wound  i.s  loft  open,  or,  at  most,  drawn  togotlior  bv  a  stitch  or  two. 
Rapidity  of  ojKM-ation  and  tlie  sniaUost  po.«sil)le  quantity  of  anesthetic  arc 
o:-'ential  to  success. 

Salphufo-odphoroeeimii  for  Puerperal  Sepsis. — An  acute  pyosalpinx  in  the 
puerperiiun  is  •.cry  rare.  Jt  is  uncommon  for  acute  septic  infection  after  hibor 
to  travel  by  the  tubes  ahine.  Intection  usually  occurs  in  the  uterine  muscle, 
the  veins,  the  lymphatics,  or  the  connective  tissue  of  the  pelvis.  When  the 
track  of  the  septic  inflammation  is  confined  to  the  nuicous  mendirane  of  the 
genital  trai-t,  the  pelvic  peritoneum,  in  a  case  serious  enough  to  tlcmand  opera- 
tion during  puerperal  convalescence,  bectmies  infected,  inflamed,  and  suppura- 
tion quickly  follows,  st)  that  the  operation  is  usually  performed  for  an  intra- 
peritoneal pelvic  abscess.  The  tube  may  be  found  somewhat  swollen,  inflamed, 
and  containing  a  few  drops  of  pus,  and  its  removal  is  recjuired  ;  but  the  pyo- 
salpinx is  a  subordinate  feature  in  the  pelvic  iuHanimatiou.  It  is  the  more 
subacute  case,  not  usually  re(|uiring  operation  in  the  conventional  period  of 
the  ]>uerperimn,  that  results  later  in  a  typical  uncomplicated  pus-tube. 

Ovarian  abscess  is  more  common  than  pyosalpinx.  The  writer  has  seen  the 
infection  travel  to  the  ovary,  both  by  the  tube  and  by  the  connective  tissue  or 
lymphatics  of  the  broad  ligament.  In  the  latter  case  the  whole  ovary  may  be 
infiltrated  with  a  thin  sero-pus  of  a  particularly  virulent  character,  and,  unfor- 
tunately, in  excising  the  ovary  the  exposure  of  the  infected  pelvic  connective 
tissue  in  the  stump  almost  surely  leads  to  infection  of  the  peritoneal  cavity  and 
to  a  diffuse  suppurative  peritonitis. 

The  commonest  indication  for  salpingo-oophorectomy  is  furnished  by  a  ]ius- 
tube  antedating  conception.  The  strain  of  labor  excites  a  fresh  outbreak  of 
inHanimation  or  leads  to  its  spread,  and  the  ])ersistence  of  septic  symptoms  with 
the  physical  signs  of  pelvic  inflammation  justifies  operative  interference.  In  one 
exceedingly  instructive  case  under  the  writer's  charge  an  operation  was  i)er- 
formed  on  a  presumptive  diagnosis  of  old  pus-tubes,  the  diagnosis  being  bated 
mainly  upon  the  patient's  history  and  the  existence  of  serious  septic  sym[)toms, 
with  tenderness  on  abdominal  palpation  over  the  region  of  the  tube  and  ovary. 
The  uterus  was  nnich  too  high  in  the  abdominal  cavity  to  permit  of  a  satis- 
factory pelvic  examination  of  the  uterine  appendages.  On  opening  the  abdo- 
men a  j)yosali)inx  was  found.     The  patient  recovered. 

There  is  nothing  peculiar  in  the  technique  of  these  operations.  Theydiflfer 
in  no  respect  from  similar  operations  upon  non-puerperal  patients.  The  ques- 
tion of  removing  the  uterus  along  with  the  tubes  will,  however,  arise  rather 
more  fre(]uently  than  in  the  non-puerperal  wo;nan,  on  account  of  the  infection 
of  the  endometrium  or  of  persistent  metrorrhagia. 

jri/s(ererfo)iiij  for  Puerperal  Sepsis. — The  latest  development  in  celiotomy 
for  ])uerperal  sepsis  is  the  removal  of  all  the  pelvic  organs  and  structures  that 
can  be  removed  when  the  septic  inflammation  or  supjmratiou  involves  tlu> 
uterine  nuisdes  and  the  broad  ligaments.  Every  ])liysician  who  has  seen  many 
cases  of  puerperal  infection  during  operations  or  j)os(-)uorte)ii  is  aware  that  there 
are  some  in  which  the  nierc  renu)val  of  infected  tubes  and  ovaries  or  the  evae- 


If' 


onSTETliR '  <S7  lid  Eli  Y 


973 


a  pns- 
?ak  of 
IS  with 

I  n  one 
as  por- 

l)abC(l 
inptoms, 

ovary. 

a  satis- 
10  abilo- 

loy  diffi'i' 
ho  (Hios- 
0  rather 
in  foot  ion 

.'liotoniy 

^ires  that 

Lives  the 

Ion  many 


nt  thoro 
the  evao- 


uation  of"  polvio  abscesses  cannot  bo  ox|)octo(l  to  save  the  patient.  Thoro  wonid 
be  left  behind  areas  of  infected  and  infiltrated  broad  ligaments  that  wonhl 
snroly  conununicate  infection  to  the  ])eritoneal  cavity,  or  there  wonid  remain 
foci  of  suppnration  or  infection  in  the  ntorino  body  tliat  mnst  surely  spread  to 
tlie  peritoneum  or  must  result  in  septic  metastases.  The  oidy  luipe  for  the 
patient  in  such  cases  lies  in  the  entire  removal  of  all  infected  areas,  leaving 
behind  in  the  pelvis  a  healthy,  non-infbctod  stump.     To  otfoct  this  result  the 


Fl(i.  r)77.— nysteri'Ctomy  for  puruloiit  siilpiiifjitis  (Uirst). 

excision  of  the  uterus,  the  broad  ligaments,  the  tubes,  and  the  ovaries  is  re- 
quii'cd.  In  addition  to  these  oases  there  arc  others  in  which,  if  the  tubes  and 
ovaries  must  be  excised,  the  uterus  might  be  removed  with  advantage,  on 
account  of  an  infected  endometrium  or  of  persistent  metrorrhagia.  Figure 
577  is  an  example  of  such  a  case.  The  young  woman  from  whom  the  speci- 
men was  removed  had  a  double  pyosalpinx  following  a  criminal  abortion.  For 
seven  weeks  she  had  been  bleeding  persistently  anil  at  intervals  had  a  foul- 


Fui.  ,'i78.-Siirri"'iitivo  (H'llutitis  (if  liniiid  lifinmcnt;  l'ys*'Ti'r|i  my  (IlirstV 

smelling  dischaigo.  Although  tiie  body  of  tiie  won  o  was  healthy  and  the 
endometrium  was  alon  inflamed  and  inlictcd.  it  was  oDviously  wis*  r  to  remove 
at  once  al!  source  of  the  trouble  ratlior  tha  ■  m  v.-ise  the  tubes  and  ovaries  and 
then  to  treat  s(>parately  at  some  trouble  ai'd  \\.  \  an  organ  that  iiad  lu'comc  on- 
tirelv  superlluous.  Tlio  rosidt  jiistitiod  the  pnx  -.'dure.  Th(>re  may  also  be  such 
widespread  sup|)uration  and  disintc'rration  '••'  'Iw  broad  ligaments,  along  with 
tubal  iuHammatioii,  that  the  compietc  rcinuv..!   'f  all  tiie  infected  area  is  more 


m  % 


!#? 


i 


.# 


974 


A^fI^n^ICAN  text-book  of  oustetrics. 


Ml'-    ■• 


easily  accomplished,  cspocially  as  regards  the  control  of  hemorrhage,  by  a  hys- 
terectomy. Figure  578  represents  such  a  ease.  In  this  woman  a  pyi)salpinx 
antedated  conception.  Labor  excited  fresh  inflammation.  The  infection  spread 
from  the  tube  downward  through  the  connective  tissue  of  the  broad  ligament, 
resulting  in  a  partial  destruction  of  it,  in  a  thick  infiltration  at  its  base,  an;]  in 


Fig.  f)"!!.— Suppurativi'  imd  iilpcriUive  iiU'tritis,  snlpingitis;  liystcrertomy  (Uirst). 

an  abscess  between  its  layers,  closely  hugging  the  whole  of  one  side  of  the 
uterine  body.  It  was  obviously  impossible  to  remove  ihe  infected  area  here 
without  removing  the  womb  as  well.  The  operation,  though  inidertaken  under 
the  most  discouraging  circumstances,  was  successful. 

There  can  be  no  doubt  as  to  the  necessity  of  hysterectomy  in  such  a  case  as 
that  represented  in  Figure  o79.  There  were  abscesses  in  the  uterine  wall  directly 
under  the  peritoneal  envelope  about  to  break  into  the  peritoneal  cavity  ;  one, 
indeed,  did  rupture  during  the  operation.    There  was  a  septic  ulceration  at  the 


Fio.  .wn.— Supiniralivc  ovaritis  (rear  view). 

placenta  site  so  nearly  ])erforating  the  uterine  wall  that  by  a  light  touch  dur- 
ing the  op(M'ation  the  forefinger  passed  into  the  uterine  cavity.  Tliere  was  also 
a  ])y()salpinx  in  this  case  that,  judging  by  the  iiistory,  antedated  or  was  coinci- 
dent with  impregnation.     The  operation  saved  the  patient. 

IndicatUmii  for  the  Operafion. — The  indications  for  hysterectomy  during 
puerperal  sepsis  are  furnished  by  the  condition  of  the  pelvic  organs  when  tlicy 
are  exposed  to  sight  and  touch  after  the  abdomen  is  opened.  The  three  cases 
described  above  are  the  types  calling  for  hysterectomy.  It  is  not  often  possible 
to  determine  upon  hysterectomy  before  the  abdomen  is  opened,  but  if  .-houid  be 
remembered  that  in  any  alxloii.'nal  section  for  pnerj)era'i  sepsis  'ly^lerei-toii  y 
may  be  necessary.     The  careful  obstetric  surgeon  therefore  shoi.Id  h>  provi':  d 


OJiSTETlilC  SURFER  Y. 


975 


loll  V 


with  the  implements  required  for  amputation  of  the  womb  in  every  abdominal 
scetion  for  puerperal  rtepsi?^,  and  be  prepared  to  remove  the  womb  for  anv  one 
of  the  three  indieations  described  above,  but  content  with  the  least  radical 
measure  that  promises  his  patient  safety.  The  operation  that  is  (piickest 
done  and  shocks  the  patient  least  is  most  successful,  provided,  of  course,  that 
it  i.''  adequate. 

lh;hni(]Ke  of  the  Operation. — There  are  two  points  in  which  the  technique 
of  hyfterecitoniy  for  puerperal  sepsis  may  differ  from  the  technicjue  of  the  ope- 
ration performed  iov  other  conditions.  One  of  these  points  is  the  necessitv 
often  of  doing  pan-hysterectomy  ;  th.'  other  is  the  necessity  often  of  tying  the 
ligatures  in  a  broad  ligament  much  thickened  by  inflammatory  exudate. 

The  writer's  preference  is  strongly  for  amputation  of  the  wond),  leaving  as 
little  cervix  as  possible,  and  this  he  always  does  unless  an  examination  of  the 
cervix  by  a  speculum  shows  septic  ulceration  or  exudate  upon  it  or  in  its  canal. 
The  reasons  for  this  preference  for  amputation  of  the  womb  over  pan-hyster- 
ectomy are  that  the  former  can  be  done  more  quickly,  there  is  not  the  same 
anxiety  about  the  cleanliness  of  the  vagina,  and  the  suture  material  is  more 
certainly  guarded  from  infection  afterward. 

The  thickened  broad  ligaments  are  often  a  source  of  serious  embarrassment 
in  placing  and  tying  the  ligatures  around  the  uterine  arteries.  The  writer  had 
this  difficulty  to  contend  with  in  the  majority  of  the  operations  he  has  ])er- 
fornied.  In  two  instances  the  inflammatory  exudate  within  and  below  the 
ligature  broke  down  into  pus,  but  in  both  cases  an  incision  in  the  posterior 
vaginal  vault  evacuated  the  i)us  and  secured  an  immediate  disappearance  of 
somewhat  alarming  symptoms.  In  one  case  it  was  neces.sary  to  do  this  as  late 
as  four  weeks  after  the  hysterectos.iy. 

Exploratcrif  Abdominal  Sccfion  for  Paerpcral  Scpxis. — ^ :>  the  writer's  opin- 
ion, an  exploratory  incision  should  be  nuule  oidy  in  cases  ;  f  suspected  extra- 
ji"  itoneal  pelvic  abscess,  to  confirm  one's  suspicion,  to  be  certain  that  none  of 
tlie  pelvic  organs,  especially  the  tubes,  are  diseased,  and  to  determine  the  best 
sitii.ation  for  the  incision  that  shall  evacuate  the  abscess-cavity  without  contaiu- 
inating  the  peritoneal  cavity.  This  rule  of  practice  would  exclude  exploratory 
a 'il  Hiinal  section  in  those  cases  in  which  there  are  no  physical  signs  of  pelvic 
inriammation,  but  in  which  there  is  evident  septic  infection  of  a  nature  ilillicult 
to  determine.  As  stated  previously,  the  writer  resorted  to  this  |)ractice  formerly, 
and  has  seen  others  do  so,  but  never  with  benefit  to  the  patients.  There  are 
possible  exceptions  to  the  rule,  however,  as  in  the  case  described  on  page  972, 
of  suspected  pyosalpinx  without  physical  signs,  owing  to  the  high  position  of 
the  recently  emptied  wond)  and  of  its  appendages. 

Figure  5(S1,  drawn  from  life,  represents  a  typical  case  reipiiring  exploratory 
abdiiminal  section.  The  woman  had  a  miscarriage  some  weeks  before  the 
writer's  first  visit  to  her.  She  had  lost  over  thirty  pounds  in  weight,  was  bed- 
ridden, had  night-sweats,  high  fl-ver,  profound  prostration,  and  exacerliations 
of  ])ain  in  the  pelvis.  On  examination  the  usual  symptoms  of  extra-perito- 
neal pelvic  exudate  and  suppuration  were  found  on  the  right  side.     When  the 


m 


i' 

1 

f/ 


97G 


AMJ'JRJCAN    TEXT-BOOK    OF   OBSTETRICS. 


mi  ^ 


abdomen  was  opened  it  was  found  that  all  the  pelvic  organs  and  the  pelvic 
peritoneum  were  perfectly  healthy.  There  was  a  large  collection  of  pus  be- 
tween the  layers  of  the  right  broad  ligament,  giving  to  this  structure  a  dome- 
shape.  The  tube  and  ovary  running  over  the  top  of  the  distended  broad  lign- 
ment  were  perfectly  healthy  and  without  a  trace  of  adhesion  or  inflammation 
of  any  kind.  With  the  abdomen  oi)eiied  it  was  easy  to  locate  the  level  of  the 
anterior  dupliciation  of  the  peritoneum.  A  mark  was  made  on  the  skin  an 
inch  below  this  point,  the  abdominal  wound  was  closed,  an  incision  was  made 


l'"i(;.  5.S1.— KxpUiriitory  nlxldininiil  soctUni :  iiu'isii)ii  in  uroin  for  extrii-piTitoiioiil  al)Si'oss  (Uirsl). 

in  the  groin,  as  shown  in  the  drawing,  and  the  pus  washed  out  by  douching. 
SiiHious  tracts  of  suppuration  were  found  by  the  finger  running  up  the  psoas 
muscle  and  down  into  the  Hoor  of  the  jielvis.  Two  drainage-tubes  were  in- 
serted, one  upward  into  the  psoas  muscle,  the  other  (Unvnward  into  the  pelvis. 
In  the  course  of  this  woman's  convilesconcc  it  was  found  advisable  to  make  a 
counter-opening  in  the  right  lateral  fornix  of  the  vagina  and  to  pass  a  drain- 
age-tube through  from  the  opening  in  the  groin  to  the  vagina.  This  estab- 
lished perfect  drainage,  and  the  patient  made  a  good  recovery. 

Cases  like  this  of  true  extra-peritoneal  pelvic  abscess  due  to  puerperal  in- 
fection and  without  intra-peritoneal  inflammation  are  rare.  There  are  some 
gynecologists  who  deny  their  existence,  but  the  writer  has  had  two  cases  under 
his  charge  in  which  the  diagnosis  was  established  by  abdominal  section. 


lI'Bli 


iWic 
bc- 
imc- 
ligiv 
iition 
f  the 
in  an 
made 


f 


INDEX. 


[The  construction  of  this  Index  Is  based  on  tlio  almost  exclusive  use  of  the  ikuiii  as  the  enteh-word, 
with  uinple  cross-references,  und  with  the  introduction  of  the  topical  lorin  of  arraUKinieiit  of  spccitie 
subjects;  that  is,  a  dash  (  — )  indicates  that  topics  thus  marked  are  all  included  under  the  precediuK 
general  head.    The  black-letter  type  is  used  to  denote  the  section-heads  of  the  work.) 


'fl  (     v 


i 


lllirsl). 

[ouclung. 
Ithe  psoas 

wore  in- 

|c  pelvis. 

1)  make  a 

i\  drain- 

Itis  estal)- 

[•peral  in- 

liire  some 

ses  inulef 


Abdomen,  distention  of,  tym- 
panitic, Hiniuluting 
presnancy,      diag- 
nosis, 17.'i 
enlargement  of,  due  to  mor- 
bid conditions,  172, 
17.} 
hydatid  of,  suppurating,  lOi) 
incisions  of,  in  (Jesarean  sec- 

tion.s,  019,  \m 
of    pregnancy,    clianges    in 
size  and  sluipe,  106 
coloration  of,  KiO 
enlargemeiit  of,  lG(i 
fetal  movements,  100 
palpation  of.  (See  Palpaiiou.) 
pendulous,  ptithological  con- 
dition, ;{")0 
Abdominal  section.  (See  Crliot- 

Abnormalities  of  fetal  appen- 
dages,   labor   com- 
plicated bv,  i'uO 
of  force-s  of  labor,  ■li)3-4!)7 
of  milk-secretion,  708-771 
of  presentation  and  position, 

386 
of  the  female  pelvis,  510 
Abortion,  2-Ji( 
after-management  of,  '272 
causes  of,  'j.xciting,  200,  201 
maternal,  200 
paternal,  200 
predisposing,  2(i0 
curettage  after,  873 
defined   2r)!»,  318 
diagii     ..<  of,  2()4 
diseases  causing,  200,  201 
due  to  libroids,  18t),  187 
duration  of,  203 
embryonic,  2o'.) 
etiology  of,  200 
e.xpulsion    of    uterine    con- 
tents, 2(i4 
fetal,  -IV.) 

causes  of,  261 
fre<iueiu'y  of,  25!) 
from  eiKlonielritis,  ISO,  UK) 
from  retroversion  of  uterus, 
101 

63 


Abortion  from  salpingites,  190 
from    puerperal   scarlatina, 

244 
"  habitual,"  256,  260 

treatment,  207 
hemorrhage  and  i)ain  in,  263 
history,  clinical,  202 
incomplete,  204 
curettage  in,  873 
treatment,  272 
induced   bv    ovarian    cysts, 

558 
induction  of,  878 

indications  for,  878 
"  mis.sed,"  272 
occurrence  of,  time,  20O 
ovular,  259 
pathology  of,  2()1 
i       prognosis  and  sequela",  265 
j      surgical     operations     influ- 
i  encing,  201 

.symptoms  of,  prodromal,  263 
threatening,  diagnosis,  265 

treatment  of,  267 
treatment  of,  2t)6 
propliyla.xis,  266 
actual" of,  208 
"tubal,"  281 
Abscess  due  to  puerperal  in- 
fection, 707 
intraperitoneal,     abdominal 
section  for,  975,  070 
mammary,  cold  or  chronic, 
700 
congenital,  840 
milk-nodes  following,  700 
parenchymatous,  702 
syniploms,  702 
treatment,  703 
l>rogiiosis,  700 
subciitaneouH,  704 
of  the  nipple,  751 
ovarian,  puerperal,  072 
peritoni'al,  oi  tlie  new-born, 

858 
submanmuiry,  7(i5 

treatment,  705 
vaginal,  trealnu'nt,  725,  7'-'f! 
Abscesses, intraperitoneal,  celi- 
otomy for,  071 


Abscesses,         intraperitoneal, 
treatment  of,  971 
mammary,  puerperal,  762 
of  the  areola,  765 

treattueul,  700 
pelvic,  indicating  celiotomv, 
000 
".Vcanthopelys"  pelvis,  530 
Accidents  and  surgical  opera- 
tions during  preg- 
nancy, 248-252 
to  the  umbilical  cord,  573 
Accouchement  force,  590 
Acepbalia,  304 
Acini,   glandular,    mammarv, 

0»),  07 
Adenitis,  treatment,  725 
Adhesions  and   biuids,   amni- 
otic. 25;> 
After-birth.     (.<ee  I'/dmitn.) 
Al'ter-coniing  head,  e.xtrnciion 

of,  355 
After-pains,  treatment  of,  (!58 
Agalactia,  771 

treatment,  772 
Air-embolistu    in   the  uterine 
veins,  death  from, 
S(l,", 
Albumin  in  the  urine  of  preg- 
nancy, 157 
of  the  e('latii]iti(',  027 
.Ubmnimiria  in  iuulti|)le  preg- 
iiaiu'ics,  5()0 
in   toxemia    of    pregnancy, 

208 
in  tiie  ei'hiiMptic,  treatment, 

o;!4 

of  pregnancy,  198,  233 
causes,  157 
fre(|ueiu'v,  iS3 
prevalence  of,  157,  158 
treatment,  150,  233 
puerperal,  7S0 
etiology,  780 
prognosis,  780 
.Ucoliol,  use  III',  in  inertia  uteri, 
40i; 
in  lactation,  708,  769 
in   pui'rperal   infection, 
728 

117  r 


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Allilllt'.l-!,    Ilic,    H\ 

A  iri(i/,iii,  71*1 

A  "K'lK.rilicii    in    cxIra-iiU'riiK' 
firi'ifimiuy,  2H t 

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Adiiifiiii  '>t   llif- <•(  |;ii(i(ili( ,  <;2'< 
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A  iiiiii'itiiis,  2''i.". 
A  rnfiullii'  'if  niiiriirMH,  I'lH 
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fciiinlc  (/ciKrrfitivc  'ir«aii-<, 
— rfinn.H  v«!ii';ri<,  .'{7 

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—  iirctlirii.    10 

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—  ureter,    II 


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\n<iiii;ili<M    in    iiit^^'cr'vtii,      >^^^»iliill'iii '  tii'lwi'''ri  llie  li't:i 
7'W  Wiii^       ^J*        ^I'yy  •   li'ii'l  (iii'l  llii":|iiiiii 

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'if     tlic     (iliii  ciihi     wliin     in 

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re  1)1  X  III  inn    '>f,  A/iiijilii  iit 

int'  l;ili'if,  'ilO 
ri(|itiiri'  'if,  ';|0,  ''ill 
llif  Ircfilnicnt,  >'i  tl 
Anli(iyMri(M    in    trcHliiicnl    <if       A-i'itc^      i ';iii(ili' .ilini.^       (ircn- 

[icritiiTiiii-i,  72'<,72'l 

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ficriil  iniiTti'iii,  'I'J-". 

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in  HiirKi'i'il  'i(i<'r.'ili'in^,  HI'M 

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A  nti-i»'|iti'x,  clicniicjil,  'il'!,  ''A  1, 
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iHc  (it,  nn  the  new  ti'irn,  K'iO 
AniiH,  iiliHcnc*'  'it,  in    IIm'    nt-v*- 
li'irii.  H'i7 
v!ii/iniirR,  "i"iO 
.ililiiliic  iif  the  new  li<irii,  ><.",0 
A  [i'i|ili"<  V     'il     tli(T     new  li'irri, 
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H'Slllts.   2"l''l 

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A  [i|ifn'liit;<'<<,  niiri' iilfir,  lO'l 
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— Vdi^lllll, 

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niftiiiiKirjili'iHi^  'if,  I0!( 


'(iii.i<'i!  (iii'l  trcdlnicnl,  H.;., 
Atli.li;!,  7  1--. 
Atonv'if  the  iiterii«,  p'lst  piir- 


tiini 


htiii'irrlini^e 


i-!(('r;il,  'livcl'i[iiiit'i 


.1  'ii,  '.<i; 


-  jifir'iviiriiirri,  '12 

-  V('Hs<.|s  jiri'l  ii'TVft, '1^ 
M 


IC  t'l,  001 
till 


If  iniiiniiiic 


0. 


ro 


Ar''il!i.     IfretKt,    !ilw<'"*M-i    'if,      Atrc-iii'i    iini    in   tlif   ncwii'irii 

flctcrnnniili'iii      'il 
fl'1.7 


itl. 


W 


An'Tnifi  'if  |iict?n;iri''y,  2.1  > 


cil'ir  !in'l  (•linriK'''',  '>'» 
tniirnriiiirv,   of   (irci^niiricy 


of  tlic  fcrvin,  .'il? 


trfsilini'iit.  2 

iii('r)i<T.il,  I  H.7 

^ii'kliiii.^  in. 


I.Vl,   ;<12 


if  till 


Artcrifv,  (ft!!!.  107 


A  iicn'  <'|ili!iliis,  .'lOl 
A  ni-tllK'.ii.'i,  "IwKIri'',  •!*12 
iinf.<llnli' H   in,   'li'ii'c   ' 


livji'ii^intn 


no 


in.l.ili'iil,  ;i;i,   I  10 
.fvic  tl'i'ir.  '10 


F' 

v;n(iiiii 


I,   l-'i 


If    iirftlirii    III   tli«'   iKW 
liorii,       'It'tiriiiiii;! 
fi'iii  'if,  'I'l.'i 
V!i'/iii:il,    'ilwtrn' lini.'     hili'ir 

.■,.v» 

A  iH'  iillJiti'iii,  Jili'I'iiiiiniil,  'I  I  Hi' 


A  rlfnliM,  iiinliili'dl,  H.w 


fl'iS|.i   llV 


110 


!i'liiiihlMtr;iti'in 


of,  ;i<i: 


in  'i)i»T,iti'iTi  of  irit«TfiHl  ver- 
sion, '.t."iH 
A  iiesljieti's,  .'l*I"i  .'I'l.'i 

in  hilior,  eflerl  of.  .'!'12   "I'L'i 
Arikvl'i^is  'if  ilf  pelvi''  jointt, 


A  rierv,  fiini'i 
oviiriiiii,  'I'l 


iliir,  o: 


Aiil'i  infi''  lion,      rl'iet.rine      ol, 


|iiifin'iniiry,      ernlKitiw      nii' 
llironitKi^iK  of,  ^ii'l 


fnl 


If  If 


y      'if. 


Hii: 


|iii(T[ier(il  fever,  'I'l'.^ 


flen 'lentil  Ir'iin,  H02      .A  iito  irnntfiiti'iri    in    (ni-l  |i:ii 


.itrii'  li'iii 


if 


lir'ii/ii'ivm 


iiiift  'tiiii.'n'M|.i 


Ho:i 


Aiioiiidlii 


iii[(eiill!il 


'I. 


tr''iitnienl  'il 


HO.'l 


vel'i|iliient    of     tli»' 


uterine,  '1.'! 


iilerni,  .i1 


Anlirilis,  HVfniit'irrix,  70' 


III  lil'  liili'ili,  7'IH 


lre;iliiieii 


t  of, 


liiiii      iieiri'irrlidi^' , 

00^1 
A  XI-  trd'ti'iii,  HHfl 

in  llie  liiirli  'i(ieriiliori,  MlU 
in    llie    low    'i(ier(itifiii,    H!|i, 

HllH 


t 

%' 


iMn:x. 


|.rt«;- 


riK  ill  itii' 
<if     pn- 
I,.,.,  ■'•'■I 
1,  -^W 
,1,  <•<■'> 

,,..<!   |.iii 
,liii,t  tlilil-"' 

iicw-li'irii, 
Kltl'lll       '>', 


t|,<'    iifw 
IctiriMiii^i 

nil-'     l;il>"' 

rilliiil,''l»t' 

,(t.iin<'      '•'. 
.,1,       -<'■'■', 

Lriii.rrliHK'' 


liiti'iii 
lriili"<>> 


I'.Ai  fi.r.i  ■<,  li'lniHiu.  21''. 
(liictcriii,     fTyii(i»'lii>(,     ill     llir 

ni-w-l,'.rii,  «;W,  H:!5)  . 
ill  liri^iiil.  Ill  I  Ik.  771 
ill  loxf^iiiiii,    'iiiimil    ri'liiii'iii 

(.1,  •;(».",, -JO  t 
in  llic  «""il"l  Iriict,  l'»'! 
ill     III)!      (iiii'i  (XTiil      liri^iiMt, 

iMddcit  of  cnl.niii'*!, 

7. ".7,  7".K 
iriviiHioii    of,    ciiimiiit;     «ori' 

iii|i|ili!4,  7  tH 
iiiiKral.ioii  iif,  from  iiiiiMtiiiiI 

to  fftiil  circiilfilion, 

l.'l',) 
of  |iMiT(ii'r!il   infcclioii,  'W.t 

tyjilioi'l,  ill  |irc!fii!iii''V,  '^42 
I'.jiir,    ol«l<lric.    C'liiiliiiii'llt.   of, 

.'i'll 
Jl!IJ(-t,     lilirllCM'H,    !!«■    o(,    ill     (Ii 

latfilioii  of  iw,  ■<■<;! 
in  iiKTiKi  iiN'ri,  4'('» 
I'.iilloii    lor    till'    iii'lii'lioii    of 
prt'iiiiiiiirf!      liilxir, 

I'.iilloHciiiciil,  I';*'.  ' 

iJiiii'lii^c,  liri'd-il  ,  *i'il 

jK'lvif,  sifter  iiyiiipli  v-iioloiiiy, 
J)l»; 

()ii<T(i<'rnl,  llie,  7  I 'J 
I'lHiiHi,    jiiiiiiiotic,     ilcforiiiitii's 

lUti:  to,  2!»!l 
r.ii«iolril.f,  !l.".l 

'liiriiifr''!,  !»:'.!,  W.'.i 
I'.fitiotrifwy,  'Iii7 
I'lilli,    cold,    ill    IrfjiliiM'iit    i}{ 

|iiTiloiiiii^,  7v!5l 
I'.atlii III; (luring;  pn'KiDiiiiy,  HI 

of  the  new  liorii,  *>*'i."> 
"  I'.altli'ilore  |.lii(«'nl(i,"  'J.'.K 
l!i''l,  [irciKi  rill  ion  of,  lor  jiilior, 

I'.f'j  n/,rci    [)iii'r|i(';"(il,  7ll7 

Ir'sihiifiil  of,  7'!'! 
I'.f'lly,  iieii'liiloiit,  in  ol«lri|(  l<!'l 

Ifilior,  'I'i'l 
r.cllv  liJiri'l     of    till'    new  Icirii, 

(JllC,  fitl7 
iJi'ldi'rV  di-t»'imc,  .'Wm 
r.ili-    of   till'   iu'wlioni   infiiiil, 

HMI 
r.iiid'T,  iilidoiiiiiiiil,  .'Wl 
lirciKl  ,  Miir(iliv,  'I'll,  I'i'i 
in      iirr<"tt     of     liii  liilioii, 

7 '17 
in  lirc'iil  illN<■«■^»^,  7'i!> 
in  iiifiitilit,  7''il 
in  Iri'fitiiKMit  of  Mori'   nip 
j.lcs,  71!» 
I'.irtli  iiiiirkH,  'i\'.\ 
I'.irlli  of  inffinf,   liyifi*'"'''  '''"■»' 

I. Iter,  KV 
I'.irtli-t,  iiniltipli',  coiiipliciitiiiK 
liilwir,  'Vi7 
pliyiiolo(;y  of,  112    H'» 
'   ('iliifk-ili'M'im*',"  Hl'i 
lllfiddcr,  iliH«'(i'«'H    of,    coinpli- 
(iitiiiK     prfr«n(inry, 
H»7 


r.lnd'li'r.ilinlfndi'l,  linni Idling 
^  pr>i/n!in<  y,  diiiKno 

-=M,  1 7;; 

di-liirlmii'  i'«  of  llii',  limclion 
III,  niter    liilior,  l-^'i 
due  to  prfj/niiniy,  I'l'J 
f.-tdl,  121 
over  di^t<■ntion     of,     in     llie 

piierpiriiini,   ''i'<') 
Ktnii  Inri'  of  tlic,   II 
l!li;itoinircK,  77 
I'.liwlii'ii,  77 
"  r.lfcd,  r-i,"  *<.",(),  <',\ 
I'.lindiifi    ill  pnyniui'v,  Hi!i 

in  llic   piifrperinni,  7'l'> 
I'.IoihI,    di-wiri;iini/,iilion    of,   in 
tooiniii     o)      \<Tiv, 
niiii'v,  2'i:;,  'I'll 
in     pr<'i;iifin(v,    londition 
of,    loj 
coiiditioimol,  iil.iioriiiiil, 
2.".". 
Ift.'il     ;ii:d     nijiltrniil,    inter 
'  liiiiiKe       of       -;nli 
i^liiiiieii,   le«ln,    l.'.'l 
fir'  iiidlion  of.   I,",*;    II') 
iiiiKr^ilion  of  Idk  leriii  irorn 
iiiiileriiiil  to,  I  .;;i 
of  llie  new  liorii  infiiiil,  •^'itl 
lr!in-;lo-;ioii  of,  Irfiit  iiiil:il,  .'u.'i 
I'pIomI  (  li!in(/ei!    of    prei/n;in'v, 

IM 
lilood  'jot,      uterine       (iiiHins; 
piierperni      liemor 
rlmi^e,   7  l'» 
"  !!lr>Ml  i^lsind^of  I'linder,"  I'll 
r.lo'><l-iiiipplv     in      prej/iiiincv, 

IM 
I'llood  tiiinor.  (erelir.il,   fif  llie. 
iiew-liorn.   '<21 
eoinplic'ilini/  Ifi'ior    'Wl   '')•■•'! 
li'iiod  ve»-!eli.        exlrii  eintiry 

oiiif,  |(i:; 

fell  I,  I  Id    112 
iiiiiiniiiJirv,  'l!) 
of  rividnelM,  'tl 
oviiriiin.  Ii!! 
|iel vie  floor,  '!■"> 
phirenliil,  K',!,  (I'l 
iiinliilieiil,  (I,'! 
iiretliril,    11 
uterine,  i|:'. 

diirint;     the     pnerperiiiiii, 
>;:,'■'. 

Iiypertrojiliv  of,   I  I'l 
vsiiriniil.   I'l 
I'lliiiil    liook.  lite  of.  in    lireei  h 

hil>or,  17'i 
I'.odv,  fetjil,  the,   lO'l 

delivery  of.      '.'-^ee  /></m./i/) 
eipiil-iion    of.      'He.e     I'ir/i'il 

■tiiiii.) 

rjipid  e^tr.'ietion  of,  in  lireerh 

l.ilH.r,  17!t 

I'.one'i,    di^'iiae«   of,    iiitrii  nte 

rine,  .",'17 

of  llie  new-liorii  infiiiil.  HI  I 

iiijnrieM  to,  K2I,  ^I'l 
VVoriniiin    (onipliintini^   In 
Itor,  o'l'i 


{>7!> 


Monifie,    iKe    of,   for    iiidnetirm 
of  preiiiiiliire  hilior, 

'<7:i 

I'.owelM,  eviii  niilioii  of,  diirin« 
preKiiiiiiey,  H.'l 
in    the    new  liorn,    Ho'i, 

H.-,(; 
in  llie   pniT     •riiiin,  'i'iO 
injuries  to,  of    n     new  liorn, 

oUlriietioii  of,eoiii;eiiit(il,M."»7 

•JVMplOIIK,   •','il 
lre;itliieiit,  HUl 
l!r;iin,dHe!it<'itol,  r  omplii  n\\uu, 

iiiiior,  'ii;; 

feldl,   ilevelopineiit    ol.    I  J.") 

I2'< 
injiirie'i  lo,  of  llie  new  l/orii, 

iiiiilloriiijiliontof,  i/)iii/eni|,il, 

:;'ii 

of  tlie  ei  Ijiifiplie,  (',.';() 
I'.riiin-vesii  '  .;,    fcidl    d,.  olop- 
ine,      '1.',,  ',l<; 
priin.'iry,  I2'> 
"  I'.rfixtoii  llieki'  <^\i'{\  of  prej/- 

njiiir'v,"  I'iV 
f'.rejKt  |p!ini|,i|/e,  <;M 

piierperfil,  7  I'l 
iJreiiit  hinder,  iiifirnniarv,  7."i.", 

.Vltirpliv,  »;(;|,7.V2 
C.re.'itt milk,  mioiMjilieii  in  «e- 
'  relioii  ol,  7'JH  77.'t 
iolo«triiiii  eorpMse|ei(  rif.  H.,'t 
dryiiii;  11)1  of.  !r(  .(riient,  'i'i2 
evaeiKition    of,     in    iiumtili.i, 

7'iO 
eTniiiiiKilion,   mi'  ro^icopicdl, 

77(1 
'|ii!iiilily  (iiid  'jiiiilitv,  'I'll 
tnlKtitiiteii  f'lr.  'I'W  '171 
'.Mee  Mill:,  l,i<iifl    , 
IlreiiHl  piim(i.  7">l 

ill  firre-il  '.f  Ifielntion,  7'17 
ill  miHlilit,  7'!') 
Itreii-ilt,  (ilwee««et  'if   llie,  7'12 
iiii'iiiKiliei  'if,  71")  7  I'l 
dj-senie^  of,  7'il 
diiriMi!'  1(11  tJili'iii,  'I'll 
fi-!|iil(e  'if   piier|i<'r!il,  7I1'1 
liy|iertr'ipiiy  of, 'llie  I'l  prej^ 

niilifi'.  lo2,   I'll 
inlhimni'ili'in   'if,   piKrperal, 

7. 'i'l 
m!i-s;u'e  of  tlie,  7-'i'l 
'if   new  li'irn  iiiffint.  H27 
^trii'  tiire  'if.  'l''i 
iNpp'irt  and  e'liiipresii'in  'if, 
7  ".2 
liree'  h  lali'ir       'Hee   l.nlnir. , 
(ireseiilali'iim       'Ht't'.   I'n^rn- 
liiliiifin.  J 
lirei/m!!,  the,    I'l". 
IJriiii,    Itow    preieritali'piit    at, 
till!,      iiiiinai'emeMl. 
of,   1(17 
fii'e  pre^eIltali'ln^^  at.  the,  in- 
terference,     iipera- 
tiv«',  1'i.'! 
iiiniin(((!iiient,  of,  1'J2 


■f  vi    I 


:;i 


980 


INDEX. 


Brim,  tumors  in  the,  producing 
fdce   presentutions, 
459 
Brow,  anterior,  position  of  the, 
niunugenient       of, 
4()G-4«8 
posterior,  positions   of  the, 
4()7 
manngenient  of,  468 
presentations.  (See  Preaenla- 
lions. ) 
"  Brown  caries,"  234 
Brush,  uterine,  874 
Buhl's  disease,  843 

anatomy  of,  pathological, 

843 
diagnosis,  prognosis,  and 

treatment,  844 
etiology,  843 
symptoms,  844 
Bulbi  vestibiili,  38 

Calcification,  fetal,  283,  313 
Canal,   cerviral,   anatomy    of, 
147 
relation  of,  to   formation 
of  uterine  sac,  147, 
148 
shortening    of,    during 
pregnancy,  103 
genital,  tumors  of,  com|)li- 

cating  labor,  5ot) 
neural,  80 

parUirient,  anatomy  of,  388 
infrapelvic  portion  of,  397 
maternal     structures    of. 
complicating  labor, 
546 
obstruction  to  labor  by  the 
structures    of    the, 
546 
pelvic  portion  of,  390 
shape  and   position,  397, 

398 
suprapelvic  portion  of,  389 
"Canal  of  Nuck,"  53 
Canal  is  artiouhiris,  107 
Cancer.     (See  Cftrci'iioDKi.) 
complicating  pregnancy, 241, 

744 
of  uterus,  187 

extirpation  in,  248 
of  the  rectum  complicating 
labor,  561 
Caput  succedaneum,  818 
■'  "gnosis,  819 
I      logy,  819 

in  Justo-minor  pelvis,  516 
prognosis,  819 
treatment,  819 
Carcinoma  of  cervix,  187 
complicating  labor,  556 
prognosis,  187,  188 
of  the  uterus,  187 

in  the  puerperium,  744 
prognosis,  188 
Cardiac  di.seii.ses  complicating 
labor,  642 
pregnancy,  237 
(Sec  Heart.) 


Caries  of  pelvic  bones,  531 
Carunculiu    mvrtiformes,    40, 

551' 
Catalepsy   during    pregnancy, 

217 
Catarrh,   septic  gastro-intesti- 
!uil,    of    the    new- 
born, 850 
Catheter,  antisepsis  in  use  of, 
347 
passing  the,  868,  869 
choice  of  instrument,  869 
method  of,  869 
position  of  patient  in,  869 
use  of,  in  retcniion  of  urine, 
660,  868,  869 
Catheterization    following 
labor,  716 
in  cystitis,  788,  789 
in  the  puerperium,  660 
"Caul,"  the,  570 
,  Cavity,  pelvic,  anatomy  of,  19 
Cecum,  116 

Celiotomy   for  puerperal  sep- 
sis, 968-970 
contra-indications      to,      in 
treatment  of  puer- 
peral sepsis,  968 
for  difluse  suppurative  peri- 
tonitis, 970 
for  intraperitoneal  abscesses, 
970 
I      indications  for,  in  treatment 
!  of  puerperal  sepsis, 

970 
Cell-division  of  ovum,  stages, 
77 
or  segmentation,  76,  77 
Cells,  Kauber's,  78 
sexual,  fertilization   of,  74, 
75,  76 
Cellulitis,  695 
diagnosis,  700 
I       prognosis,  700 
j      symptoms,  699 
treatment,  725 
Cellulitis,  difiiise,  of  the  limbs, 
707 
suppurative,  of  broad  liga- 
ment, hvsterectomy 
for,  973 
Celom,  S2 

formation  of,  79 
Cephalbeniatoma,  819 
complications,  821 
diagnosis,  820 
etiology,  820 
ireciuency,  820 
patb(ilo),'y,  822 
process  of  repair,  821 
prognosis,  822 
.symptoms,  .S20 
treatment,  822 
Cephalic  presentations.     (See 

PrefiviiUitiunii.) 
Cephalopiigus,  305 
Cephalotribe,  931 
Cephalotripsv,  indications  for, 

937 
"  Cervical  plug,"  163 


Cervix,  47 
atresia  of,  treatment,  547 
carcinoma  of,  187 

complicating  labor,  556 
cavity  of,  48 
cicatricial     contraction    of, 

treatment,  547 
closure  and  contracticm  of, 
obstructing     labor, 
547 
dilatation    of,   artificial,   in 
induction  of  labor, 
880 
for  internal  version,  949 
diseased,  treatment  of,  dur- 
ing pregnancy.  181 
displacement    of,   com)),  ica- 

ting  labor,  556 
during  the  piierperiiuu,  652 
epithelioma  of  the,  188 
fibroids  of,  complicating  la- 
bor, 557 
hypertrophy    of,    in    preg- 
nancy, 146 
lacerations  of,  (514 
causes  and  symptoms,  615 
treatment,  616 
rigid,  intracervical  tampon 
as  a  dilator  in,  875 
treatment  of,  548 
tamponing  the,  874 
uteri,    changes    in,    during 
pregnancy,  163 
softening    and    enlarging 
of,  163 
virgin,  148 
Cesarean  section,  917 

for  ovarian  cysts,  559 
history  of,  917 
immediately     after      the 
death        of        the 
mother,  923 
incision,  abdominiil,  919, 
921 
uterine,  920 
indications  for,  917 
absolute,  918 
relative,  918 
in   cancer  of  the  cervix, 
188 
of  the  uterus,  187 
in  eclampsia,  636 
in  epithelioma  of  the  cer- 
vix, 189 
in  rupture  of  the  uterus, 

613 
in  sudden  death  in  labor, 

645 

mortality  from,  925 

operation  of,  919 

I'orro,  924 

Siinger,  917 

prognosis  of,  925 

preparation    for,   gene- 
ral, 919 
time  to  operate,  918 
Children,  generative  orgau.s  of 
fenuile,    coii;reuit;il 
defe<is  of,  .">(I3 
Chill,  post-partum,  649 


t 
I 


mw 


INDEX. 


981 


Chloasma  iileriniini,  175 
Clilui-iil,  list'  ol',  ill  ecluiiipsia, 

Cholera  during'  pretjiiancy,  245 

treatment,  245,  240 
Chorda  dorsalis,  SI 
Chorea  during  pregnancy,  214 
etiology,  214 
syniptoniM,  215 
tKatnient,  217 
hysterical,  215 
diagnosis,  210 
prognosis,  2!  '• 
Chorion,  the,  S5 
diseases  of  the,  254 
frondosuni,  H() 
lueve,  8<) 
Circidation,  allantoic,  103 
fetal,  i:W-14() 

and  maternal,  interchange 
of    siihstances    in, 
138,  13!) 
development  of,  103 
of  the  new-horn  infant,  809 
placental,  138 

fetal  changes  in,  110 
vitelline,  103,  130, 138 
Circnlatory    system,   develop- 
ment of,  103 
Cleanliness,   surgical,  import- 
ance of,  807,  868 
Cleft,  vaginal,  44 
Cleidotoniy,  <.t39 
Clitoris,  structure  of,  3S 

fetal,  development,  124,  125 
Cloaca,  115 
Clothing    during    pregnancy, 

181 
Club-foot,  304 

Coils  of  umbilical  cord,  93, 258 
Coitus,    date    of    parturition 
based  on,  177,  178 
during  pregnancy,  181 
influencing  abortion,  207 

midtiple  conceptions,  144 
puerperal    infection  due  to, 
092 
Cold,   exposure  to,  puerperal 

fever  due  to,  778 
Cold  pack  in  treating  perito- 
nitis, 729 
Colic  in  the  new-born,  854 
symptoms  and  treatment, 
855 
Colostrum,  153,  102,  054 
Colostrum-corpuscles,  09,  153 

in  l,reast-milk,  774,  775 
Colpeurynter  as  a  cervical  di- 
lator, 875 
in   induction   of  premature 
labor,  880 
Compress,  Priessnitz,  724 
Conception,  occurrence  of,  time 

of,  170,  177 
Conceptions,    midtiple,   coitus 
influencing,  144 
frequency  of,  142 
occurrence  of,  factors   in 

the,  143 
physiology  of,  142-145 


Conduct  of  normal  labor,  341. 

(See  Labor,  nuniutl.) 
Confinement,  preparations  for, 
3(il 
— thn  ap|iliances,  ;>01 
—the  beil,  300 
— tiie  lying-in  room,  359 
— the  nurse,  359 
— the  patient,  301 
Conjugate,  diagonal,  measure- 
ment, 503-505 
pelvic,  359 
diameter  of,  in  Cesarean 
section,  918 
diameter   of    fminel-shaped 
pelvis,  518 
of    generally    contracted 
non-rachitic  pelvis, 
510 
of  jnsto-minor  pelvis,  515 
rachitic  pelvis,  525,  520 
external,    measurement    of, 
501,  •)02 
pelvic,  358 
in  simple  flat  pelves,  meas- 
urements   of,   510, 
511 
spondylolisthetic,  530 
(See  Pclrinu'tr;,:) 
Constipati(m  of  the  new-born, 
850 
laxatives  for,  801 
treatment  of,  850 
acute,   puerperal  fever  due 
to,  780 
Constriction-ring,    closure   of, 
about   the  neck  in 
breech  labor,  484 
Contraction,  intra-uterine  tam- 
pon     stinudating, 
877 
Contraction-ring,  147 
of  Schroeder,  583 
Contractions,  uterine,  after  ex- 
pidsion,  440 
after  labor,  377,  '>^~S 
causing  rupture  of  uterus, 

Oil,  012 
danger  of  abortion  from, 

184 
deficient  action   of,   493- 

497 
during    pregnancy,    318, 

319 
in    post-partuni     hemor- 
rhages, 003-005 
intermittent,   method    of, 

detecting,  107 
in  the  puerperium,  051 
])romote(l  by  nursing,  001 
Convalescence,      management 
of,  in   the  puerpe- 
rium, 003 
Convulsions  of  eclampsia,  020 
uremic,  without  eclampsia, 
19S 
Cord,  anatomical  and  physio- 
logical    considera- 
tions of,  827 
anomalies  of  the,  258 


93 


(,'ord,  blood-vessels  of,  93 
coils  of  the,  258,  570 

etiology,  570 
ron)plicating  labor,  571 
dimensions  of,  at  birth 
dressing  of,  827,  828 
fungus  of,  833 

healing   of,   slight    disturb- 
ance in,  832 
hemorrhage  of,  before  sepa- 
ration, 828 
hernia'  of,  833 
knots  of  the,  258 

fetal  death  from,  311 
ligation  of,  375,  829,  830 

Dubois'  method,  832 
malformations  of,  ,304 
management  of  the,  374 
prolapse  of,  573 
diagnosis,  574 
etiology,  573 
treatment,  575 
reposition   of,  instrumental, 
575 
postural,  570 
resisting  jiower  of,  579 
rupture  of  the,  and  its  ves- 
sels, 579 
treatment,  581 
shortness  of  the,  accidental 
or  natural,  577 
diagnosis,  578 
treatment,  579 
stenosis  of  the,  259 
structure,  93,  94 
torsions  of,  93,  259 
traction    on     the,    causing 
inversion    of    the 
uterus,  018,  019 
in  placental  expulsion,  378 
Cord,  spinal,  development  of, 

129 
Cords,  entanglement  of,  in  twin 

labor,  5(iH 
Corona  radiata,  00 
Corpuscles,  colostrum,  09 

genital,  38 
Corpus  luteum,  (Jl 

of  menstruation,  61 
of  pregnancy,  01 
Cortex,  ovarian,  59 
Corti,  organ  of,  133 
Cotyledons,  placental,  90 
Couveuse,  S03 
Coxalgia,  540 
Cranioclasis,  936 
Cranioclast,  930 
Craniotabes,  821 
Craniotomy,  920  941 
indications  for,  92() 
Uistruments  for.  930 
— basiotribc,  931 
— cephalotribe,  931 
— cranioclast,  930 
— craniotomy     forceps, 

933 
— dcca])itation       hook, 

933 
— hook  and  crochet,  933 
— perforators,  930 


i   I' 


-I 


■I 

,1- 


If' 


982 


Craniotomy  of  tlie  after-com- 
in>?  head,  !»;{') 
of  tin-  prc'weiiliii)?  lifad,  934 
operation,  the,  !)83 
— l)asiotrip»y,  937 
— cephaloti-ip.sy,  937 
— eranioclasiM,  93(5 
Cranium,  fetal,  KCi 

premature  fissilieation  of, 
eomplicalinjf  labor, 
")(;3.     (See  Ilidd.) 
Cretinism,  rongenital,  309,  310 

fetal.  310 
Cup,  oj)tii;,  131 
Curettiige,  H7'2-874 
after  aliortion,  873 
indieatiouH  for,  872 
in  suhinvolulion,  730,  737 
post-purtum,  (i(l3 
te(lini(|ue  of,  873,  874 
Curette,  blunt,  873 

wire,    use    of,    in    obstetric 
cases,  7 '22 
"Curve  of  Carus,"  389 
Curves,  sacral,  '2.') 
Cycle,  nienstriinl,  stages  of,  72 
Cystitis     conii)litating    preg- 
nancv,     treatment, 
197 
due  to  infection  from  use  of 

the  catheter,  347 
of  pregnancy,  treatment,  199 
puerperal,  78() 
diagnosis,  787 
etiology,  78(i 
prognosis,  788 
treatment,  788 
Cystocolpocele,  5()0 
Cysts  of  the  nunith,  congenital, 
303 
ovarian.  li'O 

complicating  labor,  558 
treatment  of,  191 

"  DAUfillTKR-CKLLS,"  77 

Deaf-nuitism,  congenital,  309 
Death  in  labor.  (144 

in  the  i)uerperium  from  en- 
trance of  air  into 
the  uterine  sinuse.s, 
803 
of  fetus  in  utero,  310 
of  mother,  Cesarean  section 

after,  923 
sudden,   during    pregnancv, 
212 
in  the  jjuerperium,  causes, 
801,  802 
from      embolism     and 
thrombosis   of   the 
])ulmonary   arterv, 
802 
Decapitation,  fetal,  938 

indications    for,   and   the 
operation,  938-940 
with    Uraun's  hook,  938, 
939 
Decapitation    hook,    Hraun's, 
933,  938 
Zweifel's,  933 


INDEX. 

Decidua,  hypertrophied,  caus- 
ing uterine  hemor- 
rhage, 740 
removal  of,  in  subinvolu- 
tion, 737 
hypertrophy  of  the,  189 
of  ectopic  gestation,  284 
retained,  curettage  for,  873 
Decidua  rellexa,  80 
sorotina,  8t> 
vera,  80 
of  pregnancy,  319 
Decidua',  anatomy  and  physi- 
ology, 8(1 
Deformities,  congenital,  299 
of  special  regions  and  or- 
gans, 302 
fetal,  299 

causes  of,  253 
pelvic,  498 

complicating  labor: 
—  coxalgic,  540 
— Hat     pelvis,     simple, 

510 
— generally- contracted, 
flat,      non-rachitic 
pelvis,  510 
— justo-major       pelvis, 

521     ' 
— justo-minor      pelvis, 

•■14 
— kvphoscoliotic      pel- 

■  vis,  540 
— kyphotic  pelvis,  537 
— narrow,     f  u  n  n  e  1  - 
shaped  pelvis,  517 
— obli(|iicly  -  contracted 

[lelvis,  518 
— osteomalacic     pelvis, 

520 
— rachitic  ])elvis,  522 
— .scoliotic  pelvis,  539 
-split  pelvis,  522 
— spondvlolisthetic  pel- 

vis,'532 
— transversely   -  c  o  n- 
tracted  pelvis,  521 
Deseneration,  calcareous  pla- 
cental, 255 
fatty,  placental,  25() 
Delivery  by  basiotripsy,  937 
by  cephalotripsy,  937 
by  Cesarean  st-iion,  923 
indications,  917,  918 
operation  of,  919 

preparation  for,  gen- 
eral, 919 
time  to  operate,  918, 919 
by  cranioehisis.  930 
by  craniotomy,  920 
by  embryotomy,  920 
by  fetal  decapitation,  938 
by  fetal  evisceration,  938 
by  laparo-elytrotomy,  925 
bv  the  I'orro  operation,  924 
by  version,  941-908 
forceps,  compression  in,  890 
indications  for,  891,892 
in   labor   complicated    by 
cardiac  diseases,  042 


'  Deliverv,  forceps,  leverage  in, 
!  891 

of  the  after-coming  litad, 
after     craniotomv, 
930 
operation  of,  the,  892 
rotation  in,  891 
traction  in,  890 
in  high  operation,  898 
delined,  892 
in  bree(h  |ire.sentati<iiis, 

902 
in  brow  and  face  pres- 
entations, 901 
in    dorsal    and    lateral 
positions,  904 
in  dorso-anterior  ]iositi(inB, 
internal  version  in, 
954 
in  dorso-posterior  jxisitioiis, 
internal  vrrsion  in, 
954 
in    hospitals,    niiinngement, 

710,717 
in  labor  bv  svmphvsiotomv, 
905-917 
in  left-lateral   position, 

903 
in  occipito-posterior  po- 
sitions, 900 
obstructed    by    vaginal 
and  vulvar  timiors, 
550 
of     the     after-coming 

head,  902 
of  the  severed  head,  903 
in  low  operation,  dcliued, 
892 
in  the  dorsal  position, 

893 
jiosition  for,  8!)3 
traction  in,  89ti-89S 
in    mcdiinn    operation,   de- 
lined. 892 
in   rupture   of    the    uterus, 

013 
instriunental,  after   rupture 
of   the   svmplivsis, 
040 
choice  of  operative  proce- 
dures, 92(i,  927 
in   sudden   death    in   labor, 

044 
management    of,    in     labor 
oljstriictcd  by  con- 
tracted i)elvi's,  543 
precipitate,  causes  of,  497 
Delivery-room     in     hospitals, 
711 
(See  LyiiHj-hi  room.) 
Descent,  normal  mechanism  of, 
in  dry  labors,  4.'11 
in  vertex  preseiilatioiis, 
431 
of  head,  normal  rotation  in. 
512 
Diabetes    during    pregnancv. 
218 
pathology,    prognosis,    ami 
"treatment,  220 


rp 


TNDKX. 


f>H:j 


Diagnosis  of  pregnancy : 

of    till'    (liii'iition    <>r    jirej?- 

iiiiiK'v,  ITti 
of  the  prolongation  of  preg- 
nancy, 17H 
of  symptoms  and  signs: 

— nausea  and  vomiting, 
15!) 

— ntenstrnal  suppres- 
sion, KiO 

— mamma  rv  changes, 
Itil 

— functional  disturl)- 
ances  r)f  the  blad- 
der, Wl 

— intrapclvic  signs,  W,\ 

— abdominal  changes, 
l(i(> 

— ballottcmcnt,  Ititi 

— intermittent  contrac- 
tions, l(i7 

— quickening  and  fetal 
movements,  lt)7 

— uterine  soiiUle,  KW 

— fetal  heart-sounds,  108 
fetal  contour,  170 

— classilication  of  the 
phenomena  of 
utero  gestation,  170 

— mental  and  emotional 
phenomena,  170 

— relative  value  of 
symptomsand  signs 
in  point  of  diaguo 
sis,  171 

— of  the  life  or  the  death 
of  the  fetus,  17.") 

Diagnosis  of  presentation 
and  position, 

85()-;ir),s 

Diagnosis  of  the  mechan- 
ism of  labor.  (See 

Ijtbiir,  (lidtjiiDnis. ) 

Diagnosis  of  the  puerperal 

state,  »)•')«) 
"Diameter  of    Haudeloccjue," 

501 
Diametert!  of  fetal  head,  403 
lenj;ths  of,  404 
relative  value  of,  com- 
pared with  diame- 
ters of  the  pelvis, 
404 
of  the  pelvis.     (See  Priri.i.) 
Diaphragm,  pelvic,  27 
JUarrhea  in  the  newborn,  Soo 

treatment,  8.')() 
Diet  in  pregnancy,  180 
in      the     prophylaxis     of 
eclampsia,  (ilU 
Dietary,   infant,   in    constipa- 
tion, 8.')7 
in  nephritis,  7;i2 
in  peritonitis,  728 
in  the  puerperium,  059 
of     the     nui-sing     woman, 
769 


Digestion,  changes  in,  due  to 

pregnancy,  155 
Dilatation,  cervical,  I'or  inter- 
nal version,  019 
of  the  OS  uteri,  artilicial,  SS2 
in  breech  presentations,  471 
mechanism  of,  after  rupture 
of  meml)rane^:,  427 
normal,  424 
with  De  Kibes'  dilator,  884 
with   origiuallv  seaniv    wa- 
ters, 429 
with  Tarnier's  dilator,  884 
with     undue     elasticity    of 
membranes,  4:>0 
Dilator,    uterine,    Itarnes'    lid- 
die-bag,  SSo 
Harnes'   fioft-rubher,    883, 

884 
Champetierde  Kibes',  884 
McLean's,  883 
six-hranched,  883 
Tarnier's,  883 
Dilators,  uterine,  llegar's,  882 
instrumental,    varieties    of, 
882 
Diphthei'ia,  congenital,  851 

puerperal,  781 
Discus  proligerus,  (iO,  71 
Diseases,  eruptive,  of  fetus  in 
utcro,  290 
infectious,   of    the   fetus   in 

utero,  295 
intra-uteriue,  of  the  bones, 
307 
of  the  nervo'.is  system,  309 
of    the    skin,    I'onnective 
tissue,   and    serous 
me.,  brane,  309 
maternal,  dvstocia,   due  to, 

023 
medical  and  surgical,  inci- 
dent  to   the   birth 
of  the  child.  Mo 
of  the  breasts,  751 
of  the  fetus  in  utero,  295 
of  the  nervous  system,  790 
of  the  nipples,  747 
of    the   nou-sexual    organs, 

778 
of  the  sexual  organs,  083 
of  the  urinary  organs,  785 
puerperal,  iiUercurrent,  780 
septic,    folhiwiug    abortion, 
205,  200 
Disinfectants  in  treatment  of 
jiuerperal        infec- 
, ion,  708-710 
Disinfecti(m    by   the  obstetri- 
cian, personal,  344 
hospital,  712-714 

—of     the     doct(U's     and 

nurses,  71. '5 
— of  the  instruments,  714 
— of  the  materials,  714 
— of  the  mu'se,  .")45 
—of  the  patient,  345,  340, 

713 
— of  the  ward,  713 
practical  rules  for,  343 


Disinfection,  vaginal,  720 

(See  Diiiirlii-  Mu\  Irrii/itlioii.) 
I)isk,  interpubic,  23 

iiivertebral,  25 
Dislocations,  congenital,  301 
i)isorders    of    vision    in    the 
eclamptic,  025,  029 
Dosage  of  the  new-born,  8t)0 
— alteratives  801 
— antacids,  8(il 
— antil'ernieiits,  801 
— antipyretics,  SOI 
—antispasmodics,  801 
— digestives,  SOI 
— diuretics,  SOI 
— hemostatics,  802 
— laxatives,  SOI 
— nerve-sedatives,  801 
—  nutrients,  800 
— siiundants,  801 
—tonics.  800 
Douche,  the,  870 

uterine,  operation,  872 
vaginal,  in  the  induction  of 
premature      labor, 
881 
method  of  giving,  S7() 
Douches,  uterine,  dangers  of, 
872 
vaginal,  utility  of,  340 
Drainage  in  i)reast-abscess,  704 
Dressing,  aiuiseptic,  following 
labor,  7  It) 
of  vulva  after  labor,  383 
Drugs,  ingestion   of,  in  suck- 
ling, 770 
"  Div  labor,"  570 
"Duct,  (iiirtner's,"  02 

lactiferous   or   galactophor- 
ous,  1)7 
Ducts  of  Cuvier,  107,  112 
.Miillerian.  120,  121 
Wolfhan,  11S-123 
Ductus  arteri<isus,  137 
venosus,  112,  130 

Dystocia : 

1.  Dystocia  due  to  anomalies 
in  the  forces  of  la- 
bor, 493-573 

deficient  power  of  the 
uterine  muscle ;  in- 
•  I  ■;   uteri,  493 

deforiiiii'.t...  of  the  pelvis, 
■kis 
— classification  of  anom- 
alies in  the  female 
pelvis,  499 
— diagnosis    of    pelvic 
deforiiiities:      pel- 
vimetry, 5(l0 
— freiiiicncy  of  deformed 
pelves,  4118 

description  of  the  several 
varieties  of  abnor- 
malities in  the  fe- 
male pelvis,  510 

excessive  [lower  in  the 
exi)iilsive  forces  of 
labor,  497 


ti 


m 


:'■    B 


'*Ah 


h  ft  ^ 


m 


I 


1* 


;     1 


i;' 


984 

DyHtociii  line  to  ankvloNU  and 
reliixatioii  of  the 
pelvic  j()iiit«,  .").'{1 
— anoiiialius  <liit>  to  (Mm- 
I'asi'H  of  till-  Hiibjii- 
(•out  skoU'loii,  .VIO 
— carit'H  anil  ni'crosis  of 

pl'lvic  l)OIU'H,  '(.'il 

— '-oxal^Mc  pi'lvis,  r)4() 

— frac'tiUL's  of  the  pel- 
vis, M] 

— general  Iv-coiitracteil, 
Hat,  iion-racliitie 
pelvis,  r)l() 

— jiisto-iiiajor  pelvis, 
.VJl 

— jiisto-iiiinor  pelvis, 
514 

— kyphoHfoliotii-  pel- 
vis, .")4() 

— kyphotie  pelvis,  't'M 

— lordosis,  540 

— liixutioii  of  the  fem- 
ora, 541 

— narrow,  funnel- 
shaped  jiel vis:  fetal 
or  iindevelo|)ed 
pelvis,  517 

— oliiicpiely  -  eontiiicted 
pelvis  from  imper- 
fect development 
of  tlie  ala  on  one 
side  uf  the  saernni, 
158 

— osteomalacic  i)eivis, 
5-_»() 

— rachitic  pelvis,  522 

— scoliotic  pelvis,  5;{!) 

—  simi)lc  Hilt  pelvis,  510 
— split  pelvis,  522 

—  spondv  loii!>thetic  pel- 

vis,"5;52 

— transversely-contract- 
ed i)elvis,  the  result 
of  imperfect  devel- 
opment of  hoth 
sacral  alic,  521 

— tumors  of  the  pelvis, 

5:{(» 
management  of  labor  ob- 
structed by  the 
commonest  forms 
of  contracted  pel- 
vis, 543 
obstruction  to  labor  on 
the  jiart  of  the  sotl 
maternal  structures 
of  tlic  parturient 
canal,  54()-5(ll 

— clo  ure  and  contra'o- 
Jon  of  the  cervix, 
547 

— closure  and  contrac- 
tion of  the  vaffina 
or  vulva,  549 

— eonjrcnital  anomalies 
of  development  in 
the  uterus,  54t) 

— displacements  of  the 
uterus,  552 


INDEX. 


Dystocia  due  to  tinnors  of  the 
genital  canal,  55t> 

—tumors   i)f  neiKhhor- 
iuK  organs,  55s 
olwtruction    lo    labor   on 
the     part    of    the 
fetus,  5(il 

— labor  complicated  liy 
abnornmlities  in 
the  fetal  append- 
ages, 570 

— overgrowth      of    the 
fetus,  5(11 
II.  Dystocia  due  to  acci<lents 
and  diseases,  5715 
accidents  to  the  umbilical 
cord,  57;!  5M2 

— coils  or  circulars  of 
the  cord,  57(i 

— natural  or  accidental 
shortness  of  the 
cord,  577 

— prolapse  of  tiie  cord, 
57:5 

— rupture  of  the   cord 
and  its  vessels,  579 
dvstt)ciii    due    to   hemor- 
rhage, 581-1)23 

— accidental  hemor- 
rhage, 5i)() 

— hemorrhage  after  the 
birth  of  the  child, 
(iOO 

— injuries  to  the  infra- 
vaginal  portion  of 
the  uterus,  (114 

— Inversion  of  the 
uterus,  (iK) 

— lacerations  and  rup- 
tures of  the  uterus, 
(ilO 

— placenta  pnevia,  581 
dystocia  due  to  disease  of 
the    nu>ther,    023- 
()44 

—diseases  of  the  brain, 
t)43 

— diseases  of  the  heart, 
(i42 

— displaced  kidney,  039 

— eclampsia,  (123 

— eventration,  ()39 

— hemorrhages,  1538 

—hernia,  ()3S 

— hyperemesis,  <i37 

— labor  in  pneumonia, 
(!44 

— paraplegia,  043 

— relaxation  and  rup- 
ture of  the  pelvic 
articulations,  040 

— shock,  044 

— sudden  death  in  la- 
bor; delivery  of 
the  child,  044 

— tumors  of  the  rectum, 
039 

Eai{,  fetal,  development  of,  132 
Eclampsia,  023 


Kclampsia,   attacks    of,   dura- 
tion. 027 
frwiuency,  020 
causes,  esHential,  032 
exciting,  ti32 
predisposing,  ti30 
convulsions,    uremic,    with- 
out, 198 
diagnosis,  029 
etiology,  030 
fre(|Uency,  023 

in  twin  labors,  509 
Induction  of  preuuiture  labor 

in,  879 
induence  of,  upon  the  uterus 

and  the  fetus,  027 
occurrence   of,  periods   and 

time,  024 
phenomena  of,  025 
prognosis,  (i29 
post-mortem      appearances, 

030 
svmptoms   of,   premonitory, 

025 
terminations  of,  028 
treatment,  034 

medicinal,  ()35,  636 
prophylactic,  ()34 
Kcouvilion  of  Dol^ris,  874 
Ectoderm,  77 

Eczema  of  the  nipple,  751 
Edema  of  the  vulva,  550 
Electricity  in  the  induction  of 
premature      labor, 
881 
Elephantiasis  of  the  labia,  19'^ 
Embolism  of  the  pulmonary 
arterv,  death  from, 
802  " 
puerperal,  790 
ceiebral,  790,791 
Embryo,  development  of,  74 
fetal  stage  of,  94 
initial  stages  of.  80,  94 
position  and  flexion,  95-100 
Embrvos,     double     formation 

oi;  305 
Embryotomes,  933 
Embryotomy,  920-941 
alter  tnatinent  of,  940 
indications  for,  927 
instruments  for,  933 
operations  of,  938-941 
—decapitation,  938-940 
—evisceration,  938,  940 
prognosis,  939,  940 
symphysiotomy  in,  912 
Emotion,  puerperal,  fever  due 

to,  778 
Emotions,-  nuiternal,  of  preg- 
nancy, 182 
aflectlng    the  (|nality  of 
breast-milk,  770 
Encephalitis,  treatment,  732 
Encephalocele    of    the    new- 
born, 819 
Endocarditis,  symptoms,  706 

treatment,  731 
Endometritis,  094 
causing  abortion,  261 


w 


7 


i\in:x. 


{W5 


EndDiiiolritiN,  dcindtml,  etiol- 
ogy, 'i'V) 
tn'utiiionl,  '2.')") 
(liplitherilic,  coiitra-inilicat- 
ing  fi'liotiiiny,  iltJlt 
diiriiiK  pri't^nancy,  I  Hit 
Huptif,  (iS"),  (IHd 

I'oiitrii  -  indicating   celiut- 
DMiy,  'Jll'J 
syniploinsand  protjnoHis,  009 
treatnienl  of,  190,  721 
Enteritis,  Ircalnient,  I'M 
Enteroct'li',  vaginal,  ti;t!) 

coriiplicalin^r  labor,  ')'>9 
Entodurni,  77 
"  Kpideniics''     of     ])iierperul 

fever,  (i9U,  (191 
EpiderniiH,  infani,  exfoliation 

of,  H2ti 
lOpilepsy   Hinmlating  ecluinp- 

sia,  ('.•29 
Episiotoiny,  373 
defined,  877 
ineiHions,  site,  number,  and 

wize,  H77,  878  | 

indieations  for,  877  | 

K(ii»taxis,  fi38  I 

Kpitlielionia  of  the  cervix,  188 
Epo<"ii)lioron,  ()2 
E(|uino-varus,  304  I 

Ergot,  use  of,  diirin/?  labor,  016 
following  lalior,  71(1,  717 
in    labor   coinplicaii'd   by 
eariliac       <lir-easeH, 
043 
in  endometritis  and  me- 
tritis, 724 
in  inertia  uteri,  49fi 
in  proniotini;  uterine  con- 
tractions, 378 
in  subinvolution,  (i(i2,  738 
lacerations  of  the  cervix 

from,  (!ir> 
rupture  of  llie  uterus  from, 
()12 
Erosion  of  the  nipple,  747 
£rn|)tion,   niiliarv,  puerperal, 

707 
Eruptions,     skin,     puerperal, 
treatment,  732 
of  fetus  in  utero,  29(! 
Erysipelas  complicating!;  prejj- 
nancv,     treatment, 
242,  243 
fetal,  297,  309 
of  the  new-born,  838 
of    pregnancy    compli,iated 
by  mechanical  in- 
juries, 2")1 
puerperal,  781 
Erythema,  puerperal,  707 
Evacuation,  alvine,  of  the  in- 
fant, 8.')-),  8ot> 
Evacuations,    alvine,    during 
pregnancy,      man- 
agement of,  183 
of  the  puerperium,  G60 
Eventration,  ()39 
Evisceration  (fetal  i,  938 
after-treatment,  940 


Evisceration,   in<lications    for, 
938 
operation.  940 
Examination,  abdominal, diag- 
nostic signs  by,  41 1 
for  position,  422 
obstetrical,  349 
vaginal,  diagnosis  by,  41 1 
for  position,  423 
(See  l\tlfxitiii)i.\ 
Exanthemata  of  fetus  in  utero, 
29(i 
puerperal,  780 
Excavation,    pelvic,  anutomv, 

394 
Exencephalus,  304 
l*'xercise  in  pregnancy,  180 
Exfoliation  of  the   infant  epi- 
dermis, 82(1 
Expulsion,  mechanism   of,  in 
second      stage     of 
labor,  437 
spontaneous,  of  (4iild,  after 
sudden     death     in 
lalior,  ti4() 
Extraction,    breech,    Harnes's 
method,  9(iti 
immediate,     versus    delay, 

after  version,  9(15 
in  tiie  dorsal  postuf  9o9 
in  tlie  Unee-elbow   ijosture, 

9(i2 
in  the  latero-prone  posture, 

9(il 
in  tiie   Trendelenburg  pos- 
ture, 9(12 
of  head  and  mums,  diflicidt, 
by     version,     '.KJ.j, 
966 
operation   of,  after  internal 
version,  9()5 
Extra-uterine  pregiuincy.  (See 

Prtiniuirtj. ) 
Extremities,  malformations  of, 
congenital,  304 
prolapsed,  492 
Eves,   fetal,   development    of, 
130,  132 

Face  defokmitiks,  congeni- 
tal, 302 
Face,  fetal,  402 

deveioixnent,  100,  101 
injuries  to,  of  the  new-born, 
824 
Face  presentation.    (See  Pren- 

flllillioil.t.  I 

Fallopian  tubes,  oO 

atlections  of,  during  preg- 
nancy, 249 
removal  of,  in  puerperal 
sepsis,  973 
Faradism  in  the  puerperium, 

()()2 
Faradization   of  the  stomach 

in  [iregnancy,  183 
F.-iscia,  pelvic,  29 

anal  or  ischio-rectal,  30 
obturator.  21! 
recto-vesical,  29,  30 


l''eces  »if  the  new-born  infani, 
810 
(See  Miriiiiiiiiii.) 
1'' ceding,  artificial,  of  the  new- 
born, 0(18,  H(i(> 
breast,  of  (he  ni-w-born,  N">9, 
8(1(1 

intervals    in,    of   the  new- 
born, (167, 671 
I'Y'eling  or  touch,  sense  of,  in 
the    new-born    in- 
fant, 812 
Femora,  luxation  of  (dystocia), 

041 
Ferments,  felal    digestive,  or- 
ganic    and      inor- 
ganic   constituents 
of,  141,  142 
I'erlilization  of  the  ovule,  74 

of  ovum,  period  of,  76 
h'etal  movements.  (See  /■'fhin.) 
l''etation,    double,    determina- 
tion of,  3.J7 
I'Vtus,  the,  401-407 
anasarca  of,  .">()9 
arteries  of  the,  107 
body  of,  4('ii 
brain  of,  devxdopment,  12o- 

128 
calcification  of,  313 

operation  after,  in  extra- 
uterine iiregnancy, 
29.-) 
calcified,  retention  of,  313 
circulation  of,  the,  13(1 
coils  and  knots  aroinid,  2o8 
contour  of,  in  diagnosis  of 

pregnancy,  170 
craniotomy  upon,  926-9.38 
cretinism  of,  310 
death  of,  in  utero,  310 

causes    resulting    from 
the  amiexes,  31 1 
from     external     vio- 
lence, 312 
from  faidty  develop- 
ment, ■">!  1 
from  liie  father,  310 
from  the  mollier,  ;!1() 
from  maternal  eciacipsia, 

628 
pre  -  natal,    post  -  mortem 
clianges  in,  312 
decapitation  of,  in  dcliverv, 

938 
deformities   of.    facial,   302, 
402 
special    regions    and   or- 
gans of,  302 
delivery  of,  operative  pro- 
cedures, choice  of, 
926,927 
(See  Dflirery.) 
descent  of,  in  vertex  presen- 
tations, 431 
normal  mechanism  of,  in 

dry  labors,  431 
of  head,  normal  rotation 
in,  r)12 
(See  Head,  fetal.) 


M  1. 


!ii>ii 


1^ 


..■■'I    k: 


I 


986 


INDEX. 


\\     * 


Fetus,  development  of,  excess- 
ive, 305 
of  external  form,  charac- 
teritstio   periods  of, 
94-101 
stages  (if,  04 
diflerentiatioii  of  the  sexes 

in  the,  122,  123 
digestive  tract  of,  140 
development  of,  112 
dise.use  of,  Bidder's,  308 
M tiller's,  300 
Schmidt's,  308 
diseases  and   death  of  the, 
coniplicating  labor, 
5(!4,  505 
dorsal    plane    and    small 
parts,    location    of, 
350 
ears  of,  lirst  appearance  and 
development,    132, 
133 
erysipfr-.s,  infection    of,   in 

titero,  243,  297 
evisceration  of,  in  delivery, 

938 
head  of,  aiiatoniy,  402 
articulations  between  the, 
anil  the  spinal  col- 
umn, 400 
diameter  of,  relative  valtie 
of  the,  as  compared 
witii   the  (liuneter 
of  the  pelvis,  404 
dimensions,  403 
heart-sounds,    detection    of, 

1(38 
hydrocephalus  of,  310 
ill  extra-iiterine  pregnancy, 

282 
influep  'e  of  diabe'es   upon 
the,  219,220 
of  eclampsia  upon,  027 
intra-uterine     iVactiiics    of, 
300 
amputation,  300 
in  tubal  extra-uterine  preg- 
nancy, 280 
in  utero,  absorption  of,  312 
attitude  of  3.S5 
death  of,  310-312 

resulting  from  faulty  de- 
velopment, 31 1 
i'rom     extenud     vio- 
lence, 312 
from  the  annexes,  311 
from  the  father,  310 
from  the  mother,  310 
diseases  of,  295-317 

eruptive,  290 
"habitual  death."  311 
life  or  death  of  the,  diag- 
nosis, 175,  170 
post-mortem    changes   of, 
312 
lengths  of  the,  at  different 
periods    of    gesta- 
tion, 103 
life  or  deiiili  of,  diagnosis, 
175 


Fetus,   lithopedion,   retention 
of,  in  utero,  313 
luxations  of,  congenital,  301 
maceration  of,  312 

operation  after,  in  extra- 
uterine pregnancy, 
295 
malformations    of,     causes, 
253,  254 
or  marking,  through  ma- 
ternal impressions, 
213 
measles  of,  in  utero,  243 
membranes   of  the,  compli- 
cating labor,  570 
movements  of  the,  167 
abdominal  signs  of,  1G6 
influence  of,  on  presenta- 
tion, 421 
location  of,  350 
period,  101 
procedure  for  detection  of, 

108 
supposed,  lOH 
mummitication  of,  313 
operation  after,  in  extra- 
uterine pregnancv, 
295 
nervous  system  of  develop- 
ment, 125 
nutrition  and  growth,  136 
organs  of  special  sense   of, 

development,  129 
overgrowth  of,  complicating 
labor,  501 
diagnosis,  503 
pemphigus  of,  309 
peritonitis  of,  309 
physiology  of  the,  130-142 

(See  Infant.) 
pneumonia    of,    congenital, 

syphilitic,  298 
position     ol',     classification, 
on  I 
defined,  3S0 

in    vertex     presentation, 
diagiKisis,  422 
etiology,  422 
prognosis,  423 
pre-natal  functions  of,  140- 
142 
secretion  of  urine,  140 
presentation  of  defined,  385 
diagnosis,  407 
etiology,  418 
inlhience   of   gravitv   on, 

418 
prognosis,  416 
presentations   of,   classifica- 
tion, 380 
conditions  influencing, 421 
(See  I'lr^riildlions.) 
putrefaction  of,  313 
rachitic,  307 

respiratory    and    metabolic 
changes,  139 
tract  of  development,  118 
saponification  of  313 
scarlatina  afleciing,  in  utero, 
243 


Fetus,  scarlatina  and  measles 
of,  in  utero,  296 
sex  of,  recognition  of,  123 
"spontaneous  evolution  of," 
mechanism,       488, 
489 
strangulation  of,  300 
struma  of,  309 
syphilis  of,  in  utero,  297 
tuberculosis     of,    in     utero, 

297 
tumors  of,  complicating  la- 
bor, 504 
congenital,  301,309 
typhoid      infection     of,     in 

utero,  242 
vaccination  of,  protection  by, 

244 
variola  of,  in  utero,  297 
veins  of  the,  110 
version,  in    delivery,    943- 
968 
Fetus  and  uterus,  adaptation, 

between    420 
"Fetus  papyraceiis,"  144,  313 
Fetuses,  attached,  302 
double,  305 

twin,  intervals  in  births  of, 
144 
membranes  of,  143 
placenta'  of,  l43 
Fever,  milk,  puerperal,  655 
puerperal.     (See  Infection.) 
scarlet,  puerperal.  780 
typhoid,  complicating  preg- 
nancy, 241,  242 
Fever-cot,  Kibbee,  729 
Fibroid,    uterine,    simulating 

f)regnancy,  173 
Fibroids  in  pregnancy,  surgi- 
cal operations  for, 
248 
puerperal,  hemorrhage  due 

to,  743 
uterine,  185 
treatment,  186 
Fibromata  complicating  labor, 
557 
prognosis,  558 
Fillet,  use  of  in  breech   labor, 

477 
Fimbria'  of  the  oviducts,  50 
Fissures  of    the  nipple,   747, 

749 
Fistula,      vesico-vaginal,      in 

pregnancy,   193 
Fistnlie,  mammarv,  puerperal, 

706 
Flexion,   mainteuHiice    of   in 
posterior   positions 
of  the  head,  453 
management  of,  at  the  pas- 
sage of  the  excava- 
tion    in    posterior 
j)ositions,  453 
mechanism  of,  432 
in  anterior  presentations  of 

the  brow,  408 
in  posterior  presentations  of 
the  face,  412 


due 


|iuil,      in 

I'.ili 
|iiL'i'\it'i'al, 

of,    in 

Ipositiiins 

la,  4'):'. 

the  [iiis- 

;  exi'iiva- 

jKistt'i'ior 

|4r);{ 

jationsnl' 

I4(i8 
liiticmsdl' 

ivi 


Flexion,  operative,  at  the  su- 
perior strait  in  pos- 
terior positions  of 
tiie  vertex,  4")() 
re-estabiishnient  of,  in  pos- 
terior positions  of 
tlie  liead,  •»•").'> 
Flexion    of    uterus,   oirlusion 
of  locliial  How,  741 
Floor,  pelvic,  30 

blood-vessels  of,  3.") 
injuries  to,  30i) 
nerves  i)f,  3(5 
veins  of,  3(1 
Fluid,  anniiotic,  84 
Fluid-pressure,    intra-uterine, 
433 
influence  of,  on  dilatation, 
424-427 
Fa?tus  sanguinolentus,  312 
Folds,  genital,  123 
Follicles,  ovarian,  number  of, 

()0,  (il 
Fontanelle,  anterior,  403 
lateral,  403,  ii. 
occipital,  posterior,  403 
Fontanelles  of  fetal  head,  402 
Food  for   the   new-born,   859, 
860 
morbid  longings  for,  in  preg- 
nancy, KiO 
selection  of,  in    pregnancy, 
180 
Footling    presentation.      (8ee 

I'lfHriittdidH.''.) 

Foramen  ovale,  107 
Forceps  (obstetric),  884-017 
action  of,  8',I0 
articulations  of,  S8S 
as  a  compressor,  890 
as  a  lever,  891 
as  a  rotator,  891 
as  a  tractor,  890 
axis-traction,  889 
catch-,    use    of,  in    internal 

version,  9C5 
craniotomy,  930 
compressing,  931 
Micks',  931 
Lusk's,  931 
small,  Meigs',  933 
"doubie-curved,"  888 
forms  of,  SS8 

indications  for  use,  801,892 
operation  of  the  applii'ation 

of,  divisious,  802 
ovum,  Schnllze's.  873 
removal   of,   iluring   opera- 
tion, 898 
rotation      f   in  deliverv  of 

head,  897 
selection  of,  S88 

proper  model  in,  889 
traction   of,    in   low   opera- 
tion, 89(1-808 
use  of,  after  rupture  of  the 
symiihysis,  (i40 
in  inertia  uteri,  49") 
injuries   to  the   new-born 
from,  82o 


INDEX. 


Forceps,  injuries  in  labor  com- 
plicated by  cardiac 
diseases,  042 
varieties  of,  880-887 
Forceps,  application  of.   dan- 
gers of,  899 
in    face    presentations    at 
the  brim,  4(14,  4(1') 
in   high  arrest  in  breech 

labor,  477 
in  high  ojieration,  indica- 
tions for,  898 
in  breech  presentations, 

902 
in  brow  a'ld  face  pres- 
entations, 901 
in   left-lateral  position, 

903 
in  occipito- posterior  po- 
sitions, 900 
to      the      after-comir.fr 

heiid,  480,  902 
to  the  severed  head,  903 
in    low  arrest    in    breech 

labor,  478 
in  low  operation,  in  dorsal 
l)osition,  893 
position  for,  893 
preparation  for,  893 
in  matuuil  rotation  of  pos- 
terior positions  of 
vertex,  451 
methods  of,  892 
of  rever.sed,  in  flexion,  454 
(See  IhUvi'ni,  fi)icrp^.) 
Forceps  of  Uarnes,  889 
of  Davis,  888 
of  Dubois,  890 
of  Hodge,  889 
of  I'ajot,  890 
of  Sawyer,  888 
of  Simpson,  889 
of  Simpson-I'arnes,  889 
of  Wallace,  888,  889 
of  White,  889 
Forceps,      axis-traction,       of 
liarnes,  880,  890 
of  Lusk,  8S9 
of  Naegele,  890 
of  I'oulet,  889,  890 
of  Simpson,  889,  890 
of  Stevenson,  889 
of  'rarnier,  889,  890 
Fore-gut,  1 13 

Formations,  fetal,  double,  305 
Fossa  navicularis,  .37 

ovarii,  59 
Fo.ssu',  ischio-rectal,  35 
Foin'chette,  anatomy,  37 
l'"ractures,  intra-uterine,  300 

pelvic,  5,31 
Freiuim  I'litoridis,  38 
Fundus  of  uterus,  47 
I-'ungus,  umbilical,  833 

<!ait,    changes    in,   of    preg- 
nancy, 15() 
( iaiactocele,  7(17 
(ialaclorrhea,  772 

symptoms  and  treatment,  77 J 


987 


Gangrene  of  the  navel,  837 
of  the  vulva,  551 

or  vagina,  treatment,  721 
"  lliirtner'b  duct,"  02 
( lavage,  8()5 

(ieneration,  organs  of,  fcnuile, 
anatoinv,    17,    30- 
70 
changes  in,  during  preg- 
nancy, 150 
external,  anaiomy,  3C 
intermediate,  anatomy,     1 
internal,  anatomy,  45 
physiology  of,  70-73 
Genitalia,  the,  .30 
(ienitals,      female,      external, 
during    pregnancy, 
changes  in,  150 
Gestation,    contractions,   uter- 
ine, during,  318 
ectopic,  273 

diagnosis,  520-528 
simulated   by  retroverted 
uterus.  195 
extra-uterine,    tnbo-titcrine, 
or  interstitial,  281 
tidjal,  280 
injuries    as    allecting,    249, 

250 
length  of  fetus  at  dilil'rent 

periods,  10.'! 
medication  favoring,  184 
menstruation  during,  72 
mvomata    in,  influence    of, 

18(1,  187 
prolonged,  178,  179 
sm-gical  operations  as  aflect- 
ing,  251 

(See  I'l-fijiKiiicii.) 
Gestation-sac,  extra- peritoneal 
evacuation    of,    in 
extra-uterine  preg- 
nancy, 294 
rupture  of,  in  extra-uterine 
pregnancy,      treat- 
ment, 293 
(ilands,  alimentarv,  j)re-natal, 
140,  141 
mammary,   care  of,  during 
pregnant'v,  181 
changes  in,  due  to  preg- 
nancy, 151 
congestion    anil    engorge- 
ment of,  751 
faidty  development,  773 
inllamniaiiou  <if,  75(1  7(12 
in  the  uew-liorn,  840 
of  infaiUs,  827 
structure  of,  (15 
su|i|)uraliou  of,  702  7(18 
of  liartholiii,  38 
of  lirunner,  fetal,  lit 
of  .Montgomery.  (Ill,  153 
salivarv,   of    the    new-born 

infant,  800 
sexual,  development  of,  121, 

122 
.iterine,  49 
vaginal,  45 
(ilans  clitoridis,  38 


•■'!< 


u 


ir 


ik  r 
1 1' 


i; 


ki 


I 

■1 

i'. 

It 

\ 

! 

i 

S  ( 

!:f 


988 


INDEX. 


Glycerin,  injection  of,  in  the 
induction    of    pre- 
mature labor,  8H7 
Glycosuria  of  the  nuerperiuni, 

650 
Goitre  during  pregnancy,  21^5 
Gonorrhea  of  pregnancy,  23!) 
(Jraafian  follicles.  59,  CO,  71 
(iroove,  genital,  123,  124 

j)riinitive,  78 
Growth    of    new-born  infant, 
807 

Hairs,  fetal,  development  of, 

101 
Hand  and  a  foot  presentation. 
(See  PreKenlntionii.) 
introduction  of,  in  operation 
of  internal  version, 
!)()4 
Hare-lip,  congenital,  302 
origin,  98 
treatment,  302 
Head  and  a  hand,  pres'jntation 
of. 
(See  Pnvcnidliniis.) 
and  arms,  extraction  of,  dif- 
ficult,    in     breech 
presentations,   480, 
484,  487 
rapid,  in  breech  labor, 
480 
high     arrest,    in     breech 
labor,  482 
Head,  fetal,  402 

arrest  of,  at  the  inferior 
strait,    in     breech 
presentations,  487 
due   lo   contraction   of 

the  pelvis,  487 
from    e  x  t  e  n  s  i  o  n,    in 
breech  labor,  486 
articulations  between  the, 
and  the  spinal  col- 
umn, 40<i 
at  fifth  month,  101 
compression    of   the  pro- 
montory on  the,  in 
contracted     pelvis, 
52(i 
configin-ation      of,      after 
moulding    in    face 
hibor,  4(iO 
craniotomy       of       after- 
coming,  935 
of  the  presenting,  934 
upon  the,  92(1-938 
(leiivery    of,    arrested    at 
the  superior  strait, 
484 
forceps,  of  after-coming, 
ill  high  operation, 
!)(t2 
compression   in,  890, 
891 
depressions  on,  in  engage- 
ment wiili  the  pro- 
miintorv.  51.'! 
descent  of,  in   jiisto-minor 
pelvis,  51  ti 


Head,  descent  of,  in  obliquely- 
contmcted     pelvis, 
520 
rotation  of,  in,  512 
(See  Descent.) 

development  of,  95-101 

diameters  of,  relative 
value  of,  as  com- 
pared with  diame- 
ters of  the  pelvis, 
404 

dimensions  of,  403 

entrance  of,  into  the  pel- 
vis in  posterior 
positions,  442 

expulsion    of,    regulation 
of,  370-373  _ 
obstetric  position  in, 
371,  372 

large,  com()licating  labor, 
563 

management  of  the  pas- 
sage of,  in  poste- 
rior positions  of 
the  excavation,  453 

manual  rotation  and  the 
application  of  for- 
ceps in  posterior 
positions  of  vertex, 
451 

moulding  of,  in  brow  pres- 
entations, 466 

operative  delivery  of  a 
high  arrest  of,  in 
posterior  positions 
of  vertex,  451 
flexion,  in  posterior  po- 
sitions, 450 

overlapi)iug  of  cranial 
bones  of,  in  engage- 
ment at  the  supe- 
rior strait  in  a 
rachitic  pelvis,  527 

passage  of  the  excavation 
of,  in  right-poste- 
rior positions  of 
vertex  presenta- 
tions, 444 
of  the  superior  strait  of, 
in  posterior  jiosi- 
tions,  450 

restitution    of.    in   expul- 
sion, 439 
in  occipito-posterior  po- 
sition, 448 

rotation  of,  in  ilescent,  512 
forceps,  of,  891.  898 
in  face  presentations,460 
in  poorly  Hexed  right- 
anterior    positions, 
in  vertex  i)resenta- 
tioiis,  445 
in  unllexed  right-poste- 
rior   positions,    in 
vertex   presenta- 
tions, 446 
in     weil-llcxcd      right- 
posterior  jiositions. 
In  vertex  presenta- 
lioUN    144 


Head,  shape  of,  irregular,  433 
sutures    and     fontanel le.s, 

402 
unequal    lengths    of    the 
ends  of,  in  descent, 
432 
Head,  hind,  fetal,  undue  length 
of,  in  face  presenta- 
tions, 458 
Head  of  the  new-born,  injuries 

to,  824 
Hearing,  sense  of,  in  the  new- 
born infant,  812 
Heart,  diseases  of,  complicat- 
ing labor,  642 
pregnanev,  237 
fetal,  104 
conversion   of,    from    the 
sin'-'"  to  a  double. 
It 
enibryon:      >age,  95 
preponderance  of  size,  101 
pulsations  of,  169 
hypertrophy    of,    in    preg- 
nancy, 154 
in  puerperal  infection,  688 
malformation  of,  congenital, 

304 
of  the  new-born  infant,  809 
Heart-.sounds,  fetal,  168 

diagnosis  of  presentation 

by,  410 
during  labor,  365 
in  breech  labor,  475 
in      extra-uterine      preg- 
nancy, 286 
Heart-tones,  fetal,  location  of, 

354 
Hegar's  sign  of  pregnancy,  164 
Hematoma  complicating  labor, 
680 
etiologv  and  symptoms, 

680 
treatment,  682 
of  the  sterno-inastoid,  824 
of  the  vulva,  191 
Hematomata    obstructing    la- 
bor, 549 
Hematuria  complicating  preg- 
nanev,    ti-eatment, 
197  ■ 
puerperal,  790 
Hemicepbaiia,  304 
Hemorrhage,  aci  idental,  596 
concealed,      coiiiplicatiiig 
pregnancy,  2(10 
diagnosis,  201 
mortality,  200,  201 
prognosis,  202 
symptoms,  200,  201 
treatment,  201 
etiology,  597 
prognosis,  599 
symptoms,  598 
treatment.  599 
cerelmil,  818  822 

during  pregnancy,  212 
puerperal,  790 
congenital,  from  the  female 
genital  organs,  853 


' 


I     I 


INDEX. 


989 


Heiuorrhuge,  gastrointestinal, 

diagnusis,  854 
prognosis,  854 
symptoms,  854 
treatment,  854 
dystocia  due  to,  581 
from    intrapelvic     tumors, 

treatment,  (582 
from  lacerated  cervix,  treat- 
ment, GIG 
from  the  uterus  during  preg- 
nancy, 238 
in  Cesarean  section,  preven- 
tion of,  920,  921 
in  extra-uterine  pregnancy, 

285 
in  placenta  prajvia,  589-592 
in  symphysiotomy,  907,  915 
in  syphilitic  infants,  299 
in   the   new-born,  diathesis 
of,  852 
treatment,  85S 
intra-ulerine,  877 
treatment,  (itW 

by  bandage  and  tampon, 

GOG 
by   bimanual   compres- 
sion, G05 
by  compression   of  ab- 
dominal aorta,  GOG 
by    uterine    injections, 
G04 
of  abortion,  2G3,  2()4 
of  pregnancy,  caujes,  590 
post-partum,  GOO 
etiology,  GOl 
prognosis,  G02 
symptoms,  G02 
tampon   in,  intracervical, 
874 
puerperal,  causes  of,  739-745 
diagnosis   and   treatment, 

740 
due  to  fibroids,  743 
from    maligiutnt   disease, 

744 
from    jielvic    congestion, 

744 
from    relaxation    of    the 

uterus,  743 
from  secondary  bleeding, 

744 
from  separation  or  disin- 
tegration of  tliroin- 
bi  in  the  sinuses  at 
the   placental   site, 
742 
umbilical,  828 
diagnosis,  8;{2 
etiology,  830 
from  ruptured  cord,  580, 

581 
symptoms  and  signs,  S.'il 
therapeutics  of,  8:i2 
Hemoptysis  complicating 

pregnancy,  2;)S 
Hemorrhages  in  labor,  (i;!S 

in  the  pucrpcriiuii,  738 
Hemorrhoids,  puerperal,  785 


Hepatitis,  symptoms,  706 

treatment,  731 
Hermaphroditism,  125 
Hernia,    cerebral,   congenital, 
304,  821 
complicating  labor,  G38 
inguinal,  congenital,  303 
and  umbilical,  of  the  new- 
born, 858 
of  the  uterus  complicating 

lab(U',  552,  553 
umbilical-cord,  anatouiy, 833 
clinical  appearance,  834 
diagnosis,  834 
operation  for,  83;>,  834 
])rognosis,  834 
treatment,  834 
vaginal,  complicating  labor, 
559 
HerniiT    funiculi   unibilicalis, 

833 
Herpes  of  pregnancy,  211,  212 
Hilum  folllculi,  71 
Hind-gut,  114 

Hips,  fetal,  relation  of  the,  in 
the  mechanism  of 
labor,  40G 
Hook  and  crotchet,  933 

decapitating,  933 
Hospitals,  puerperal  infection 
in,    prevention   of, 
710 
I  f vdatid,  stalked,  of  Morgagni, 
G3 
suppurating,   of    the    abdo- 
men, 199 
Hydatids  of  Morgagni,  123 
Ilydraumion,  311 

death  of  fetus  from,  311 
determination  of,  35() 
I Iy<lrencephalocele,  819 
Hydrocele,  congenital,  303 
Hydrocephalus     complicating 
labor,  505 
diagnosis,  5G5 
treatnicut,  5GG 
fetal,  309,  310 
Ilydrometra  sinnilating  preg- 
nancy,     diagnosis, 

17;'.  ■ 

Hydrorrhcea  gravidarum,  255 
llydrothorax,  fet;.l,  309 
Hygiene  and  thera])eutics  of 

infant     soon    after 

birth,  859 

Hygiene  of  pregnancy  : 

—bathing,  ISI 
— clotliinu',  181 
—diet,  18(t 
— exercise,  180 
—rest,  181 

— sexual  interc()urse,  181 
Hymen   during    llie    puerpe- 
fiuiti,  052 
rupture  of  the,  39,  40 
structure  of  tlu',  39 
uiu'uptured,  549 
variations  in  shape  of,  39 
Hyomaudibular  clelt,  9S 


Hyperemesis,  G37 
etiology,  G37 
treatment,  G38 
Hyperlactation,  777 

treatment,  778 
Hypertrophy,  decidual,  189 
causing     uterine    hemor- 
rhage, 740 
of  i)lood-vessels,  14G 
of  breasts,  152,  IGl 
of  cervix,  140 
of  heart,  154 
of  liver,  155 
of  nipple,  153 
of  spleen,  155 
of  uterus,  14ti,  185 

nuicous  membrane  of,  145 
of  vagina,  150 
Hysterectomy    for    puerperal 
sepsis,  972 
for  uterine  fibroids,  18G,  187 
indications   lor    the    opera- 
tion, 974 
in  uterine  cancer,  187 
technicjue  of  the  operation, 
975 
Hysteria  of  pregnancy,  221 

IiK-HAo  in  mastitis,  701 
in  treatment  of  peritonitis, 
i  72G,  729 

!  Icterus  of  the  new-born,  82G 
symptomaticus,  843 
Idiocy,  congenital,  309,  310 
'      syphilitic,  310 
Impressions,  maternal,  305 
inlluence  of,  213 
I  op|)()sing  theories,  300,307 

I  results  of,  182 

i  Incision,  abdominal,  in  Cesar- 
I  can  section,  919,921 

uterine,  in  Cesarean  section, 
920 
I  Incisions,  symphysiotomy,  913 
Incubators,  infant,  8(53,  8ti4 
Induction  of  aliortiou,  .s78 
of  labor.  |irematin-e,  878 
cousiderations  involved, 

882 
electricity  in,  8SI 
indications  for,  S78 
operation,    methods   of, 
879-881 
Cohen's,  880 
Kiwisch's,  881 
KruseV,  S79 
I'elzer's,  88 1 
Scheel's,  879 
prognosis,  879 
time  to  operate,  879 
Inertia  uteri,  I'.tli 
diajniosis,  494 
etiology,  493 
trealuieni,  495 
Infant,  cloth  lug  of  the.  11(10,  GG7 
early  life  of,  deviations  from 
some  of  the  ]>alh(>- 
logical       |iriicesses 
which  characlerize 
the,  82(1 


:iiiii 


III 
11 


■r 


^*  I 


:i  f\ 


!.    ' 
i     i 


^^1 

.-.Hi 


990 


INDEX. 


Infant,   feedinjj  of    the,  arti- 
lioial,  t)(;8 
ingestion      of     drugs      bv, 
tliroiigli  the  breast- 
milk,  770 
new-born,  apoplexy  of,  822 
aspliyxia  of,  818 
extra-uterine,  SI") 
intra-iiterine,  81-1 
atelectasis  of,  8-J2 
body -growth  of,  807 
bones  of,  81 1 
Buhl's  disease  of,  843 
eare  of  the,  ti(14 

hygienic,     iinniediatelv 
after  birth,  8.')!) 
catarrh,  se[)tic   gastro-in- 

testinal,  8.')0 
chest  growth  of,  808 
circulatory  system  of,  809 
colic  in,  8')4 
consiiiiation  in,  SoG 
laxatives  for,  8(il 
diarrhea  in,  8").") 
diathesis,  hemorrliagic,  of, 

8o2 
digestive  system  of,  809 
diphtheria  of,  8ol 
disejises   of,    general    and 
iinelassilied,  80I 
infectious,  8.'!.") 
of  the  navel  of,  827 
fat  of,  811 
feeding  of,  850,  SdO 
growth  of  head,  etc.,  80S 
hemorrhage  from  the  fe- 
male    genital     or- 
gans, 8'>;! 
gastro-intestinal  in  the, 
853 
hernia   of,   inguinal    and 

umbilical.  8.'!3,  S.>S 
icterus  sy  nipt  omaticiis,  843 
Inl'ection  of  the  digestive 
and         respiratory 
tracts  of,  80O 
etiology,  80") 
frequency,  8.')") 
pathology,  83(1 
sym])toms,  830 
intestinal   obstruction  in, 

8.-,7 
la  grippe  of,  840 
length  of,  808 
lymphatic  system  of,  811 
mastitis  in,  840 
melcna  of,  84o 
nnisdes  of,  811 
nniscidar  action  in.  812 
navel   wound  of,  disturb- 
ance in,  832 
nervous  system  of,  811 
nursing  of,  Otil 
ophthalmia  of,  847 
parotitis  of,  840 
[latliolo^y  of,  813 
I  See  I'dthiiliKiii.) 
pemphigus  of.  845 
lieritoncal  abscess  of,  858 
peritonitis  of,  840 


Infant,  new-born,  phlegmasia 

of,  840 
physiology  of,  807 
(See  PlijiKiology.) 
respiration  of,  80S 
rhinitis  of,  851 
sclerema  of,  851 
septicemia  of,  687 
skin  of,  810 
special  senses  of,  812 
stomatitis  aphthosaof,  850 
syphilis  of,  840 
temperature  of,  81 1 
tetaiuis  of,  841 
therapeulii's  of,  800 
thrusli  of,  850 
traumatic  injuries  of,  823 
tuberculosis  of,  847 
mnbilical        hemorrhage, 

828,  82i) 
iH'inary    organs    ol",    dis- 
turbances of,  .S58 
urinary  system  of,  810 
weight  ol',  807 
conditions     inlluencing 

the,  808 
increa.se  in  size  and,  808 
AVinckel's  disease  of,  844 
wound-int'ection   of,    830- 
838 
niM'sing  of  the,  0(')7 
preiiuiture,  delined,  802 
bo(ly-temperatureof,main- 

tenance  of,  802 
nourishment  of,  885 
jirevention  of  exhaustion, 
804 
vitality  of,  instances  of.  407 
weaning    of,   707,    773-775, 

777 
wet-nuising  of  the,  (iOS 
Infants,  premature,  802-805 
care  of,  8t;2-805 
nourishmeiU  of,  methods 
of     administering, 
805 
stimulants  for,  8()l 
syphilitic,  208 

heuiorrhage  of,  200 
liere<litarv,   treatment  of, 
8(n 
Infection,  gonorrluval,  in  preg- 
nancv,     treatment, 
230  ' 
in  the  new-born,  835 

from  wounds,  830-838 
of  the  digestive  tract  in  the 

new-born,  850 
of  the  respiratory  trad  of 
the  new-born,  850 
puerperal,  083 
contagion  of,  GS9 
(liHerent  forms  of,  085 
due  to  acute  constipation, 

780 
due  to  causes  other  than 
puerperal        infec- 
tion, 778 
due  to  diseased  conditions, 
780 


Infection,   puerperal,    due    to 
emotion,  778 
due  to  exposure  to   cold, 

778 
entrance  of    the    poisons 

of,  091 
epidemics  of,  090,  091 
etiology,  087 
mortality,  093 
nervous  disturbances    in, 

700 
non-infectious,  778 
of  the  bladder,  787 
of  the  limbs,  707 
of  the  urinary  tract,  780, 

787 
j)athology  of,  094 
prevention    of,    antiseptic 
precautions,     712- 
714 
in  hospitals,  710 
in  private  practice,  717 
putrefaction  causing,  090 
skin  diseases  due  to,  707 
sources    of     the    poison, 

089 
symptoms,  diagnosis,  and 

prognosis,  098 
su]tpuration  causing,  089 
time  of,  093 
treatment,  708 
curative,  719 
zvmotic  (li.sea.ses  causing, 
091 
septic,  celiotomy  for,  908 
following     Cesarean    sec- 
tion in  uterine  can- 
cer, 187 
in  syphilis  of  pregnancy, 
240 
small-j)ox,  in  pregnancy,  244 
syphilitic,     t)f      jiregnancy, 
diagnosis  an<i  prog- 
nosis, 240 
treatment,  240,  241 
tetamis,  in  pregnancy,  241! 
typhoid,  of  pregnancy,  241 
Infundibulo-pelvic     ligament, 

52 
Infundibidm))  of  the  oviduct, 

50 
Injection,  inlra-uterine.  715 
in  endometritis  :md  metri- 
tis, 723 
in  the  induction  of  labor, 
880 
intravenous,  of  normal  salt- 
solution,  009 
vagiiud,  during   pregnancy, 
181,  182 
Injuries,    mechanical,    <liMing 
pregiiiincy,  249 
nerve,  following  liibor,  791 
perineal,  prevention  of,  30!>, 

374 
to     the     external      genital 
organs      following 
lalxir,  072 
to  the  intravaginal  jiortion 
of  the  uterus,  014 


J: 


Injuries  to  the  perineum  fol- 
lowinjjf  labor,  (iT.'l 
to     tlie     viigina    following 

labor,  (178 
to  the  vulva  following  labor, 

(572 
traumatic,  of  the  new-born, 
823 
Inlet,  pelvic,  anatomy  of,  18 
axis  of,  20 
dimensions  of,  18 
measurement  of,  oOl— ')09 
oblique  diameters  of,  meas- 
urement, oO!t 
transverse  diameter,  meas- 
urement, 507,  508 
Insanity  of  eclampsia,  C28 
of  labor,  71*7 
of  lactation,  798 
of  pregnancv,  797 
puerperal,  794-SOl 

classification  of  types,  798 
diagnosis,  799 
etiology,  794 
pathology,  797 
prognosis,  799 
symptoms,  797 
treatment,  799 
Inspection,   abdomin;d,    diag- 
nosis by,  407.    (See 
Palpation. ) 
Instrument-table,     e<iuipment 
of,  in  internal  ver- 
sion, 957 
"  Internal  os  of  Hraunc,"  583 
Intestines,    malformation     of,  i 
congenital,  303 
of  the  new-born   infant,  810 
anatomical      pecidiarities 
of,  856 
obstruction  of,  in  the  new- 
born, 857 
Intussusce|>tion   in   the    new- 
born, 857,  S58 
Inversion  of  puerperal  uterus, 
742 
of  the  uterus,  (U6 
diagnosis,  t)19 
etiology,  018 
freiiucncy,  617 
post-mortem,  (')46 
prognosis,  021 
symptoms,  ()19 
treatment,  621 
varieties,  617 
with  prolapse,  619 
Involution  in  the  jjuerperiimi, 
652 
tardy,  197,  662,  734 
Irrigation    in     breast-abscess, 
763 
vaginal,  in  the  induction  of 
prenuitnre      labor. 
881 
in   treatment   of    vaginal 
liiceratiims,  679 
utility  of,  346 
Ischiopagns,  305 
Isthnuis  of  the  oviduct,  56 
Isthmus  uteri,  46 


INDEX. 


Jaundick  during  pregnancv, 
232 
treatment  of,  232 
"Jelly  of  Wharton,"  94 
Joints,  pelvic,  ankylosis  of,  531 
relaxation  of,  532 

KiUN'KV,  displaced,  complica- 
ting labor,  639 
of  the  new-born  infant,  810 

"Kidnev  of  i)regnancv,"  197, 
198 

Kidnevs    din-ing    pregnancv, 
197 
fetal,  development  of,  118- 

121 
in   toxemia    of    pregnancv, 

205 
of  the  eclamptic,  630 

Kiesteiii,  163 

Knee-and-elbow  i)resentations, 
diagnosis,  by  vag- 
inal examination, 
416.  (See  J'resi-n- 
talioii.i.) 

Knots  of  the  cord,  258 

Koumijs  in  stomach  disorder 
of  pregnancy,  183 

Kyphoscoliosis,  540 

Kyphosis,  537 

Labia,  elephantiasis  of,  192 
fetal,  devclopmeMt  of,  125 

Labia  majora,  anatomy  ol',  37 
minora,  37 

Labor,  mechanism  of: 

auatomv  of  the  pelvis  in, 
388 
— infra|)elvic     portion, 

397 
— pelvic  portioti,  390 
— sujirapelvic    portion, 

389 
of  the  male  and  female 
pelvis,     ditli'rences 
between,  398 
of  the  parturient  canal, 
397 
classification  of,  386 
of  |iosition,  387 
of  presentations,  386 
-natural    and    uimat- 

ural,  386 
— normal    and    abnor- 
mal, 386 
diagnosis,  407 
bv  abdominal   inspection, 

107 
by  auscultation,  410 
by  examination,  sinnmary 
of  diagnostic  signs 
fiirnislied  by,  411 
by  jialpation,  407 
bv    vauiiial    examination, 

411 
of  presentation,  frequency 

of  each.  4Ui 
summary  of  signs  of  each 
presentation,  414 


991 


Labor,  mechanism  of,  in  breech 
presentation,  415 
I  — brow       presentation, 

415 
— face  ))resentation,  415 
I  — head  or  a  foot  presen- 

tation, 415 
— knee   and   the  elbow 

l)resentation,  416 
— transverse     presenta- 
tions, 41(1 
fetus,  the,  401 
attituile  of,  385 
bodv  of,  406 
head  of,  402 

arti<'iilations      between 
the,  and  the  spinal 
column,  406 
diameters    of,    relative 
value,       compared 
with  diameters  of 
the  i)elvis,  404 
dimensions  of,  403 
position  of,  (lelined,  3.S(; 
presentation    of,    defined, 
385 
presentations,  417-492 
brow,  diagnosis,  466 
etiology,  4il6 
freiiuency,  166 
management  of,  at  the 

brim,  467 
mechanism  of,  466 
prognosis,  466 
face,  diagnosis,  4."9 
etiology  of,  458 
frc(|U(n('y,  458 
nuuiiigcment  of,  462 
mech;misni  of,  460 
of  posterior,  M.  D.  P., 
162 
prognosis,  459 
footling,   mechanism   and 

manngement,  487 
pelvic,  diiignosis,  470 
eiioloiry,  470 
fre(inency,  470 
management  of,  474 
meciianisin  of,  470 
prognosis,  470 
transverse,  diagnosis,  488 
etiology,  487 
fre(iuency  of,  487 
management  ot',  489 
mei  hanisni  of,  488 
prognosis  of.  488 
vertex,  417,  458 
— posterior  positions  of, 

442 
— the  first  stage,  417 
— the  second  stage,  430 
—the  third  stage,  440 
prognosis  of,  416 

Labor,  normal : 

anesthetics  in,  'M'2 
administration  of,  363 
choice  of,  3(13 

antisepsis  in,  341 

abdominal  binder  in,  the,  384 


J'ls 


ill 


II 

j 
.'i 


•J    t 


,»       ! 


;    t 


992 


ixnh\y. 


n-  ' 


It      J 


Labor  (ni)rm!il),  breech,  nor- 
Diiil      luana^enient 

of,  -l".') 

eathiter  in,  imssin^  of  tlie, 

808 
clasiiiticatioii  of,  ;?S() 
coiuliii't  of,  ;>  11-K84 
in  hospitals,  71(1-717 
and      jirivale     |)raetiec 
compared,  717,  718 
antiseptic,     in     hospitals, 
714-717 
in  private  })ractice,  718, 
71S) 
contractions,    uterine,  after, 

I>77,  lii  8 
defined,  ;U8 

delivery  of  the  head,  maii- 
aijenient,  ;}70-;{73 
of  the  trunk,  ;>7I 
descent  of    feltis  in,  second 

stage  ol',  ■i'M 
detachnicnl   and    expidsit)n 

after,  440 
diaj!;nosis  liv  abdominal  ans- 
>'uliation,  410 
l>alpatioii,  407 
dilatation  in,  niechanisni  of, 

4'J4,  8>-' 
disinfection  in,  rules,  !M.'> 
expulsion  of  fetal  shoulders,  I 

4;!'.»  ! 

examination,        abdominal,  | 
during,  8(1") 
diagnostic     signs     fur- 
nished by,  411 
vaginal,  80(5 

fretpiency  of.  o(i9 
techiii(iue  of.  41 1 
forces  acting  in,  i'S-i 
injuries  to  the  external  geni- 
tal  organs,  follow- 
ing, ()72 
to    pelvic    floor,    during, 
l)i'evenlion   of,  liC'J 
ligation  of  cord  after,  875 
management  of,  84S 

of  patient  after,  ()57-G71 
of  the  cord,  874 
of  the  lirst  stage,  807 
of  the  .second  stage,  808 
of  the  third  stage,  87() 
relation  of  the  fetal  hips 
in  the,  400 
of   the   fetal   shoulders 

in  the,  400 
of  the  fetal  trunk  in  the, 
4(10 
obstetric  position  in,  808 
onset  of  cau.ses,  :!18 
over-distention     of     uterus 

causing,  8'JO 
phenomena  of,  80r> 

Labor,  physiology  of,  818- 

888 
clinical  course  of  the,  888- 
840 
— beginning  lubor,  sigiis 
of,  883 


Labor  (physiology  of  \  change 
in  the  pelvic  floor, 
887 
— duration  of  labor,  840 
delinitions  of,  .818 
phenomena  of",  8'21-8.'i8 
— action   of  abdominal 

nnisclcs,  1)28 
— action  of  the  vagina, 

8'J4 
— bag  of  waters,  880 
— changes  in  the  body 
of  the  uterus,  82".t" 
— changes  in  the  cervix, 

.824 
— changes  in  the  lower 
uterine      segment, 
.827 
— character  of  the  li(i- 

nor  anniii,  822 
— formation     of    caput 

succedancuni,  888 
— uterine    contractions, 
821 
lireniature,  detined,  2.")",),  818 
|)resentations,     contact     be- 
tween   breech    and 
fundus    in    vertex, 
4.88 
vertex,  diagnosis  of  posi- 
tion in,  422 
by  vaginal  examina- 
tion, 414 
etiology  of  position,  422 
flexion  in  second  stage 

of  lalior  in.  4,82 
force  of  gravity  in,  482 
l're(picncy  of,  4l7 
influence     of    gravilv, 

418,421 
infra-uterine  fluid-pres- 
sure in,  4i>8 
irregular  shape  of  fetal 

skull  in,  4.")8 
mechanism   of    descent 
in,  481 
of  left  anterior  posi- 
tions, 440 
of  right  posterior  po- 
sitions, 442 
prognosis,  41() 

of  position,  428 
rotation  in,  48"),  488 
une(iual   lengths  oi   the 
ends  of  the  head  in, 
482 
prognosis  of,  800 
repair   of  lacerations   after, 
870 
method  of,  880 
restitution  of  fetal  hea<l.  480 
retraction  of  uterus,  488 
rotation   of   fetal   shoulders 

in,  48!) 
rupture  of  membranes  in,  8()8 
third  stage  of,  miuiagement, 
442 
mechanism  of,  4  10 
toilet  of  patient  after,  882 
vulva,  dressing  of,  after,  888 


Labor,  pathology  of: 

deliverv   in,  bv  basiotripsy, 
■  087 
by  cejihalotrip.sy,  087 
by  Cesarean  section,  028 
"  indications,  017,  018 
the  operation  ot',  010 
preparation  for,  gen- 
eral, 910 
time     to    operate.    018, 
010 
(See  ( V.s(ii'C((»  fccliiiii.) 
by  cranioclasis,  OliC) 
by  craitiotomy,  020 
by  end)ryotomy,  020 
by  fetal  "decapitation.  0.88 
by  fetal  evisceration,  088 
by  biparo-elylrotomy,  02") 
bv    svmjthvsiotomv,  Oor)- 

017" 
by  version,  041-008 
in   dor.so-anterior   posi- 
tions, Ool 
in  dorso-posterior  posi- 
tions, 054 
bv    the    I'orro  operation, 

024 
of  the  after-coming  heiid, 
after     craniotomy, 
085 
of    the    presenting    head 
after     craniotomv, 
084 
forcep.s,    compression    in, 
800 
high  operation,  808  008 
indications  for,  801,802 
low  operation,  808,  890- 

808 
operation,  tlie,  892 
traction  in,  890 
chorea  in,  inlhience  of,  210 
complications  during,  800 
death  in,  sudden,  044 
diseases,   infectious,  compli- 
cating, 088  784 
of  the  brain  complicating, 

(i48 
of  tlu^  lu'art  complicating, 
(i42 
displaced  kidnev  complicat- 
ing, 080 
eclampsia  in,  occurrence  of, 

021 
ele|ihanliasis    compliciiting, 

102 
eventration       (tomplieating, 

080 
forces  of,  anomalies  in   the, 
408 
deficient    power    in    the, 

408 
expulsive  power  of,  exces- 
sive, 497 
hematoma  complicating,  080 
heinorrhiige    in,   accidental, 

500 
hemorrhages  in,  0."iS 
hernia  complicating,  088 
induction  of  premature,  878 


i 


I 


IT 


Lulior   ^|iallii>li>v'.vl,   iniliiclinn      li 
of  iiri'iiiMliirc,  !is)ii- 
ration  of  till-  iilt'i'iis 
l'<ir,  SSI 
iiiili(-a<i(iii>  I'lir,  S7S  j 

in  I'danipsia,  (i.'lT  I 

in  placcnla  pru'via,  "tiMi 
in  |Milvliyiiraniniiis,  '2')',\ 
irrlKalion  ol'  llic  vMKiiiii 

lor,  HSO 
()|H>rnliiin,   nu>tli<iils   ol', 

S7<»  j 

prognosis,  ST'.t 
Hnffjical  opiTalions  lor, 

H7S 
lainponin^r    I  he    va^'iiiii 

lor,  sso 
tinio  to  operate,  ST'.I 
infeelion,   Heptie,   lollowinfj, 

()H7  flSlt 
injuries  |o  llie  inl'ra-vaKinal 
po  r  t  i  on    ol'    (lie 
nteruH  in.  till  )i|(> 
in  inanaKeiiient  ol'  I'aee  pre.s- 
entalions     at      llie 
liriin.    111;! 
insanity  ol',  7'.i7 
intrapelvie   liiinors   eoinpli- 

eatintc,  (ISO  CSli         | 
inversion  of  the  uterus  in, 

(ill)  i;-j:t  j 

JiiHlo-niiuor   pt^ivis  in,  inllu- 

ence  of,  ol") 
kypliolie    pelvis    in,    inllu- 

enee  ol",  .");!',» 
Iiieeratioii    anil    rupture    of 

tile  uterus  in,  (illl 
iniinaKCiueut    of,   olistrueted 

Ity   llie  eoliiiuoiiesi 

foiiiis  of  eonlraeled 

pelvis,  r)|;t 
of  tlie   eoi'il,    patlio|ouii'<i| 

eoiKJilioiis    ill    the. 

ilioeliaiiisni   of,  with   lioulile 
iMonsli'i's,  otilt,  "((I  I 
in   posterior   positions  of 
vertex,  iiislruiiu'iit- 
al  operations,    lot, 
4.').-, 
"iniHScd,"  -72 
narrow,  funnel  shapeil    pel- 
vis,    iiiliueiice     of, 
517 
neural  and  spinal   alleeiions 
following-,  7111 
treatiiieiit,  7'.t  I 
(thli(|iiely-eoiitra('ted    pelvis, 

inlliieiiee  of,  ^'Jd 
oitHtrili'tion  to,  hy  almoriiial- 
ili(>s    ill    the     fetal 
appeiida;;es,  "i7() 
hy  anus  vayiiialis,  ."lod 
hy  ('(lils  of  the  cord,  .'"i7il 
hy  closure  and  eoiilrailiou 
of  cervix,  ol7 
of    the     vauiiia      or 
vulva,  'il!) 
by   (^(iiitrenital    anomalies 
of  the  uterus,  "illi 

6» 


iihor  (  paiholo^'y  1,  olistriielion  ! 
to,    hy    narrowness 
of  vavrina  and  viil-  | 
va,  .Vil  I 

hy    displacement    of    cer 
vix,  .■>.">( i 
of  uterus.  •'<:>'! 
hy  edema  of  vulva,  o")(i 
hy  faulty  posilioiis  of  the 

uterus,  'ilid 
hy  felal  enlerocele,  ."ill I 
hv  ,u;aii^;rene  of  the  vulva, 

.-..-.1 
hy  lieinatomata,  >'•  I'.l 
hy  lualpreseiilatioiis.  ."i(l(» 
hy  multiple  hirtlis,  .'ili7 
hy  pl.icenla  piievia.  oSI 
liv  prolapse  of  cord,  ")7.'f 
")7() 
of  uterus,  !'f'i'.'>  ■")■")•"• 
hy    rij^iility   of  tissues  of 
the    pa  r  t  11  r  i  e  n  I 
canal,  ofd,  o.'i'J 
hy     sacculation      of     the 

uterus,  o"i;', 
hy  shortness  of  cord,  o77 
hy   tilliiol's  of  the  Kcliiliil 

canal,  r).")!! 
liy  vaginal  atresia,  o'ld 
and    vulvar    tuiiKU's, 

.'(rid 
cicatrices,  5  I'.t 
enlerocele.  ■>■>'.) 
hy  llie  soft  maternal  slriic- 
(ili'cH  of  (he   partu- 
rient canal.  ■'>  Hi 
symphysiotomy  in,  !l|  I 
osleiinialacic     pelvis,     inlhl- 

eiice  of,  rrJit 
paraplegia  coinplicatiiiLr.  (i  l.'t 
pneumonia        coinpliiatiiiK, 

i;ii 

positions,  ohstetric,  in.  '.to'.t 

!l(i:t 
post-part  nm       hemorrha^'c, 

(iOd,  (idl 
preinallire.  (See  liiihiilioii.) 
pri'wentations  in  hreccli.  ar 
rest  of  an  aim  lie- 
liiiid  the  occiput  in, 
IS  I  I 

arrest  of  the  head  at 
the  inferior  strait 
ill,  ■|S7 

arrest  of  the  head  at 
ihe  superior  strait 
in,  IHI  j 

arrest    of    head    at    the  | 
superior  strait,  use 
of  I'orceps  in.  |s('i 

arrt;st  of  head  clue  to 
conlractioii  ol  the 
pelvis  in,  ■IS7 

arrest  from  extension  of 
the  head  in.   tsi; 

arrest,  hiLdi,ol  llieMiiiis 
anil  head  in,  (s-J 

arrest,  low,  of  aiiris  and 
head,    methods    of   , 
delivery,   ISd  I 


!I!KJ 


Iiilhor  (pallioloi:y ^.  presenlii- 
tioiis  in  hicci  h, 
closure  of  a  coii- 
striciion  rin^  ahouf 
the  liei'k  in.  IS  I 
dillicull  extraction  of 
head  and  arms  in, 
ISI 
diagnosis  of,  hy  va;iiniil 

examination,   115 
operative         tri'iitmenl. 

17(1.  177 
pro^iiosi'.  of,   1 17 
rapid  extiaclion  in  hi^h 
arrest,  l7o 
in  low  arrest,  'ITH 
hrow.  Kid 

diii>?nosis  hy  vai^iiial  ex- 

amiuatiiin.   115 
pronnosif.,    117 
eompound.    complicalin^, 

.")(>(1,  ."i(l7 
etiolourv  of,  lis 
face,  (lianiiosiH.  hy  vaginal 
exaiiiinalion,  115 
mana^i'ment  of,  IdO 
niechanism  of,  |5S 
pmmiosi.s,  III) 
foollini;.  mechanism,  ■\X7 
hand  and  loMt,diauiioHis  hy 
vaginal     examina- 
tion, ll.'^i 
head  and  a  hand,  I'.l'J 
inlluence  of  gravity,  I  IK 
of  fetal  movements,  121 
knee  and  clhovv,  diagnosis 
hy  vaf^inal  exainin- 
aiinii,  III) 
pelvic,  I7d 

transverse,    diiij^'iuisis    hy 
vaginal     examina- 
tion, IK) 
manajiemeiit,   IS'.I 
mechanism.  IS7,  |S,S 
prof;noHis.  1 17 
relative  lici|ueiicy  of  four 

posilioiis,  '1 17 
vertex.  iiialiai;cmeiil  nf.  in 
posterior  positions, 
I  lit 
(See   I'liKiiitiiliniiK.  I 
relaxation    and    riiptun'   of 
pelvic  articulations 
colllplil'alill^^  (i  Id 
rachitic     pelvis     in,     inllii 

ciice  ot',  5'J('( 
sliocU  compiicatiiiir,  '•  I  I 
simple  Hat   pelvis  in.   inlhi 

encc  of,  51  I 
spondylnlislhclic   prdvis   in, 
inlluence  of,  olid 
treatment,  51)7 
tumors  of  the  rectum  coih 

plicalini.;,  ():!!( 
twill,  mecliaiiism  of,  5(1K,  5mi 
varieties  of.  delilied,  ;>|H 
diagnosis,    l'i'e(pieiicy,   and 
proLtliosis      ol      the 
several,   Id7 
vomiting'  in,  ^'<M 


illl  I 


^1  ; 


■  \-'t 


994 


lyDEX. 


LaburpiiinH   in   extrauterine 

preKiiancv,  '285 
Labors,  dry,  oontra-iiidicatinp 
version,  04;) 
normal  nieclianisin  of  de- 
scent in,  4;>1 
Lacerations,  cervical,  ;{79,  (il4 
repair  of,  37il 
pelvic- t'oor,  after-eare  of,382 
prevention  of,  8()1> 
repair  of,  liTi) 
types  of,  ;{71t,  381 
perineal,  l)7;>-()78 

after-treatment  of,  ("7 
repair  of,  method,  379,  380 
vaginal,  ('i78-(180 

and  vulva,  suturing  of,  720 
vulvar,  (17"J,  720 
Lactation,  t)54-(l(ll 
anomalies  in,  7()8-773 
arrest  of,  707 
i'leanliness  of  nipple  during, 

748 
mammary    glands    during, 

changes  in,  08 
insanity  of,  7',I8 
jjcriod  of,  normal,  0")4-777     ' 
prolongation  of,  777 
La  grippe,  congenital,  84it 

diagnosis   and   treatment, 
849 
Lanugo,  fetal,  appearance  and 
disapj)earanee.  lOl, 
102 
Lajiaro-elytrotoiny,  925 
Laparotomy  in  local  peritoni- 
"tis,  730 
in  rupture  of  the  uterus,  014 
^A'g,  extraction  of,   in  breech 
labor,  477 
phlebitis  of  the,  097 
symptoms,  703 
Leukemia  in  pregnancy,  230 

treatment,  237 
Ligauient,  ovarian,  -VJ 

pelvic    sacro-coccygeal,   an- 
terior, 25 
|)osterior,  25 
sacro-iliae,  anterior,  24 

posterior,  25 
sacro-sciatic,  anterior,  20 
posterior,  20 
pubic,  anterior,  23 
inferior,  24 
posterior,  23 
su|)erior,  23 


Ligaments,  broad, 
removal  of, 
sepsis 


ill  puerperal 
973 


pelvic,  22-26 

relaxation    of,    in    preg- 
nancy, 202 
recto-uterine,  54 
round,  52 
uterine,  51 

anterior,  52 
utero-sacral,  54 
Ligature    of    the     umbilical 
cord,  375,  829-832. 
(See  Cord.) 


Limb8,  fetal,  first  appearance 
and  development, 
95-101 

injuries  to,  of  the  new-born. 
824 

puerjienil  infection  of,  707 
Linea'  albicantes,  150,  175 
"  Lipoid  (Icgcneration,"  312 
Liquor  amnii,  138 

follicidi,  171 
Lithopedion,  283,  313 
Liver,  fetal.  118.  141 

atrophy  of,  acute  yellow, 
during  pregnancv, 
232 

hypertrophy  of,  due  to  preg- 
nancy, 155 

of  the  new-l)l^ru  infant,  810    ' 

of  the  eclamptic,  030 
Lochia  alba,  054 

micro-orgiiuisins  in  the,  ()54  ' 

puerperal,  054 

rubra  or  eruenta,  ti54 

serosa,  054 
Lordosis,  540 

Lungs  of  the  eclamjitic,  030      I 
Lutein,  01  i 

Luxation  of  the  femora,  541      j 
Luxations,  congenital,  301. 
Lymphangitis,  095 

and  i)hlebitis, ditlerentiation 
of,  705 

diagnosis,  701 

symptoms,  700 

treatment,  720 
Lymphatics,  mammary,  ()9 

of  internal  organs  of  gene- 
ration, 04 

of  the  new-born  infant,  811 

vaginal,  45 
living-in,    regulation    of    the. 

ti04 
Lying-in  room,  307  j 

pivpanition  of,  3.")9  ' 

ventilation  of,  ()59 

Maceration,  fetal,  273,  283,  i 

284,  312 
Malaria,  puerperal,  782 
diagnosis,  782 
treatment,  782 
Malformations,  congenital,  299 
of  the  brain,  304 
of  the  circnlatorv   appa- 
ratus, ,304  ' 
of  the  cord,  .304 
of  the  extremities,  304        j 
of  the  generative  organs 
of  female  chil(iren,  ' 
303  ; 

of  the  stomach,  303 
fetal,  complicating  labor,  503 
Malpighian  bodies,  119-123      : 
Malpresentations  complicating  j 

labor,  5f)0 
Mamma',  the,  05 
abscesses  of  the,  702 
blood-ves-sels  of,  09 
changes    in,   due    to    preg- 
nancy, 152,  102 


Mammr     olianges   in,  during 
the       puerperium, 
(554,  055 
nerves  of,  70 

position  of,  variations  in,  70 
supernnmerary.  70 
Mammillaplasty,  748 

Management  of  the  puer- 
perium,  057-071. 
(See  I'licrjxriiim.) 
Mania      complicating     preg- 
nancy, 222 
of  pregnancy,  159 

diagnosis   and    prognosis, 

222 
treatment,  222 
(See  fiL^iuilli/,) 
Ma.ssage,  breast,  001,  750,  755 
in  agalactia,  772 
in  arrest  of  lactation,  707 
in  mastitis,  70(t,  7til 
technique  of.  755 
Mastitis,  congenital,  840 
prognoses,  841 
.symptoms,  840 
treatment,  841 
infant,  prognosis  and  treat- 
ment, 827 
liuerperal,  etiology  and  pa- 
thology, 750 
frequency,  750 
symi)toms  of,  759 
treatment,  curative,  700 

l)ro))hyl;ictic,  759 
varieties  of,  750 
Maturation,  74 

Measles     complicating    preg- 
nancv, 243 
fetal.  290 

prognosis,  297 
Measurements,    jielvic,   exter- 
nal. 358 
internal,  358 
Meatus  uriuarius,  38.  40 
Mechanism  of  breech  presen- 
tations,   abnormal. 
472 
normal,  470 
of   face   presentations,    458, 

4t;o 

of  labor,  tirst  stage,  423-430 
second  stage,  430 
third  stage,  440 
of  transverse   presentations. 

488 
of  twin  labor,  508,  509 
of  right  posterior  positions 
in  vertex  preseni:i- 
tions,  442 

Mechanism  of  lahor,  384- 

492.      (See   Ltthor, 
iiiechaiiixm  iif.) 
Meconium  at  term,  102 

chemical  composition  of,  142 

tirst   traces  of,   period   and 
characteristics,  HH 

of  the  new-born,  810,  855 

source  of,  141 


r 


\ 


ini. 


,70 


uer- 

t)71. 

1)11.') 


nosis, 


a,  755 

m,  7()7 
1 


,a  treat- 
ve,  7G0 


ii«    preSJ- 


k-    exU'i- 


40 
iilmormnU 


lOUS, 


458. 


;t.,423-4o0 


) 


jsentauoiis, 

5l>9 
|v  jHisitioU!- 
Ix  iireseiu;i- 


Jlbor,  384- 
[See   Iaiooi; 
m  of.) 

liliim  of,  1  '•- 
Iperioa   nn. 

810,  855 


Mediillii,  ovariiin,  59,  60 
^[^'lt'lm  iiei>imti)riiiii,  845,  853 
Meinbruna  ^niiiiilosM,  tlO,  71 
Menibraiie,  vitulliiie,  of  ovum, 

71 
Membranes,  fetal,  88 

complieatiiiK  labor.  570 
in  twin  pre^'naiicy.  143 
elastieity  of,  undue,  dilata- 
tion of  OH  witli,  430 
of  uterine  cavity,  378 
rupture  of  bag  of,  in  labor, 
3t>8 
in   the  induction  of  pre- 
mature labor,  879 
dilatation  of  os  after,  127 
Meningiti.s  during  pregnancv, 
213 
treatment,  732 
Meningocele,  congenital,  304, 

819 
Meningo-myelocele,  304 
Menstruation,  72 
corpus  luteum  of,  (SI 
cycle  of,  stages  of,  72 
during  pregnancv,  presence 
of,  Kil 
suppression  of,  ItiO,  1(51 
return  of,  suckling  after,  77(1 
Mesoderm,  79 
Metritis,  forms  of,  (194 

symptoms  and  prognosis,  (599 
treatment  of,  721 
Metritis,  dissecting,  treatment, 
725 
suppurative,  indicating  celi- 
otomy, 909 
and   ulcerative,  hysterec- 
tomy for,  974 
Microcei)lialia,  305 
Microma/ia,  74(5 
Micro-organisms     in     Iniman 
milk,  757,  774 
in  the  genital  tract,  193 
of  puerperal  infection,  084, 

087,  (592,  093 
of  the  navel  cord,  839 
of  the  urinary  organs,  787 
transmission  of,  to  fetus,  835 
Microthelia.  745 
Mid-gut,  114 

Milk,  breast,  analyses  of,  770 
bacteria  in,  774 
changes    in,    qualitative, 

771 
drugs  in,  ingested  by  the 
infant  in  suckling, 
770 
drying  uj)  of,  707 
ingestion  of,  infant,  850 
quality   of,  abnormalities 
'  in,  7(58 
diet    influencing,    708, 

709 
emotional      excitement 
influencing,  770 
qiiantity  of,  abnormalities 

in,  771 
supply  and  (piality  of,  061, 
771,  772 


INDEX. 

Milk,     condensed,    in    infant  ' 
feeding,  (570 
cow's,  composition  of,  (i(>9 
pasteuri/.atioii  of,  (i71 
transmission   of    tuber- 
culosis in,  S47  I 
hinnan,  composition  of,  (i.')5, 
6(19  ■ 
micro-organisms    of,  757, 
774  I 
Milk-ducts,  devt'lopment  of,  (58 
Milk-glands,  accessory,  (Ki 
Milk-mixture,  fornuda,  070 

Kotcli-Meig'.s,  069 
Milk-nodes,  766 
Milk-ridge.s,  70  | 

Milk-secretion,  anomalies  in, 
708  i 

due  to  pelvic  diseases,  1(12 
inlluence  of  malaria  on,  782 
in  the  new-born.  827 
of  pregnancy,  162 
puerperal.  (155 
variations  in,  771 
Milk-sinuses  of  mamma,  68 
Milk-stasis    causing    mastitis, 

757 
Milk-supply,  delicient,  771 
excessive,  772 
variations  in,  771 
Miscarriage  defined,  259,318 
Mole,  "blood,"  262 
cvstic.  254 
'•flesh."  262 
vesicular,  254 
jiathology,  254 
symptomatology,  254 
synonyms,  254 
treatmenf,  255 
"Mole  pregninicy,"  312 
Moles,  hairy   and   pigmented, 
congenital,  3(19 
hydatidiform,    iutracervical 

tampon,  874 
"tubal,"  -JStl 
Monstrosities   (double  forma- 
tions), 305 
complicating  labor,  563 
Mons  veneris,  anatomy  of,  '.V! 
Morbidity,    pueriieral.    rciiuc- 
tion  of,  by  vaginal 
disinfection,  346 
"Morning     sickness,"      (See 

Morphia,  hypodermatic  injec- 
tions of,  danger  of", 
in  pregnancy,  212 

use  of,  in  eclampsia.  636 
Mortality,  fetal,  due  to  syphil- 
itic infection,  24(J, 
299 

from  accidental  hemorrhage, 
599 

from  Cesarean  section,  925 

from    eclampsia,    623,   (128, 
(129,  6:{(),  636,  637 

from  inversion  of  the  uterus, 
621 

from  labor,  complicated  by 
brain  diseases,  643 


995 


Mortalitv  from  placenta  prte- 
via,  591 
from    puerperal   erysipelas, 
781 
infVcti(m,  341,  693,781 
reduction  of,  by  anti- 
seiisis,  709 
from    radical    treatment    of 
uterine        fibroids, 
186,  187 
from  retrovei-sion  of  uterus, 

195 
from  rupture  of  (iclvic  artic- 
idations,  641 
of  uterus,  61;} 
from  sudden  death  in  labor, 

644 
from   svmphvsiotomv,  905- 

!H)7" 
from   the    I'orro  operation, 

925 
from  velamcntous  insertion 

of  the  cord,  580 
in  breech  presentations,  470 
in     labor     complicated    by 
rigidity   of   tissues 
of    the    parturient 
canal,  552 
from   ovariiin  ('ysts,  558, 
559 
infant,  860 

of      concealed       accidental 

hemorrhage  in 

])rcgnancy,  20O 

of  delivery  comiilicated   by 

pelvic  tumors,  53() 

in  kyphotic  pelvis.  5159 

in     obli(iuelv  -  contracted 

pdvei,  520 
in  osteomal  icic  pelves, 529 
of  face  presentations,  459 
of  ovariotomy  for  cysts.  191 
of    [iregnaucy   from    mitral 

stenosis,  237,  2.'>8 
of  tetanus  neonatorum.  841 
of  twin  lrd)ors,  570 
puerperal,  iviluction  of,  anti- 
septic, 341 
by   vaginal   disinfec- 
tion, 346,  .■147 
septic,  341 
"  Morula,"  77 

Mouth  during  pregnani'y.  ab- 
normal   conditions 
of,  234 
treatment,  234 
Movements,  fetal.    I  See  Feins.) 
Mucosa,  cervical,  49 
of  ovi<lu('ts,  56 
uterine,  49 
vaginal,  45 
Miilier's  disease  of  fetus,  309 
Multiple      pregnancy.       (See 

Pmjnani']!.') 
Munmiification,  fetal,  273,  283, 

313 
Muscle,  coccygeus,  28 
levator  ani.  27 

hypertrophy  of,  28 
obturator  internus,  26 


S      1 

I    < 


K 


99(5 


INDEX. 


Muscle,  pyrirorniiH,  2fi 

uterine,  (lelicieiit   puwer  of, 
ill  liiliiir,  lit;} 
Miisiles  of  the  new-born,  811 
pelvic,  'ifi 
ueriniei  builHi-ciivernosns, 

Wl 
i((L'lii()-<'iivi'ni()suH,  \V1 
milH-rlii'ial  t  runs  versus,  If;? 
uterine,  -l!i 

eliiinj,'es  in,  din'in^  I'l'^'K^ 
nancy,  14"),  lin 
during'  the  puerperiuni, 
(l.')H 
contnietious  of,  inlluenee 
of,    in    (lilutation, 
425,  427 
(See  rui-ii.i.) 
Myoniiitii  of  tiie  uterus,  1S5 
intra-iiterine,      contra-indi- 
cating    celiotomy, 
iKill 
Myomectomy  in  pregnancy  for 
tihroids,    list),    187, 
248 
Myxoma  of  the  placenta,  2")4 

JsAlsEA     and     vomiting    of 
pregnancy,        l"),"), 
l.')!»,  222  " 
causes,  22o 
diagnosis,  228 
pathological  anatomy,  225 
plvalism       complicating, 

2;;i 

sym{)toms,  224,  225 
treiumcnt  of,  IS.S 
medicinal.  229 
rational,  227,  228 
Navel,  arteritis  of,  837 
diseases  of,  827 
dnssing  of.  827,  828 
gangrene  of,  >^'-M 
symptoms,  >*88 
treatment,  8.S8 
phlebitis  of,  S87 
woinidsof,  healing  of.  slight 
disturbance  in,  882 
Neck,  injuries  to  the.  of  the 

uew-borii,  824 
Necrosis  of  pelvic  bones,  51)1 
Needles,  suturing,  380 
Nephritis   following    toxemia 
of  pregnancy,  208 
of  pregnancy,  197,  ]'.I8 

prognosis,  191' 
puerperal,  symptoms,  70t) 
treatment,  781 
Neuritis,  nndti[)le,  complicat- 
ing pregmuicy,  218 
septic,  puerperal,  792,  798 
Nerve-injuries  following  labor, 
791 
of  the  new-born,  825 
Nerves,  mammary,  70 
of  oviducts,  57 
pelvic-lloor,  8G 
urethral,  41 
uterine,  (15 
vaginal,  45 


Nervous  disturbances  in  puer- 
peral        infection, 
tlS8,  7()G 
system,  diseases   of,    h)   the 
pnerperinm,  790 
intrauterine,  809 
oftlienew-l)orn  infant,  81 1 
NeiU'algia  of  ])regnancv,  208 
facial,  of  pr.'gnancv,  209,  210 

trealnieut,  209,  210  : 

pelvic,  209,  210  i 

New-bom  infant,  care  of, 

()(i4-(i71  i 

nin'sing  of  the,  (i()7,  S(iO 

by   syphilitic    mothers, 
775 

conditions     interfering 
with.  778 

intervals  in,  708 

syphilitic     inoculation 
in,  840 

transmission  of  tubercu- 
losis in,  847 

New-bom  infant,  pathol- 
ogy of.  (See  I'dlli- 

iiIdijII.  ) 

New-bom    infant,    physi- 
ology of,  807-818 
—bones,  the,  811 
— digestive  svstem,  809 
—fat,  the.  81'! 
— growth,  807 
— lymphatic  system,  811 
— liiuscles,  the,  811 
—  nniscidar  action,  812 
— nervous  system,  81 1 
— respiration,  808 
—skin,  the,  810 
— s])ecial  senses,  812 
— speech,  818 
— temperature,  the,  81 1 
— lu'iuary  system.  810 
trainnatic  injuries  of,  828 
weights  ot',  variations  in, 
108 
Nipple,  abscess  of  the,  751 
eczema  of  the,  751 
hypertrophy  of,  due  to  j)reg- 

nancy,  158 
muscular  tissue  of,  07 
of  pregnancy,  101 
structure  of,  t)5 
Nipples,  anomalies  ol'.  745 
develoi)meut  of,  faulty,  74i'> 
diseases  of,  747 
during   lactation,  trealnieut 
of,  tiOl 
pregnancy,  care  of,  184 
in  mastitis,  700 
sore,  747 

and  iissin-ed,  treatment  of, 

184 
etiology  of,  747 
symptoms,  748 
treatment.  748,  749 
Nipple-shield,  749 
Notochord,  81 


Nourishment    for    premature 
infants,  methods  of 
administering,  8ti5 
Nozzle,  douche,  uterine,  selec- 
tion of,  870-872 
Niiilens,  segmentation,  70 
Nurse,  the.  auti.septic  precau- 
tions ot,  845 
Nursing  of  the  new-born,  ()()7, 
800 
by    sy|ihilitic   mothers, 
775 
conditions  interfering  with, 

778 
i'ltervals  in,  708 
syphilitic  inoculation  in,  840 
transmission  of  tuberculosis 

in.  847 

wet-,  of  the  new-born,  068 

Nutrition,  changes  in,  due  to 

pregnancy,  155 
Nymiilne,  87 
Hottentot,  .87 

OuKsiTY,     simidating     |ireg- 
naucy,  178 

Obstetric   surgery.       (See 

Sitn/rri/.} 
Obstetrician,     the,     antiseptic 
precautiouB  of,  844 
Occlusion,     intestinal,      from 
retroverted  uterus, 
195 
Ointment    for    sore     nipples, 
formula,  749 
iodoform,  I'ormula  for,  720 
Oligohydraimiios,  258,  254 
Omphalitis,  887 

prognosis    and     treatment, 
887 
Omphalorrhagia,  828,  830 
Oiiphoritis,  095,  (i99 

complicating  pregnancy,  190 
Operations,  surgical,  807 

during     j)regnaucv,    251, 

252 
general  reciuirements  and 
preparations      for, 
807 
(See  .S'h/y/cc//,  (il»!li'lrii-.\ 
Ophthalmia  neomUorum.  847 
etiology,  847 

pathological  anatomy.  848 
prognosis,  symptoms,  and 
treatment,  848 
"Organ  of  Uoseumiiller,"  02 
Organs,  digestive,  in  the  puer- 
periuni.  O'll 
generative,    congenital,   de- 
fects  of.  in   female 
(4iildreu,  .")08 
hemorrliage  from,  85:, 
female,  anatomy  ol'.     (Sec 
AiKiliniii/.) 
external,  80 
intermediate,  42 
int(>rnal,  45 
pelvic  nerves  of,  04.  Oi 
physiology  of.  70 


7 


(Sco 


2.-M, 


Lriun.  1^-1" 

Jatoiny.  S4S 
liiloins,  iiiitl 
In.  SIS 
liilkT,"  t>-^ 
li  the  l>iit-'i- 

lenital,   <1«.- 
in   t'l'iiiaU' 

Itl-DlU,  S.>.' 

Iv  Ol".      1!^«->C 

•12 
l-s  of,  (>4.  t!"> 

.r,  :*• 


Oiniiiis,  gi'iuTiitivi',    iV'tal,  ox- 
U'l-iiiil,  12". 
pi'riod     (if    ilistiiu'tion, 
101,  121 
ill  till!  |)iu;i'|)i!riiiiii,  (i'>l 
iion-sexuiil,    liisuasus   of,    in 
tin*       puerpuriiiiii, 
77S 

pi'lvic,    IlOSt-pMI'tlllll    OXIIIIii- 

iiiitioii  (if,  ()(!•'> 
si'xiiiil,  (lise:i»c's  of,  (iSli 
nriimrv,  disi^iises  of  the,  7Sr> 
disorders  of,   in  preRniui- 
cv,   ll»(J 
trc'iilniiMit,  lost 
distiirliMiiiTS    of,    ill    liie 
iiew-liorn,  S."(«i 
()s,    dilaliitioii     of,     iirtillciul, 
SS2 
in    breech    prcscntulions, 

471 
ineeiiiiniiiin  of,  uftor  ni|i- 
tiire  of  nieiiibnines, 
427 
noniiiil  of,  424 
witii      originally    scanty 

waters,  42',i 
with  inidiie   ehisticity  of 
nieinhranes,  1I!0 
Os  externum,  anatomy,  48 
iiiterniiin,  48,  148 
uteri,  47 

dihitalioii  of,  artificial,  8X2 
Ossilicalion,   epiphyseal,    first 

fetal,  102 
"  Osteogenesis  imperfecta,"  308 
Ostium  alxloriiinale,  !Hi 

iiiteninm,  ')(» 
Outlet,  pelvic,  IS 

diameter    of,    antero-pos- 
terior         measure- 
ment of,  SIO 
transverse        measure- 
ment, oOl) 
dimensions  of  the   plane 
of,  1!) 
Ova,  alecithal,  77 
iiolohlastic,  77 
lilieration  of,  time  of,  71 
number   of,    in    ovaries    of 
voungfemaleohild, 
70 
Ovaries,  blood-ve8.sel8  of,  ()3 
dimensions  of,  o7 
removal  of,  in  puerperal  sep- 
sis, !)7;} 
structure,  5i) 
tumors  of,  cystic,  congenital, 

•.m 

Ovariotoniv  during  gestation, 
'I'.ll,  24!>,  .V)8 

Ovaritis,   suppurative,  hyster- 
ectomy for,  !t74 

Ovary,     diseases     of,    cumpli- 
catiiig     pregnancy, 
11)0 
tumor  of,  in  pregnancy,  24S, 
•>4'.) 

Over  distention  of  iiie  bladder. 


/.y/H'jx. 


Over-distention  of  the  uterus, 
causing  labor,  IVJO 

rupture  of  uterus  from,  (111 
Oviducts,  "i(i 

blood-vessels  of,  r)7 

nerves'  of,  '')7 

structure  of,  rifj 
Ovisacs,  number  of,  tiO 
Oviilie  Nabotiii,  19 
( )vulatioii,  70 

ill  multiple  (^inceptions.  111 
Ovum,  cell-division  of,  stages, 
77 

diseases  of  tlie,  2">2 

form  and  structure,  71 

fusion  of  speriiiato/o(">n  and, 
75 

impregnation  of,  period  of, 
177 

nintiiratioii  of,  74 

polar  bodies  of,  74 

st.!ges  of  development,  94 

villi  of,  78 
Oxygen,  source  of,  in  jilacental 
eirculiition,  139,140 

I'ai.atI';,  clel't,  congenital,  ori- 
gin, 9S  " 
Palpation,    .•ibdomiual,    deter- 
mining  involution 
of  uterus  'ly,  V.5(i 
diagnosis  by,  407 
diagnostic  signs  furnished 

by,  411 
during  labor,  3(!") 
pregnancy,  IS;} 
for    examination    of    the 
cephalic        promi- 
nence, o'j^ 
of  the  lower  fetal  pole, 

:{.")2 
of  the  upper  fetal  pole, 
;5:)4 
imj)ortance     of,    for    the 
diagnosis    of    fetal 
piesentation      and 
position,  :5")() 
lociiting  anterior  shoulder 
in  vertex  presenta- 
tions, by,  ;5")U 
dorsal  plane  and  small 
parts  by,  3")0 
pathological       condition.s 
deterinineilbv,  3")G, 
3o7 
in  placenta  previa,  oOO 
of  fel;d  presentation   and 
position,  .'?"iO 
Pam])inifi)nn  plexus,  (14 
Pancreas,  fetal,  1  IS 

chemical     substances    in, 
141 
of  tile  new-born  infant.  810 
Paradidymis,  12;> 
Paralysis,  congenital,  S22 
olistctrical,  of  the  new  iiorn, 
,S2.") 
diagnosis,  82(J 
prognosis,  82(i 
treatment,  S2t) 


!)97 

Paralysisof  prcgtmncy,79(),7!i| 
puerperal,  tit:!,  til  1,  791  794 

Parametritis,  (199 

Paraplegia  complicating  labor, 
(i4;{ 

Paroiiiihoron,  (i2,  123 

Parotitis,  congenital,  840 

I'arovai'ium,  (12 

Parturition,  rule  for  determin- 
ing date  of  ex- 
peeled,  17(i 

Pathology  of  the  new-born 
infant,  8i;!  8(i7 

1.  Medical  and  surgical  dis- 

eases incident  to 
the  hirlh  of  the 
child,  Si 3  823 

— apoplexy,  822 

— asphyxia,  813 

—atelectasis,  822 

intra-iiterine,  814 
extra-uterine,  8l"i 

— caput     sueceiianeum, 
818 

— cephal hematoma,  S19 

2.  Traumatii;  injuries  of  the 

iie\v-l)orn,  S23 
—  injuries  to  the  brain 
and  pe  r  i  p  li  e  r  a  I 
nerves:  obstetrical 
paralysis,  82-") 
— injuries  to  the  scalp, 
face,    neck,    limbs, 
trunk,  and  bowels, 
824 
— injuries  to  the  .skull 
and    other     Ixmes, 
82') 

3.  Deviations  from  some  of 

the  [ihysioiogical 
processes  which 
characterize  the 
early  lite  of  the  in- 
fanti  82(1 
— diseases  of  the  navel, 

827 
— exfoliation  of  tlie  epi- 
dermis, 8:iG 
— mastitis,  S27 
anatomical  and  physiolog- 
ical  ciinsiil(M'ations 
and     dressing    the 
navel,  827 
omphalorrhagia,  828 
— hemorrhage  from  the 
umliilical     vessels, 
S-J9 
slight      disturbances      in 
hcalini;    of    navel 
wounds,  832 
— umliilical  fungus,  S33 
umhilical-coi'd  Iiernia',833 

4.  Infections  diseases  of  the 

new-born,  S;?.") 
— wound-in  led  ion,  8.''(! 
int'ection     through     the 
umbilicus;  diseases 
of    the     umbilical 
vessels,  830,  837 


{ 

; 

:■ 
I! 


i 


1 


I 


^p 


998 


IND/'LV. 


'1 

h 


ri 

tri! 

■ 

1  •ill 

!•' 

m 

tmi 

\l^ 

i 

1  II 

■' 

1  '#1 

'B 

'  ■  ^  '9 1 

w 

1  "«-Vt 

u 

M- 

Jilr 

Fiitholofty  of  the  new-born  iii- 

I'iiiit  (iiili'i'tion  I  : 
— urifrilisuiiil  phlfhitw, 

8H7 
— gaii^Tt'iieol'tlie  imvel, 

KM 
— oiiiplialitiH,  H,'{7 
iiiffciidii       of      otiier 

wouiuIh,  8;{8 
— Hiihl's  (lisoiise,  843 
— fr_vsi|K'l!i.H,  8;{8 
— iftiTiiN    Nvriiptoiuuti- 

ciis,  8i;{ 

— la  f,'ri[)|ii',  811) 

—  mastitis,  840 

— nielt'iia  iifonatoniin, 
84") 

— opiitlialinia  nuonalo- 
rum,  847 

—parotitis,  840 

— pt'iiipliiniis,  84") 

— pi-ritonitis,  840 

— piik'giiiiisia,  840 

— sypiiilis,  84(; 

— tetanus  iiuotiatoruin, 
841 

— tiiliercnldsis,  847 

— Wiiickiil's  disc'iise, 
844 

infection  of  the  diges- 
tive and  respira- 
tory trat'ls,  SoO 

— diphtheria,  8')1 

— rhinitis,  851 

— thrnsh,  80O 

— stomatitis     aphthosa, 
8.-)0 
5.  General  and  inielassilied 
diseases,  80 1 

— eolie  and  diarrhea, 
8r)4 

— constipation,  HhCt 

— disinrliances  (>f  the 
urinary  orjj;ans,  8.'p8 

— gastro-inteslinal  hem- 
orriiaj^e,  X'>'-\ 

— hemorrhage  from  the 
female  K<^'nital  or- 
gans, 8.");i 

— hemorrhagic  diathe- 
sis, 8.")'2 

— inguinal  and  mnhili- 
cal  hernia,  858 

— intestinal  obstruction, 
857 

— peritoneal  abscess, 
858 

— phimosis,  858 

— sclerema  neonatorinn, 
851 
(5.  Hygiene  and  tlierapentics 
soon     after     birth, 
85!) 
hygiene,  85!t 

—food,  85!) 
therapeutics   and   dosage, 
8ti0 

external  remedies : 

— antiseptics,  8()0 

— astringents,  8(30 


Pathology  of  the  new-born  iii- 
fantltheriipeuticHi : 
— couuter-irritaiitN,  siiO 
—heat  and  cold,  8ti0 
internal  remeclies: 
— alteratives,  8(il 
— antipyretics,  Stil 
— antispasmodics,  8(11 
— digestives,  etc.,  801 
— diuretics,  8(>1 
— hemoslalics,  H&2 
— laxatives,  Mil 
— nerve-sedatives,  8tll 
— iniiricnts  and   tonics, 

8(iO 
—   timidants,  8()1 
7.  I'remuture  iiifants,  8G'J 

Pathology  of   pregnancy. 

(See  Priijnniicij,  ah- 
imniKil.) 

of  the  puerperium.    (See 

I'litrpiiimn,  fmlhd- 

'>!/!/  "/■  I 
Patient,  tiie,  antisepsis  of,  345, 

:M() 
Pellicle,  kiestein,  lot! 
Pelves,    deformed,    fre(|uency 
of,  4i»8 
indications  for  svmphvsi- 
otomy  ill,!)!  I,  iil'2 
in  breech  presentations, 
470 
Pelvic   floor,  injuries   to   the, 
l)revenlion  of,  3t)(t. 
(See  /V/c/.x.) 
])ri'sentations,   diagnosis    of, 
by  palpation,   409. 
(See  IWnfiildliiiii.t.) 
Pelvimeters,    tvpes    of,     ;i(il, 

500-509 
Pelvimetry,  500-509 
I'elvis,  anatomy  of,  17-3(;,  388 
anomalies  of,  due  to  diseases 
of     the     suhjacent 
skeleton,  540 
antero-posterior  section   of, 
diflerenees  between 
the    male   and   fe- 
male, 3!li) 
articulations  of,  22 

changes    in,  due  to  preg- 
nancy, 150 
relaxation  and  ruptiu'eof, 
t>40 
bones  of,  diseases  of  the,  531 
cavity  of,  19 

measurement  of,  509 
conjugate    of,    for    internal 

version,  948 
contracted,    arrest    of    lie;id 
due   to,  in    breech 
presentations,  487 
management  of  labor  ob- 
structed     by      the 
commonest     forms 
of,  543 
coxalgic,  540 

diameter,  conjugate,  in  Ce- 
sarean section,  918 


I'elvis,    <liaineter,     plane     of 
least,  18,  19 
diameters  of,  relative  value 
of.as compared  with 
the     (liamelers    (if 
the   fetal  head,  4U4 
measurements  of,  20 
external,  35K 
of  inlet,  501,  507-509 
of  outlet,  509,  510 
vaginal,  358 
deformities     of,     producing 
face   presentations, 
459 
excavation  of,  anatomy,  394 
expansion,  plane  of  greatest, 

l.s,  19 
false,  anatomv  of,  389 

delincd,  18' 
fascia'  of,  29 

female,    abnormalities     in, 
varieties  of,  510 
anomalies    of,     classifica- 
tion, 499 
diagnosis,  500 
characteristics  of,  21 
dimensions  of,  21 
felal  or  inideveloped,  517 
tiat,  simple,  510 

characteristics,  510 
etiology,  510 
diagnosis,  51 1 
inlluence  on  labor,  51 1 
generally-contracted,  non- 
rachitic, 51() 
characteristics,  510 
diagnosis,  510 
etiology,  510 
rachitic,  characteristics, 
522 
floor  of  the,  .30 

blood-vessels  of,  35 

nerves  of,  30 

prevention  of  injuries  to, 

3t)9 
veins  of,  3() 
form    of,   influences  of  race 

on,  22 
fractures  of,  531 
inlet  of,  diameter  of,  antero- 
posterior, 501 
diameters  of,  obli(pie,  509 
transverse,  507,  508 
justo-major,  521 
diagnosis,  521 
justo-minor, 
characteri.- 
diagnosis,  •«■.- 
etiology,  515 
influence  (m  lali'  :  of,  ' '  > 
kyphoscoliotic,  540 
kyphotic,  537 

characteristics,  537 
diagnosis,  539 
frequency,  539 
influence  on  labor  of,  539 
male  and   female,  anatomi- 
cal ditlercnces   be- 
tween, 398 
Naegele,  518 


I 


T 


INDEX. 


909 


of 

ItlllU 

with 
(  of 
.404 


r)09 


ilions, 

y,  :w4 

I'utcst, 


I'S      in, 
issilii'ti- 


21 

,517 

■)10 


r,  nil 
tell,  non- 
10 

.•s,  510 
0 

iteristiw, 


J5 

liiries  to, 

(it'  nice 


|f,  aiitero- 
501 

Ihine,  50'.! 
")0H 


I 


87 


I)!-  O 


i;  5;5u 

iiiiiitoini- 
be- 


■omes 


Pelvis,  narrow,  funncl-shnpeil, 
r,l7 
diuKiioHin  of,  olT 
iiilluciicii   on    liilior   of, 
-)17 
olili(|iit'ly coiitriictt'fl,  olS 
clmrin'liTiHtics,  ")I8 
(liii^'niMiH,  '>IU 
elioloifv,  MM 

inlliionco    on   labor  of, 

pro)?nosis,  ^'JO 
trc:itincnt.  o'JO 
(mti'oinalacic,  ^'iO 
(lintfiioHis,  ')2H 
infliieiicf  on  lalior  of,  o'J'.l 
ontli'i  of,  diameter,  antero- 
poHlerior,  oiO 
IransviTHe,  50SI 
posilion  of,  'JO 
"  lisendo-oHteoinalaoiu,"  5'22, 

524 
rachitic,  522 

eliaracteristirs,  522 
diiiKnosiM,  521 
jjenerallv       e(|Maliv  -con- 
tracted,  521' 
influence  on  labor  of,  520 
Robert.  521 
scoliotic,  5.'1'J 
split,  522 

sponilylolisthctic,  5,'12 
cbaracleristicH,  5152 
diiiKuosis,  5115 
eiiolojry,  5.'14 
iiilliienee  on  labor  of,  5150 
strait  of  iIk!.  inferior,  anato- 
my, ;!H2 
superior,  anatomy,  lillO 
transversely -contracted,  521 

treatment,  521 
true,  anatomy  of,  390 
delined,  IM 
dimensions  of,  21 
nnisdcs  of,  20 
lumors  of,  5,'iO 
"  I'elvis  plana,"  of  Deventer, 

51(» 
I'elvis  spinosa,  5,'{() 
I'empbiijus,  fetal,  HOi) 
neonatorum,  845 
etiolofiy,  H45 
treatment,  840 
I'enis,   lelal,  development   of, 

124 
lVptt)ne  in   toxemia  of  prej;- 
naney,  absence   of, 
205 
PeptoiuM'ia  in  pregnancy,  2.'13 

of  the  puerperium,  ()50 
Perforator,   scissors,    Harnes's 
t»;{0 
Naegele's,  VM) 
Pinard's,  WM) 
Simpson's,  930 
Smel lie's,  IHIO 
Perforators,  types  of,  928,  930 
Pericarditis,  (i9(> 
symptoms,  703 
treatment,  731 


Perimastitis,  coiiKeidtal,  841 
"  I'erineal  shelf,"  32 
Perineum    (I'cmale),  structin-e 
of,  31-35 
injuries    to    the,    following;  ' 
labor,  073 
causes  of,  074 
sympionis  ot',  ti75 
treatiiienl  of,  070 
Peritoneum,    pelvic,    changes 

in,  149,  150 
Peritonitis,  cougenital,  840 
ttyniptoms  and  treatment, 
840 
during  pregnancv,  200 
fetal,  3(19 

in  retroversion  of  uterus,  194 
puerperal,  095 

prognosis,  702,  703 
symptoms,  701 
treatment,  720 
ver.iion  in,  200 
Pessary,  use  of,  in  retroversion 

of  uterus,  194 
Plinntoin,  pregnancy,  2."il 
Phenomena,  mental  and  emo- 
tional, due  to  preg- 
nancy, 170 
of  utero-gestation,  classiliea- 
tion,  170 
Phimosis  in  the  new-born,  858 

treatment  of,  859 
Phlebitis,  090 
treatment,  733 
mnbilical,  837 
uterine,  diagnosis,  705 
symptoms.  704 
treatment.  733,  734 
Phlegmasia  alba  dolens,  097 
symptoms,  703 
treatment,  733 
congenital.  840 
Piiysician,    visits    of,    in    the 
puerperium,  057 

Physiology  of  the  female 
generative      or- 
gans, 70-74 
of  labor.     (See  Liilinr.) 

of  the  new-bom.     iSee 

Xi'ir-lxini  liij'iiiil.) 

of  pregnancy,  74-159 
of  the  puerperium.    (See 

I'lti'riuriiim. ) 
Pliysometra,  273 

siimdatiug  pregnancy,  17.3 
PiginentatioTi,  skin,    in    i)reg- 

nancy,  150 
Placenta,  anatomy  and  physi- 
ology, 80 
anomalies  of  the,  257 

when  j)ra'via,  5.s7 
aj)oplexy  of  the,  250 
attachment     of,     in     extrM- 
uterine  pregnancv, 
283 
at  term,  size  and  shape,  90 
blood-vessels  of,  8!»,  90 
calcareous   dcgeneratiiai  of, 
255 


Placenta,  detachnipnt  and  ex- 
pulsion of,  440 
diseases  of  tbe.  255 
expression  of,  715 
('redi'''s,  377,  378 
fatty  degeneration  of,  250 
fetul,  in  extra-uterine  preg- 
nancy, 280 
implantations    of     the,    in 

pra'via,  584 
location  of,  by  palpation,  35(i 
maternal   attachment   ol',  in 
tidial      pregnancv, 
281 
myxoma  of  the,  254 
retention     of,    complicating 
labor,  571,  572 
cnreftage  I'or,  873 
of    portions    of,    causing 
hemorrhage,  7.'>9 
separation     of,     premature, 

causes,  590-598 
structure  of,  90 
syphilis  of,  257 
tumors  of  the,  257 
villi  of,  90 
"  I'lacenta  mend)ranacea,"  258 
I'lacenta  |)ra'via,  581 
causes  of,  587 
fre(piency,  580 
induction    of    premature 

labor  in,  .s7it,  sso 
intracervical    tampon    in, 

874 
prognosis,  591 
symptoms   and  diagnosis, 

589 
treatment,  592 
varieties  of,  584 
Placenta',  fetal,  twin,  143 
Placentitis,  255 
Pleurisy,  puerperal,  090 
symptoms    and     prognoses, 

703 
treatment  of,  730 
Pneumonia  complicating    la- 
bor, ()44 
during  pregnancy,  244 
progniisis,  245 
treatmeni,  245 
fetal,  sypliililic,  298 
puerperal,  781 
svmptoms  and  ])rognoHis, 

703 
treatment  of,  73(1 
Poisons,  toxemic,  of  pregnan- 
cy, 20:! 
Polydramnios,  253 
Polygalactia,  772 
Polvhvdranuiios,  pathology  of, 
253 
symptomatology,  253 
treatment,  253 
Polymazia,  740 

Polvpi  complicating  labor,  558 
Polythelia,  740 
Position,    fetal,    abbreviations 
used   to  designate, 
387 
classification,  387 


y 


S     ! 


1000 


INDEX. 


Position,  fetal,  defined,  386 
diii^nosis  of,  by  imlpution, 
409 
in  vertex  presentations, 
422 
etiology  of,  in  vertex  pres- 
entations, 422 
prognosis    of,    in    vertex 
presentations,  423 
Position,  obstetrie,  for  ajjplying 
forceps  in  ilie  low 
operation,  .S!)3 
Positions,    left-anterior,     me- 
elianisni  of,  in  ver- 
tex    presentations, 
44!t 
right-posterior,    niechanisni 
of,  in  vertex  pres- 
entations, 442 
posterior,   delivery    in    per- 
sistently, 457 
labor  in,  management  of, 
449 
relative    frequency    of,     in 
brow  presentations, 
4G(i 
in  face  preseiitations,4r)S 
Post-mortem  changes  of  fetus 

in  iitero,  312 
I'ostiire   and    bearing   of   the 
jjregnant     woman, 
202 
for    operation    of    internal 
version,  !)oi)-9()3 
"  Poucli  of  Douglas,"  o4 
Pouch,  vesico-uteriiie,  o2 
Pouches,  pharyngeal,  113 
Pregnancies,  twin,    frequcncv 
of,  142 
proportii)!!    of   sexes    in, 
143 

Pregnancy  (abnormal) : 

accidents  during,  24.S 
acute  aflections  during,  239 
atleclions  of   the   i''allopian 

tubes  in,  249 
all>iuninuria  in,  233 
appendicitis  in,  2.'S3 
a.sciles  complicating,  231 
blood  during,  abnormal  con- 
ditions of,  23") 
cancer  coniplicatiuu:,  241 
••ariliacdi'^ease  complicating, 

237 
i'atalepsy  (hiring,  217 
cereljral      thrombosis      and 
hemorrhage      dur- 
ing, 212 
"cervical,"  2(>2 
I'holcr.i  complicating,  24") 
chorea  diu'iug,  214 
<lealh  (luriui;,  sudden,  212 
(liabcti's  complicating,  218 
<liscascs  <'omplicating,  185 
ilisorders  of,  general,  19(1 
erysipelas  complicating,  212 
eruptive  disoases   in,   inllii- 
ence     of,     on     the 
fetus,  290 


Pregnancy  (abnormal) : 
extra-uterine,  273 
classitication  of,  278 
conditions  simulating,  174 
diagnosis,  173,  28(3 
mistakes  in,  174 
etiology,  277 

extraperitoneal      evacua- 
tion   of   gestation- 
sac,  294 
after-treatment  of,  295 
rupture    of   gestation-sac, 

285 
tinnors  simulating,  287 
operation  in,  291 

after       mununitication, 
etc.,   of   the   fetus, 
295 
after  rupture  of  gesta- 

tion-.sac,  292 
pre|>aration  for,  289 
symptoms,  284 
treatment,  288 
tubal,  280 

intraperitoneal         rup- 
ture, treatment,  288 
tubo-uterine,  281 

rupture  of  gestation-sac 
in,  281 
the  fetus,  282 
fil)roids  complicating,  185 
gastric   nicer   complicating, 

232 
general    accidents    and   in- 
juries during,  249 
goitre  during,  235 
gonorrhea  of,  239 
hemorrhage,  concealed  acci- 
dental, 200 
from  uterus  during,  238 
hemoptysis       comiilicating, 

■  238 
herpes  of,  211 
hysteria  during,  221 
measles  iiompiicaling,  243 
insanity  of,  797 
interruption   of,    in    cardiac 
diseases,  042 
in  eclampsia,  (135 
jaimdice  complicating,  232 
nuuiia  complicating,  222 
meningitis  during,  213 
molar,  254,  312 
]ieptonuria  in,  233 
jieritonitis  during,  200 
placi'Uta  [jra'via  of,  581 
plin-al,       predisposing       to 

eclampsia,  (131 
pneumonia  during.  244 
pi'uriius,  idiopatliic,  compli- 
cating, 220 
salivation  of,  2I(( 
scarlatina  complicating,  243 
spleen    in,    hvpertropliv  of, 

155  ■ 
surgical    operations  during, 
218.    (See  Snnji'nj.) 
sy])hilis  during,  210 
tet!inii.>  complicating,  24(1 
tct.iuy  complicating,  24(1 


Pregnancy  (abnormal) ; 
toxc'nia  of,  202 
transmission    of    infections 

to  the  fetus  in,  29(1 
tumoi-s    complicating,    248, 

249 
tyi)hoid  complicating,  241 
variola  complicating,  244 
(>See  I'rej/iianci/,  pathology  of.) 

Pregnancy  (normal) : 

abdominal  changes  due  to, 
KIO 
walls,  changes  in.  due  to 
pregnancy,  151 

blood,  condition  of,  154 

breasts  of,  hypertrophy  of, 
152 

cervix  in,  livpertrophy  of, 
14(5" 

circulatory  system,  changes 
in,  thie  to,  153 

corpus  luteum  of,  01 

decidua  vera  of,  319 

diagnosis   of,    157-179.  183, 
184 
diflerential,  171 

duration  of,  170-178 

evidences  of,  positive,  171 
presumptive,  171 
probable,  171 

female  external  genitals 
during,  changes  in, 
150 

heart  hyj)ertrophy  in,  154 

llegar's,  sign  of,  104 

hygiene  of,  180 

innervation  of  the  uterus  in, 
320 

kidneys  during,  197 

length  of  fetus  at  various 
periods  of,  103 

liver  of,  hypertrophy  of,  155 

nuunmarv  changes   during, 
"101 
glands  of,  changes  in,  151 

nuuiagcment  of,  180-183 
dietetic,  180 
medicinal,  183 

(See  MniHii/nne)!!.) 

maternal  organisms  in,  gen- 
eral    changes     in, 
153 
local  changes  in,  115 

mental  I'ondition  duritig,IS2 

menstruation  during,  72 

moi'bid  conditions  simulat- 
ing, diliereiitiation 
of,  172,  173 

mouth  and  teeth,  duriui;, 
abnormal  condi- 
tions ol',  233 

nniltiple,  determination   of, 
by  abdominal   (lai- 
pation,  357 
diagnosis,  171 
physiology,  M2-145 

nausea  and  vomiting  of,  155, 
159.  222 
treatment,  183 


T  f 


INDEX. 


1001 


I're{);n!incy  (normal) : 
nervous  system  in,  changes 
in,  loy 
disorders  of,  208 
neuralgia  of,  20S 
nipples  of,  livpertrophv   of, 

153" 
pelvic  articulations  during, 

changes  in,  150 
phantom       ( pseudo-cyesis), 

231 
physiology  of,  74-159 
presence  of  chorionic  villi, 

evi(leni:e  of,  80 
prior,  diagnosis  of,  175 
prognosis  of,  complicated  by 

tumors,  252 
prolongation  of,  178 
res|iiratory  changes  in,  155 
signs  and  symptoms: 

— abdominal     changes, 

lt)t) 
— ballottement,  lOO 
— clahsilication  of,  170, 

171 
— disturbances    of    the 
bladder,  functional, 
1(;2 
—  evidence  of  prior,  175 
— evidences    of    extra- 
uterine pregnancy, 
173,  174 
— evidences    of    mulli- 

|ile,  174 
— fetal  contour,  170 
— fetal       heart-sounds, 

108 
^intermittent  contrac- 
tions, 1()7 
— intrapel vie  signs,  103 
— uuimmarv      changes, 

Kil 
— menstrual       suppres- 
sion, lliO 
— mental  and  emotional 

piienomena,  170 
— morbid        conditions 
simulating,       '72, 
173 
— muisca  and  vondiing, 

l.V,* 
— ((uickening  and  fetal 

movements,  l{i7 
— relative    value  of,  in 
{loint  of  diagnosis, 
171 
— uterine  K'^nJHe,  l(iS 
skin,  gait,  and  osseous  ele- 
ments, chauges  in, 
15(; 
suckling  in,  77() 
termination  of,    by    nipple- 
iiivagination,  748 
chief  factors  in,  318 
twin,   dctcrmiiiaticin   of,   by 
alidomiiial     palpa- 
tion, 357 
umbilical    changes   due    to, 

151 
urinary  changes  in,  15i) 


Pregnancy  (normal) : 

uterine  i-avitv  din'ing,  shape 

^  of,  420,  421 
uterus  in,  changed  position 
of,  1(!5 
changes  in  the,  145 
conditions,     pathological, 
during,  185 
vagina  during,  changes  in, 
150 

Pregnancy,  pathology  of, 

185-1% 

1.  Uterus     during,     patho- 

logical condition  of, 
185 

— bacteria  in  the  genital 
tract,  193 

— diseased  coiulition  of 
the  ovary,  compli- 
cating,' pregnancy, 
190 

— diseased  conditions  of 
the  vagina,  193 

— disorders  of  the  vulva, 
191 
I  — displacements    of    the 

'  pregnant       uterus, 

193 
!  — end<mietritis        during 

pregnancy,  189 
!  — epithelioma  of  the  cer- 

vix, 188 

• — hvpertropliv  of  the  de- 
cidua,  "189 

-  mvomata  of  the  uterus, 
185 

— salpingitis  during  preg- 
nancy, 190 

— spontaneous  rupture  of 
uterus,  189 

2.  General  disorders  of,  196- 
239 

— abnormal  conditions  of 
the  blood,  235 

--abnormal  conditions  of 
the  mouth  and 
teeth,  234 

— acute  vellow  atrophv  of 
the  liver,  232 

— albiuniiniria  of  preg- 
nancy, 233 

— a|>peiulicitis  of  preg- 
nancy, 233 

— ascites  of  [jregnaucv, 
231 

— cardiac  diseases  compli- 
cating pregnancy, 
237 

— catalepsy  during  preg- 
nancy, 217 

— cerebral  thrombosis  and 
hcMioirhageiliU'ing 
prcuTiaiu'v,  212 

— cliDiva  (luring  preg- 
niuicy,  214 

— comcaicd  accidental 
lu'iniirrhage,  21)0 

~dial)cti's  'iiriiig  [ircg- 
na'icy,  219 


preg- 
preg- 
preg- 


Pregnancy  (pathology  of) : 
— exophthalmic  and  sim- 

j)le  goitre,  235 
—gastric   ulcers  of  preg- 
nancy, 232 
— hemoptysis         compli- 
cating   ])regtuuicv, 

23S 
— hemorrhage    from    the 

lUerusdiM'ing  preg- 

luuicy,  238 
—  herpes    of    pregnancy, 

211 
— hysteria   during 

nancy,  221 
— kidneys    during 

nancy,  197 
— mania     during 

nancy,  222 
— maternal      impressions 

(luring  pregnane V, 

213 
— meningitis  during  preg- 
nancy, 213 
— nausea    and     vomiting 

during  pregiuuicv, 

222 
— neuralgia  of  jjregiiancv, 

208 
— peptonuria     of      preg- 

iiaiu'y,  233 
— peritoiutis  during  preg- 
nancy, 2(10 
— l>osture  and  bearing  of 

the    pregnant   wo- 

iu;m,  202 
— l)riM'itus,i(liopatliic,(iur- 

iug  pregiumcy,  220 
— pseudo-cyesis   of    ju'eg- 

naiicy,  231 
— relaxation  of  the  pelvic 

ligamcTits,  202 
— salivation  of  pregnane v, 

210 
— spinal  irritation  com])li- 

caling    labor    anil 

pregnancy,  213 
— suppurating  hydatid  of 

the  abdomen,  199 
— sudden     death    diu'ing 

pregnaiu'v,  212 
— toxemia  of  preirnaiicv, 

202 

3.  Acute    infectious  during, 

239  -247 

—  cancer,  211 
— cholera,  245 
— erysipelas,  212 
— gonorrhea,  239 
— measles,  24;') 

-— pnciuiiouia,  244 

— scarlatina,  243 

• — svphililic     infection, 

'  240 
— tetanus,  24t) 
— tetany,  2ll> 

-  tvpliiiid  inlci'tiim,  241 
—variola,  214 

4.  Accidents     and    surgical 

opcratioiis,2  18-252 


^1 


r- 

u 
I 

If;. 

ft 


^.\ 


ll 


f! 


I! 


% 

■vS 


I 


1002 


INDEX. 


Pregnancy  (pathology  of) : 

— accidents  and  in- 
juries, 249 

— aflections  of  the 
Kallopiun  tubes, 
241> 

— amputation  of  tiie 
uterus,  248 

— niyoniectoniy  and 
myotomy,  248 

— tumors  of  the  ovarv, 
248 

5.  Diseases    of    the    ovum, 

2o2-2oit 
of  the  amnion,  2oo 

— adhesions  and  bands, 

253 
—polyhydramnios,  253 
of  tiie  chorion,  254 

— myxoma  and  vesicu- 
lar mole,  254 
— oligohydramnios,  254 
decidual  endometritis,  255 
of  the  placenta,  255 

—  anomalies  of  tiie  pla- 

centa, 257 
— apoplexy,  250 
— calcareous  degenera- 
tion, 255 
— fattv      degeneration, 
2r)() 

— placentitis,  255 

—  syphilis,  257 

—  tumors,  257 
anomalies  of  the  cord,  258 

--coils,  258 
—knots,  258 
— stenosis,  25S) 
— torsions,  25St 

6.  Abortion,  251)273 

— clinical  history,  2(52 

— diagnosis,  2ti4 

— definition,  25'.* 

— etiology,  2()0 

— fre(jucncy  of,  25'.t 

— missed   abortion  and 

missed  labor,  272 
— fiatliology,  21)1 
— ])rodi'omal  svmptoms, 

2ti:J 

—  prognosis  and  seque- 

lip,       ~ 
— time 

2(i0 
— treatment,  2()(! 

7.  Kxtra-iilcrinc,  27:5-295 

— diagnosis,  2S(i 

— etiology,  277 

— ex  tra-peritonetil  evac- 
uation of  gcstation- 
siic,  294 

—fetus,  the,  282 

— history,  273 

— operation  after  mum- 
milication,  calcifi- 
cation, etc.  of  fetus, 
295 

— preparatioii  for  ope- 
ration, 289 

— symptoms,  284 


205 

of   occurrence, 


Pregnancy  (pathology  of): 

— symptoms  of  rupture, 

285 
-treatment,  288 

— treatment  after  rup- 
ture, 292 

— treatment  at  the  time 
of  rupture,  288 

— treatment  before  rup- 
ture, 288 

— tubal  pregnancy,  280 

— tubo-uterine  or  inter- 
stitial gestation,281 
8.  Diseases  of  fetus  in  utero, 
295-299 

infectious:  eruptive, 
295,  29() 

— erysipelas,  297 

—measles,  29(5 

—scarlatina,  290 

— syphilis,  297 

— tubercidosis,  297 

— variola,  297 

deformities  and  malfor- 
mations, 299- 

— amniotic  l)ands,  299 

— congenital  defects  of 
the  generative  or- 
gans in  female 
children,  308 

— congenital  luxations, 
301 

— congenital  tumors,301 

^leformities  of  the 
lace,  302 

^leformitics  of  special 
regions  ;md  organs 
of  the  body,  302 

— double  formations, 
305 

—excessive  develop- 
ment, 3t'"> 

— intra-uteri.ie  frac- 
tures, 300 

— mall'orniations  of  the 
bniin  and  cord,  304 

— mall'ormatioiis  of  the 
circulatory  ap[iar- 
atiis,  304  ■ 

— malformations  of  the 
extremities,  304 

— midtbrmations  of  the 
stoniach,  303 
materuiil  iriipressions,  305 
intra-uterine    diseases   of 
bones,  307 

— Hidiler's  disense,  308 

—fetal  rachitis,  307 

—  Miilier's  disease,  309 

—Schmidt's  (liscase,308 
intni-uterine    diseases   of 
the  siuii,  etc.,  309 

— anasarca,  309 

— |)einphigiis,  309 

— peritonitis,  309 

—tumors,  309 
struma,  309 

intra-uteriiic  disea.scs  of 
the  nervous  system, 
309 


Pregnancy  (pathology  of) : 
— cretinism,  310 
— hydnx'ephalus,  310 
— syphilitic  idiocy,  310 
sudden  death  of  the  fetus, 
320 
post-mortem      changes, 

812 
— calcification,  318 
-  maceration,  313 
-mummification,  313 
— putrefaction,  3i;> 
— saponification,  318 
— suppuration,  313 
Prepntium  clitoridis,  38 
Presentation  and  position,  di- 
agnosis, 350 
during  labor,  3(i5 
abdominal  palpation,  im- 
portance    of,      for 
diagnosis  of,  350 
cephalic.     (See  Virtrr.) 
classification  of,  380 
diagnosis   of,  by  palpation, 
408 
differential,  bv  palpation, 
409 
defined,  885 
etiology  of,  418 
fetal    moveinents,    influence 

of",  on,  421 
frequency  of  each,  41(),  421 
infitience    of   gravity,    418, 

421 
natur:il,  380 
normal,  880 
relative   freciuency   of   four 

])ositions,  417 
summarv  of  signs  of  each, 

'414 

vertex,  changed  to  a  breech 

by    version,  o[)cr!i- 

tion,  947 

condilionsinlluencing,  421 

contact     between     breech 

and  fundus,  438 
descent  of  fetus  in  .second 
stage  of  labor,  4."1 
determination   of,  during 

labor,  800 
diagnosis  of,  by  palpation, 
408 
bv  vaginal  examination, 

414 
ditierential,    by    palpa- 
tion, 409 
of  position,  422 
freiiiiency  of,  417,  421 
gravity  in,  force  of,  432 
infhamce  of,  4 IS,  421 
intra-uterine      fluid-pi'cs- 

sures  in,  433 
irregular  shape  of    fetal 

skull  in,  433 
locating  anterior  shoulder 

in,  353 
management  of  labor,  pos- 
terior positions,  1 19 
mechanism    of    hibor,    iu 
second  stage  of,  4.'!0 


Ti, 


\f 


Presentation,  vertex,  mechan- 
ism of  Ict't-iinterior 
(msitioHK,  44'.> 
of  rifjlit-posterior  posi- 
tions, 442 
position  in,  diagnosis,  422 

etiology,  422 
positions,  387 
prognosis  of,  41G 

of  fMisition,  423 
rotation  in,  435 

mechanism  of,  438 
nnccjual    lengtlis    of    the 
ends   of  tlie    liead 
in,  432 
Presentations  (al)nornial),  386 
breech,   a]i|>lication  of   for- 
ceps  in   the    high 
operation,  902 
arrest  of  tlie  liead  at  tiie 
inferior    strait    in, 
487       _ 
at  tlie  superior  strait  in, 
484  I 

forceps  in,  48(5  ' 

due  to    contraction    of 

the  pelvis,  487  j 

from  extension,  48()         | 

closure  of  extension-ring  ; 

about  the  neck  in,  > 

484 

diagnosis,  470  I 

by  palpation,  40!'  ' 

by  vaginal  examination,  : 

41.")  j 

short  cord  in,  578  | 

diiiicult  extraction  of  head  j 

and  arms  in,  484 
etiology  of,  470  \ 

fre(|uency  of,  470  i 

nuiiiagenient  of,  474 
mechanism  of,  470 
prognosis  of,  417,  470 
brow,  application  of  the  for- 
ceps  in    the    high 
operation,  t)01 
diagnosis,  4(11) 

bv  vaginal  examination, 
415 
etiology  of,  4fiG 
fre(iuency,  4(i(j 
management  of,  4()7 
after  entrance  into  the 
pelvis,  4i)!) 
mechanism  of,  4tit) 
moulding  of  fetal  head  in, 

4titi 
prognosis,  417,  4('p(i 
treatment,  operative,  4(19 
face,  application  of  the  I'or- 
cei)s    in    the   high 
oi)eration,  901 
at  the  brim,  operative  in- 
terference  in,  4(13, 
4(14 
diagnosis  of,  459 

by  vaginal  examination, 
415 
etiology  of,  458 
frequency,  458 


INDEX. 


Presentations,  face,  low,  chin  | 

anterior,     manage-  ! 

ment  of,  4(14  , 

chin  posterior,  manage-  I 

meat,  4(15  j 

mat  agement  of,  4(i2  i 

mechanism  of,  458 

of  posterior,  M.  O.   P.,  ' 

4(12  ! 

of  M.  L.  A.,  1(10  ' 

moulding  of  fetal  bea<l  in  ! 

delivery  of,  4(il         ^ 

normal  labor  in  manage-  ! 

ment  of,  4(13  ■ 

obliquity  or  abnormality  | 

producing,  458  j 

operative  treatment,  4(54, 

4(15 
pelvic    deformities    pro- 
ducing, 459 
prognosis,  41(1,  459 
tight    adaptation    in   the 
posterior   positions 
producing,  459 
tumors  in  the  brim  pro- 
ducing, 459 
undue  length  of  the  hind- 
head       producing, 
458 
footling,  mechanism  of,  487 
hand  or  a  foot,  diagnosis,  by 
vaginal     examina- 
tion, 415 
in  twin  labors,  5(17-570 
of  a  hand  and  a  foot,  -M)2 
of    the   head   and    a   hand, 
492 
j)rognosis,  492 
treatment,  492 
of  the  knee  and  elbow,  diag- 
nosis,   by    vaginal 
examination,  410 
])elvic.     (See  Jirarli.) 
transverse,  487 
diagnosis,  488 
by  palpation,  409 
by  vayinal  examination, 
4U1 
etiology  of,  487 
fre(|uency  of,  487 
management  of,  489 
mechanism  of,  4>.8 
neglected,    treatment    of, 

492 
prognosis.  417,  488 
version  in,  48>l 

internal  podalic',  190 
inmatural,  3S(1 
Pronucleus,  female,  75 

male,  7t) 
Prophylaxis  nf  labor  in  poste- 
rior positiimsiif  the 
vertex,  149 
Provertebric.  SI 
Pruritus  of  the  vulva,  191 
treatment.  192 
idiopathic,         cmiiplicating 
prcLTiiancv,  'J'JO 
treatment.  2211.  221 
Pseudencephalus,  .'!(i| 


1003 


Pseiido-cyesis,  231 

simulating  pregnancy,  173 
F'tomaVnes  in  toxenda  of  preg- 
nancy, 204 
Pubic  section.    (See  Si/mplnjiii- 

(itomy. ) 
Piidendimi,  37 
Puerjieriiim,  the,  (149  80(1 
celiotomy  for  sepsis  in  the, 
"9(18-970 
curettage  in,  873 

indications  for,  872,873 
chill  of,  post  partiim,  (149 
condition  of  the  parturient 

tract  in,  (151 
contractions  in,  uterine,  (151 
death   in,  rapid  or  sudden, 

801  80(1 
diagnosis  of,  (15(1 
digestive  organs  during,  (iol 
embolism  in,  790 
hemorrhage  in,  738 
cerebral,  in,  790 
insanity  of,  798 
involution  during,  052 
lactation  din-ing,  (154 
lochia  of  the,  (154 
loss  of  weigiit  during,  (150 
passing  the  catheter  (luring, 

(1(10,  8(18,  8(19 
pulse  during,  (149 
secretions  and  excretions  of, 

(150 
sepsis  in  tlie,  celiotomy  for. 
908-970.     (See  [,i- 
fiction.) 
temperature     during,    (149, 

C50 
uterine   muscularis   during, 

(153 
uterus  during,  (151 
changes  in,  (152 
contractions  of,  (151 

Fuerperium,  management 

of,  (157  (171 
— after-pains,  (158 
— asepsis,  (158 

-  diet,  059 

— evacuation     of     the 

bowels.  (1(10 
— lactation,  (1(11 
— physician's  visits,  (157 
— posture.  (157 

-  regidatioii,  (1(13 

-  rest,  (157 

— retention  of  urine.  (159 
— special        directions, 

(1(53 
— tiirdy  involution,  0112 
^nse  of  the   catheter, 

(160 
— veutilation,  ()V,» 
care   of    the    new-born 

infant.  (1(14 
^biithiiig,  tH15 
— clothing,  (Itid 
—feeding,  artificial,  668 
— nursing,  (107 
— wet-nursing,  (168 


■J 


I     t 


;:': 


1004 


INDEX. 


m 


I 


Puerperium,  pathology  of, 

072 
injuries  to  the  external  geni- 
tal  organs   Ibllow- 
ing     labor,      672- 

— Iieinatonia, 
— injuries  to  tlie  peri- 
neum, (173 
-  injuries  to  the  vagina, 

(178 
— injuries  to  the  vulva, 
'()72 
diseases  of  the  sexual  organs, 
()83 
puerperal  infection,  ()83 
etiology,  ()87 
mortality,  093 
pathology.  094 

ac'utest      septioemia, 
<)97 
— eellulitis,  OOr) 
-encloiiielritis,  094 
— lymphangitis,  095 
— ui'.'tritis,  094 
— oiiphorilis,  095 
-  peritonitis,  095 

—  phlebitis,  090 

— pleurisy  and  pericar- 
ditis,' t!9() 

— salpingitis,  09o 

— vulvitis   and   vagini- 
tis, 094 
symptoms,  diagnosis,  and 
prognosis,  (i98-708 

— absi'ess  and  ditl'use 
cellulitis  of  the 
limbs,  707 

— actitest  septicemia, 
70S 

— arthritis,  707 

—cellulitis,  099 

— endocarditis,  706 

— endometritis  and  me- 
tritis, 099 

— hepatitis,  706 

—  lymphangitis,  700 
— nephritis,  70() 

— nervous  disturbances, 

700 
— pericarditis,  703 
—peritonitis,  701 
— phleliiiis,  uterine,  704 

—  phlegmasia  alba   do- 

leiis,  70;{ 
—pleurisy,  703 
— ]ineumonia.  701! 

—  salpingitis  and  oopho- 

ritis, 099 
— skin  diseases,  707 
— splenitis,  7(l(i 

—  vidvilis   and    vagini- 

tis, 09S 
treatment.  7(IS 

1.    prevention   of  puer- 
peral   infection    in 
iiosjiitals,  710 
disinl'cction,  71  "J 
— antiseptic  conduct  of 
labor,  7 1 4 


Puerperium,  pathology  of: 

— disinfection  of  the 
doctors  and  luirses, 

7i:{ 

— disinfection  of  the  in- 
struments, 714 

— disinfection  of  the 
materials,  714 

— disinfection  of  the 
patient,  713 

2.  prevention  of  puer- 

peral infection  in 
l)rivate  practice, 
717 

3.  curative  treatment  of 

puerperal     infec- 
tion, 719-734 
--acutest      septicemia, 
734 

—  arthritis,  732 

— cellulitis  and  adeni- 
tis, 725 

— encephalitis  and  men- 
ingitis, 732 

— endocarditis  and  peri- 
carditis. 731 

— endometritis  and  me- 
tritis, 721 

— enteritis,  731 

— hepatitis,  731 

— nei  hritis,  731 

—  peritonitis,  720 
— |)hlebitis,  733 
—pleurisy,  730 
— pneumonia,  730 
— skin,  732 

2.  subinvolution,  734 

3.  hemorrhages  in   puer- 

perium, 738 

—  fibroids,  743 

— hemorrhage  from 
malignant  disease, 
744 

— pelviccongestion,  744 

— rela.xation  of  the  ute- 
rus, 743 

— secoiularv  bleeding, 
744     ■ 

—  separation   or    disin- 

tegration ol'  throm- 
bi in  the  sinuses  at 
the  placental  site, 
V42 
— uterine  displace- 
ments, 741 

4.  anomalies  of  the  nip- 

ples    and    breasts, 

745 
— amazin,  74(5 
— athelia,  745 

—  mii'romazia,  740 
— microtheiia.  745 
— polymazia,  740 

—  polythelia,  74ti 

5.  diseases  of  the  nipples, 

747 
— abscess  of  the  nipple, 

751 
— eczema,  751 
— sore  nipples,  747 


Puerperium,  pathology  of: 
0.  diseases  of  the  breasts, 
751 

— abscesses  of  the  areola, 
765 

— cold  or  chronic  ab- 
scess, 706 

— congestion  and  en- 
gorgement of  the 
mammary  glands, 
751 

— fistula-  of  the  hreasts, 
766 

— galactocele,  767 

— mastitis,  756 

— milk-nodes,  706 

— parenchymatous  ab- 
scess, 702 

— subcutaneous  abscess, 
704 

— submammary  abscess, 
7(i5 

7.  arrest  of  lactation,  707 

8.  anomalies  in  the  milk- 

secretion,  768 

abnormalities  in  qual- 
ity, 768 

abnormalities  in  (|uan- 
tity,  771 

— agalactia,  771 

— conditions  interfering 
with  weaning,  777 

— galactorrhea,  772 

-  hyperlactation,  777 
— polygalactia,  772 
diseases  of  the  non-se.x- 

ual  organs,  778 
fever     due     to     causes 
other    than    puer- 
peral infection,  778 
— from  acute  constipa- 
tion, 780 
— from  emotion,  778 
— from  e.xpostu'etocold. 

778 
intercurrent       disea.ses, 

780 
— diphtheria,  781 
— erysipelas,  781 
—exanthemata,  780 
— hemorrhoids,  785 
—malaria,  782 
— pneiunonia,  781 
— puerperal  anemia, 785 
— rheuiniitism,  781 
disea.ics  of  the  urinary 

organs,  785 
— albiuninuria,  789 
— cvstitis   and   pvelitis, 

'  780 
— functional       disturb- 
ances, 785 
— hematuria,  790 
diseases  of  the  nervous 
system,  790-801 

-  acute  tympanitis.  Sd! 
— cerebral   hemonhaLie 

and  embolism  in 
the  puerperium, 
790 


78 

causes 

pntT- 

t  ion,  778 


diseases, 


"^ 


— !  ■  11 


781 
u'liiiaJS.') 

7S1 
;  urinary 

i!  78'.l 


vy 


elilis. 


ilistiirl)- 

'.10 

nervous 
k)0-80l 
jmitis,  Sdl 
}inorrliani' 

lisni    in 
leriierium. 


Piu'rperiuni,  pathology  of: 

— insanity  in  the  ciiiid- 
bearinjf  wotnan, 
794-801 

— neural     and      spinal 
afiections  following 
lalior,  7!)1 
rapid  or  sudden  deatii  in  tlie 
puerperiutn,  801 

— einliolisin  and  ihroin- 
hosis  of  the  pul- 
monary artery,  802 

— entrance  of  air  into 
the  uterine  sinuses, 
80S 

Puerperium,  physiology  of, 

()4'.)-6o(J 

— blood-vessels  of  the 
uterus,  ()5;{ 

— digestive  organs,  (i51 

— genital  organs:  par- 
turient tract,  0-")l 

— involution,  ()52 

— lactation,  <io4 

— lochia,  (l')4 

— loss  of  weight,  (>")0 

— post-partuni  chill,  (149 

— pulse,  t)49 

— reconstruction  of  the 
uterine  mucosa,  tir)4 

— secretions  and  excre- 
tions, (ioO 

— uterine  contractions, 
(iol 

— uterine      niuscularis, 

— uterus,  (552 
Pulse  of  the  new-born  infant, 
809 
puerperal,  t)49 
Purpura  luLMuorrhagica,  236 
Putrefaction,  fetal,  81;? 
Pyelitis,  78(i 

"treatment  of,  788 
Pyemia,  t)97 
Pyopagus,  T)!):? 

Pyosalpinx,  acute,   puerperal, 
variety  of,  972 

Qi'ADHiil'iJ-ns,  mode  of  origin 
of,  144 

(Quickening,  period  of,  lt)7 
time   of    parturition    deti'r- 
inincd  by,  17.S.  (See 
Fffi(.i,in(iri  nil  iil.idf, ) 

(juinin   in  treatment  of  puer- 
peral malaria,  782- 
78") 
use  of,  in  inertia  uteri,  496 

Kaciiitis,  fetal,  307 
"Rauber's  cells,"  78 
Kectocele,  otiO 

Rectum,  conditions  of,  compli- 
cating   labor,    (i.S9, 
5(50,  oOl 
malformation  of,  in  the  new- 
born, diagnosis,  857 
treatment,  857,  858 


INDEX. 


Rectum,  operations   n])on,   in 

pregnancy,  251 
Remedies  for    the   new-born, 
external,  StiO 
internal,  861 
Rejjosiiion  of  prolapsed  cord, 

575.  576 
"Rei)tilian  heart,"  304 
Respiration,  changes  in,  due  to 
pregnancy,  155 
of  new-born  infant,  808 
artiiicial,  niethoils  of,  816, 

817 
measures  for  induction  of, 
664,  ti65 
Rest  in  jiregnancy,  181 
Retroflexion  causing  abortion, 

261 
Retroversion  of  gravid  uterus, 

193 
Rheumatism.  i)uerperal,  781 
Rhinitis  in  the  new-born,  851 
Ridges,  genital,  121,  123 
Ring,  contraction.     (See  Von- 
tniclioii.) 
Mailer's,  148 
of  Band),  583 
Rotation    in    brow    ])resenta- 
tions,  461).  4()7 
in  descent  of  the  head,  512 
in  inei'iuuiism  of  face  i)res- 
enfations,  460-465 
in  seccmd  stage  of  labor, 
435 
manual,  and  application  of 
forceps,    in    poste- 
rior   positions    of 
vertex,  451 
Kug.c,  vaginal,  43 
Rupture  of  the  uteriLs,  610 
causes,  61 1 
frequency  of,  612 
from  cancer,  187,  188 
from  lil)roids,  1S6 
prognosis,  (113 
spontaneous,  189 
symiitoms,  612 
treatment,  613 
Ruptures  of  the  perineum  fol- 
lowing labor,  t!73- 
1)78 

Saliva  of   the  new-born   in- 
fant, S()9 
pre  natal,  ply.ilin  in,  141 
Salivation  of  pregnancy,   16((, 
210 
treatment,  210,  211 
Salpingitis.  ti!t5,  (199 
during  pregnancy,  190 
hysterectomy  foi-,  i)7l!,  974 
purulent,  hvsterectoinv  for, 

973 
suppurative,  indicating  celi- 
otomy, 9(1!) 
Sal|iiugo-o(")phoreclomy        tnr 
puerperal      sepsis, 
972 
iudicutions     for     (jperation, 
972 


lOOf) 


Salt-solution,  609 

transfusion  of,  in  post-par- 
tum     hemorrhage, 
609 
Saponification,  fetal,  313 
Sapremia       contra-indicating 
celiotomy,  969 
etiology  of,  (i85 
Scalp,   injuries  to,  of  the  new- 
born, 824 
tumors  of,  in  the  new-born, 
■S 18-822 
Scarlatina  complicating  preg- 
nancy, 243 
fetal,  296 

prognosis,  297 
Scarlet  fever,  puerperal,  780 
prognosis  and   treatment, 
7.S1.     (See  Feirr.) 
Schmidt's  disease,  308 
Schuitze's  method  of  artiiicial 
resi)iration,817,818 
Sclereniii  neonatorum,  851 

diagnosis   and    prognosis, 

852 
etiology,  851 

pathological  anatomy,  851 
.symptoms,  851 
treatment,  852 
.Scoliosis,  539 

Secretions      and      excretions, 
puerperal,  650 
pre-natal  gastric,  141 
intestinal,  141 
salivary,  141 
lu'inary,  140 
Secundines,    retained,    hemor- 
rhage   from,    739. 
(See  I'ldccnta.) 
.Segment,  jielvic,  anterior,  31 

jxtsterior,  31 
Segmentation  of  ovum,  7(i 
Scgmeiitalion-nucleiis,  7(! 
Sepsis,  causing   puerperal   in- 
sanity, 796 
of  the  new-born,  835 

causing  umbilical  hemor- 
rhage, 831 
pnerjieral,  341,  342,  346,  347 
from  svphilitic  iul'ection, 

240 
abdominal  section  lor  tlie 

treatment  of  9liS 
exploratory        abdominal 

section  ill,  975 
hysterectomy  for,  972 
techuii(ue  of  operation, 
975 
indications  for,  974 

for  oiicratiou.  968,  9()9 
sal|)ingo-odphorec  t  o  ni  y 

for,  (172 
mortality  of,  341 
,*^cpta    of  tlu'   cervical    canal, 
548,  549 
of  the  vagiiui,  549 
Septicemia    in    the  new-born, 
687 
etiology  of,  685 
acut-st,  697 


1006 


INDEX. 


Septicemia,  aciitost,  symptoms, 
708 
trentmi'iit,  T,\\ 
Sliei't-sliiij,',  !»;")<) 
Shock,  coinpliciitii)g  lal)or,(J44 
Shoulder  jiresentation,  podalic 
versi(m     in,     490. 
(See  J'ri'xciiUitiiiiin.] 
Slioiilders,  fetal,  exi)idsion  of, 
489 
relation    of    the,    in    tiie 
median  ism    of    la- 
bor, 40(i 
rotation  of,  nn  expulsion, 
489 
Sifjhf,  sense  of,  in   the   new- 

liorn  infant,  812 
Sinus  venosiis,  105 
Sinuses,  uterine,  entrance  of 
air  into,death  from, 
808 
etiolofiy,  Xin 
s.vnijjtonis,  804 
treatment,  804 
thrombosis  of,  090,  (!97 
Skin,  diseases  of,  intrauterine, 
809 
puerju'ral,  707 
eruptions,  jjuerperal,  treat- 
ment, 782 
of  the  new-born   infant,  810 
pigmentation    of,    in    preg- 
nancy. ]")(1 
Skin-protectives  for  the  new- 
born, 800 
Skull,  injuries  to,  of  the  new- 
born, 825 
Small-i)ox,  fetal,  297 

infection  of,  in   pregnancv, 
244 
Smell,  sense  of,  in  the   new- 
born infant,  812 
Somatopleurc,  80,  82 
Somites,  Si 

Soutlle,    funic    or     umbilical, 
170 
uterine    or    placental,    108, 
411 
"Space  of  Ketzius,"  80 
Speech,  development  of,  in  the 
new-born       infant, 
818 
Spermatozoiin,  fusion  of  ovum 

and,  75 
Spina  bifida,  804 
Splanchnopleure,  80,  82 
Spleen,  hypertrophy  of,  due  to 

pregnancy,  155 
Splenitis,  symptoms,  70(') 
Spondylolisthesis,  582-587 
Spongiosum,  87 
"  Spontaneous       amputation," 

800 
Stenosis,  mitral,  complicating 
pregnancy,  287, 288 
of  the  cord,  259 
Sterility,  18t) 

Slerili/ation  by  boiling,  843 
by  chemicals,  848 
by  dry  heat,  848 


Sterilization  by  steaming,  343 
Stomach,     malformations     of 
congenital,  808,809 
Stomatitis  aphtliosa,  850 

etiology    and     treatment, 
850,  851 
Stomato<la'um,  1 18 
Strait,  inferior,  18,19,392-394 
didijrences    between     the 
male    and   female, 
400 
superior,  18,  19 
arrest  of  head  at  the,  the 
application  of  for- 
ceps, 486 
in  breech  presentationB, 
484 
diameter  of   the   antero- 
posterior, measure- 
ment, 501 
diflt'rences    between    the 
male    and    female, 
899 
operative  treatment  at,  in 
posterior   jiosilions 
of  the  vertex,  450 
shape     and     dimensions, 

890-892 
transverse    diameter    of, 
measurement,  507 
Strangulation,  fetal,  800 
Stratum  compacta,  87 
Streak,  jirimitive,  78,  79 
'"Striic  gravidarum,"  151,  ()5t) 
Stroma,  ovarian,  00 
Struma,  fetal,  809 
Subinvolution,  197,  784-738 
Suckling  after  return  of  men- 
struation, 770 
conditions  interfering  with, 

778 
diseases  interfering  with, 778 
ingestion  of  drugs  in  breast- 
milk  in,  776 
in  pregnancy,  776 
in  puer]ieral  anemia,  775 
Supcrt'e<'undation,  144  i 

Snperfetation,  144 
Superimpregnation,  144  | 

"Super-rotation,"  489 
Sup[iositorv,  iodoform, formula 

■for,  722  '. 

Suppuration,  fetal,  318  j 

Surgery,  obstetric  (instm-! 

mental),  807-941 
operations,  807 

— Cesarean  section,  917 
— craniotomy,  92(i 
— curettage,  872 
— dilatation  of  the   os, 

882 
— douche,  the,  870  ; 

— embryotomy,  926 
— episiotomy,  877 
— forceps,  the,  884 
— passing  the  catheter, 

808 
— premature    induction 

of  labor,  878  I 


Surgery,      obstetric      (instru- 
mental) : 
— symphysiotomy,  905 
— tampon,  the,  874 
general      recpiircments 
and      preparations 
for,  867 

Surgery,  obstetric  (manual ), 

941 
operations,  941 
version,  941 

— contra-  indications 

for,  948 
— dangers  of,  948 
— indications  for,  942 
—methods  of,  942 
— varieties  ol',  941 
bipolar,  940 
cei>lialic,  94."> 
external,  944 
internal,  948 
preparations    for,    957. 
(See  ViTKion.) 
Suture,  amniotic,  88 
coronal,  402 
frontal,  402 
lambdoidal,  402 
sagittal,  402 

uterine,  in  ( 'esarean  section, 
921 
Suture  materials,  880 
Sutures  of  fetal  head,  402 
Suturing  alter  svmjjhvsiotomv, 
915,"  916  " 
in  Cesarean  section,  921- 
Svmphysiototuy,  905-917 
contra-indications  for,  912 
history  of,  905 
incisions  for,  918,  914 
indications  for,  911 
limitations    of,    anatomical, 

909 
operation  of,  after-treatment, 
910 
Harris.  914 

instruments  required  for, 
912 
method  of,  912 
Morisaui,  918 
results  of,  900 
Symphysis,    injuries   to,    from 
svmpliysi  o  t  o  m  y. 
907 
separation    of,    amount    of, 
bv  svmphvsiotomv, 
9()8,"914 
Symphysis  jmbis,  articulation. 

Syndactylism,  304 
Svphilis  causing  abortion,  200, 
2()t; 
congenital,  84(i 

causing  imibilical  hemor- 
rhage, 881 
etiology,  840 
treatment,  840,  861 
fetal,  297 
diagnosis,  29S 
hereditary,  298,  299 


sasm 


957. 


to,   fro'" 
lot  II  my, 

ii\inl    ol', 
ysiotoiny, 

liculiilii'"' 
Hum,  '2t><>, 
III  hemor- 


1 299 


Syphilid,  fetal,  mode  of  trans- 
miHsion,  297-299 

inateriiHl,siickliii|^  in,  775 

of  pregnancy,  240 

of  tlie  placenta,  2o7 
Sypliilis  lia>rnorrlia)iica,  299 
Syrinf<e.s,  disinfection  of,  717 
Syrinf^o-niyelocele,  ;W4 

Taiiios,  lactka,  777 
Table,  instrument,  ecjiiipnient 
of,  for  internal  ver- 
sion, 9-)7 
obstetric,  equipnieiit  of,  for 
the  lyin{?-in  room, 
3t)0 
Talipes  varus,  .'{0-1 
Tampon,  the,  874-877 
intracervical,  874 
intrauterine,  87(5 
application    of,    method, 

877 
utility  of,  877 
materials  for,  87o 
vaginal,  874,  875 
vulvar,  874 
Tampon   in    actual    abortion, 
2fi8-271 
in  threatening  abortion,  268 
Tainjionage,    indications    for, 
874 
in  endometritis  and  metri- 
tis, 723 
in  intra-uterine  hemorrhage, 

(iOll 
in  placenta  pricvia,  592,  593, 

(iOti,  ti07,  (108 
in  po.st-partum  hemorrhage, 

874 
of  uterus,  techni(|ue,  877 
of  vagina,   technicpie,   875, 
87G 
Taste,   sense  of,  in   the  new- 
born infant,  812 
Teeth,  during  pn-gniuicy,  al)- 
nornial    conditions 
of,  234 
Temperature  in  eclampsia,  (527 
reduction  of,  in  peritonitis, 

729 
of  the  new-born  infant,  811 
puerperal,  049,  ()50 
Testicles,  fetal,  descent,  101 
Tetanus  and  tetany,  diagnosis, 
difterential,  247 
in  pregnancy,  24() 
Tetanus  neonatorum,  841 

diagnosis    and   prognosis, 

842 
etiology,  841 
Tetany  during  pregnancy,  246 

treatment,  247 
Theca  folliciili,  60 
Therapeutics  of  the  new-born, 
860 
— antiseptics,  S()0 
— astringents,  860 
— counter-irritants,  860 
— heat  and  cold,  860 
— protectives,  860 


I      urinary, 

I 


INDEX. 


TiKiracopagus,  305,  563 
Thrombosis  anii  hemorrhage, 
cerebral,       during 
pregnancy,  212 
of    the    pulmonarv   artery, 
death  from,  802 
Thrush,  congenital,  850 

diagnosis   and    treatment, 
8.50 
Tongue-tie,  congenital,  303 

treatment,  303 
Tonics   for  debility  following 
childliirth,  663 
heart,    in    the    puerperium, 
724 
Toothache  of  pregnancy,  160, 

209 
Torsions  of  the  cord,  259 
Toxemia  of  eclampsia,  628,  632 
of  pregnancy,  202,  785 
diagnosis,  207 
treatment,  207 
Toxins  of  pregnancy,  203 
Tract,  parturient,  condition  of, 
in  the  puerperiiun, 
651 

disorders    of,    in 
pregnancy,      treat- 
ment, 199 
in  the  pucriieritnn,  785 
(See  Vamd.) 
Traction,   axis-,    in    the    low 
oiieration,  89()-S98 
in  the  high  operation,  899- 
904 
Transfusion     in     post-partum 

hemorrhage,  609 
Transverse   presentations,   de- 
fineil,  386 
(See  Pri'si;iUalii>ii!<.) 
Trendelenburg  apparatus,  im- 
provised, 962 
Trephine,  JJraun's,  9.30 
Triplets,  modeof  origin  of,  144 
Trisnuis  of  the  new-born,  842 
Trimcus  arteriosus,  106,  136 
Trunk,  fetal,  relation  of  the, 
in  the  mechanism 
of  labor,  407 
injuries  to,  of  the  new-born, 
824 

(See  Bod  I/,  ft'litl.) 
Tubercle,  genital,  123,  124 
Tuberculosis  causing  abortion, 
260 
congenital,  847 

diagiu)sis  and   treatment, 
847 
fetal,  297 
Tubes,  Fallopian,  anatomy,  .5() 
during    pregnancy,   atli'c- 

tions  of,  249 
removal  of,  in  juicrperal 
sepsis,  973 
Tumor,    blood-,    complicating 

labor,  680-68;? 
Tumors,   abdominal,  congeni- 
tal, 301 
indicating  celiotomy,  969 
congenital,  301,  302,  309 


1007 


Tumoi-s,  cystic,  302 

indicating  celiotomy,  970 
ol'  the  ovaries,  303 
fetal,  .309 

complicating  labor,  564 
fibroid,  com])licating   labor, 
558 
in     i)regnan(;y,     surgical 
operations  for,  248 
uterine,  hemorrhage  from, 
743 
genital,  infected,  indicating 

celiotomy,  970 
head-,  of  the  new-born,  818- 

822 
in  the  brim,  producing  face 

presentations,  459 
of  the  genital  canal  compli- 
cating   labor,  .556- 
560 
of  the  rectum  complicating 

labor,  639 
of  the  vagina  and  vtdva  ob- 
structing labor,  5.50 
ovarian,  190,  191 
in  prcgnanc;y, 
sinndating 

diagnosis,  173 
pelvic,  .530 

indicating  celiotomy,  969 
treatment,  530 
'placental,  257 

.111(1  decidual,  740 
p:)lvpoi(l,complicating  labor, 

558 
sacral,  congenital,  301 
simulating        extra-uterine 
pregnancy,  287 
Tunic,  vaginal,  fibrous,  45 
Tunica  lilirosa,  71 
Twins  complicating  labor,  567 
formation  of,  305 
growth  and  development  at 
birth,  disi)arity  in, 
Ml 
homologous.  143,  305 
nioile  of  origin  of,  143 
Tvinpaiutes,   (luerperal,  acute, 

801 
Tympanites  uteri,  273 
Typhoid    fever    cumplieatiiig 
pregnancy,        241, 
242 
diagncjsis     and     treatment, 
242 


¥ 


248 
pregnancy. 


Ulcer,  gastric,   complicating 

pregnancy,  232 
Umbilicus,  changes  in,  due  to 
pregnancy,  151 
hemorrhage  from,  828-832 
hernia  of,  858 

infection   of    the    new-born 
through  the,  836 
(See  ('(inl.) 
I 'rea  in  toxemia  of  pregnancy, 

204 
[Uremia  of  eclampsia,  t)27 
Ureter,  female,  siruclurc,  41 
Urethra,  blood-vessels  of,  41 


r. 

f    lid 


I, 


ii 


I 


1008 


JNDl'LV. 


;  ^t- 


Urutlira,  nerves  of,  41 

sirui'tiire  of,  40 
Irination,     (liilieult,    in     the 
I)iiei']ieriuiii,   treat- 
ment, (iiVJ,  titiO 
I'rine,  blood  in  the,  after  hibor, 
7 '.10 
fetal,  |)re-natal  secretion  of, 

140 
incontinence  of,    puerjieral, 
78;"),  7H() 
treatment,  781) 
of  pregnancy,   albumin   in, 

changes  in,  loO 
examination  of,  183 
peptone  in,  'IWi 
of  the  eclamptic,  (j27,  633 
retention   of,   in   the   puer- 

periuni,  (i'j'J 
secretion  and  execretion  of 

pnerperal,  (i.JO 
toxicity    of,    in    pregnancv, 

208,  20o 
uric  acid  in  the,  of  the  new- 
born, 858 
Utero-gestation,    first    period, 
170 
second  period,  171 
third  period,  171 
phenomena  of,  classification, 
170 
L'terns,  the,  4o 
aspiration   of,  in  the  induc- 
tion  of  premature 
labor,  881 
blood-vessels  of,  03 
during    the    puerperiutu, 
6o3 
cancer  of  the,  187,  241 
in  pregnancy,  241,  244 
in  the  puerperiem,  744 
obstructing  labor,  "jSO,  o61 
changed  position  of,  in  preg- 
nancy, 1(1") 
changes  in,  during  the  puer- 

periuin,  C)")2 
condition    of,    for    internal 

version,  949 
contraction    of,   after  labor, 

_  377,  378 
contractions  of,  during  gesta- 
tion, 318 
influence  of  muscular,  in 
dilatation,  425,  427 
puerperal,  (551 
development  of,  congenital, 

anomalies  of,  540 
displacement     of,     anterior, 
complicating  labor, 
552 
conditions  following,  197 
lateral,   complicating    la- 
bor, 553 
puerperal,  causes,  742 
hemorrhage  from,  741 
douche  of,  (>|)eration,  872 
during     pregnancy,    ))atho- 
logieal     conditions  ' 
of,  185  1 


Uterus,  entrance   of  air  into, 
ileatli  from,  803 
excision  of,  in  puerperal  sep- 
sis, 973 
extirpation  of,  for  cancer,248 

in  carcinoma,  187,  188 
fibroids     of,     complicating 
labor,  557 
complicating  the  puerpe- 

rium,  743 
hysiereclomy  for,  180, 187 
flexion     of,     occlusion     of 
lochial     (low      bv, 
741 
hemorrhage     from,    during 
pregnancy,  238 
puerperal,  causes,  738-740 
hernia  of  the,  ct)niplicating 

labor,  552,  553 
hypertropiiy  of,  during  ges- 
tation, 145,  185 
incarceration    of   pregnant, 

treatment,  195 
incision  of,  in  Cesarean  sec- 
tion, 920 
influence  of  eclampsia  upon, 

027 
infravaginal  portion  of  the, 

injuries  to,  (114 
innervation  of  the,  during 

pregnancy,  320 
intermittent  contractions  of, 
during   pregnancy, 
107 
introduction    of   an    elastic 
bougie    for   induc- 
tion  of  premature 
labor,  879 
inversion  of  the,  010 
post-mortem,  046 
puerperal,  742 
involution  of,  tardy,  602 
lacerations   and  rupture  of, 

010 
ligaments  of,  51 
lymphangitis  of,  treatment, 

720 
muscle  of  the,  influence  of, 

in  dilatation,  425-427 
muscles    of    the,    deficient 
power  of,  in  labor, 
493 
nuiscnlar  coats  of,  49-51 
mydmatii  of,  185 
nerves  of,  03 
normal     position    of",    after 

labor,  741 
obli(juity  or  abnormality  of, 
l)ro(lucing    a    face 
l)resentation,  458 
over-distention  of,  causative 

of  labor,  320 
position  of,  normal,  54 
pregnant,     amputation     of, 
2-18 
changes  in,  145 
in  form,  140 
in  position,  149 
displ.iceirents  of,  193 
retro ver:ii)n  of,  193 


Uterus,  pregnant,  retroversion 
of",     complications, 
195 
simulating,  ectopic  ges- 
tation, 193-190 
prolapse  of,  following  peri- 
neal      lacerations, 
075,  076 
in  inversion,  019 
partial,  with  hypertrophic 
elongation   of   cer- 
vix, 553 
puerperal,     relaxation     of, 
hemorrhage    from, 
743 
phlebitis  of  the,  090,  704 

treatment  of,  734 
putrescence    of,    treatment, 

725 
retraction  of,  in  second  stage 

of  labor,  438 
retn)version    of,    mortality, 
195 
frequency,  194 
rupture  of,  from  fibroids,  186 
spontaneous,  189 
version  in,  013 
sacculation  of  the,  compli- 
cating labor,  553 
shape    of     cavity,     during 
pregnancy,  420, 421 
structiu'e  of,  49 
subinvolution  of,  734 
diagnosis,  735 
etiology,  734 
treatment,  736 
taniponage     of,    technique, 

/877 
tamponing    the, 
partum 
rhage, 

600,  007,  608 
veins    of,   air-embolism 

the,  803 
virgin,. cavity  of,  46,  48 
Uterus   and    fetus,  adaptation 

between,  420 
Urine,   retention    of,    passing 
the     catheter     for, 
868,  869 

Vaccination    during    preg- 
nancy, 244 
maternal,  protection  to  fetus 
in  utero  by,  297 
Vagina,  atresia  of,  obstructing 
labor,  550 
axis  of  tiie,  43 
blood-vessels  of,  45 
changes    in,    during    preg- 
nancy, 150 
cicatrices  in,  obstructing  la- 
bor, 5 19 
diseases     of,     complicating 

{jregnancy,  1 93 
douche  of,  operation  of,  870 
injuries  to,  following  labor, 
078 
causes  of,  678,  679 
treatment  of,  679 


in     post- 
hemor- 
592.     593, 


of 


' 


r^DEX. 


Vagina,   irrigation   of,  in  ,i„. 
"iiliiction    ,,(■    ,„.^,. 

."mture  labor,  «.si 
Ivmi'liaii.s  oi;  .|.-, 

""'•'■"»"e.s«    oi;    ..oMKcMH.al, 
^■«mi)licatin.r|,,l,or, 

nerves  of,  4.j 

'"•  vulva,  closure  and  oon- 
ti'iiction  of.ojisinict-  ' 
inff  Jailor,  rA\) 

P">ritnsof,,|„riny,.re,M,aM. 

ey,  220 
stnietnre  of,  ^2 

«an),,oninKtl.e,forin,Iuoti„n 
J^'J,pn'niature  labor, 

'"   '''"^;"^   I'nevia,  m, 

U'clini,ji,e  of,  87-,,  87« 
't'^'l'ni'li.e  of  ,|i^.i(,,|  ,.^^,,^^_ 

*  a^'inisinns,  o.",] 
Vaginitis,  (i!)4,  ,;(|.s    ,;,,,, 

treatment  oi;  7->() 
Variola    .•on.pli,,,,!,,^,     ...-e., 

,.     .         nancv,  244  " 

Mai,  297 
>.w'tis,  the,  454 
»»""is,  allantoic   III 

fetal,  110 

"lanirii.irv,  (i!) 

ovarian,  (i;;  '      " 

l>elvie-(lo,ir,  .S(j 
nmliilioai,  \r,i 
uterine,  (l;{ 
air-en.holi„„     i„,     .j^.^,, 
ironi,  .so;; 
var,..ose,eo,„j,|i,,„i,     ,,,, 

in/la/nniation  of,  7;j4 

vitelln.e,  110,  111      ' 
\  enie  advehentes,  111 

'■■•iva,  III,  112 

revehentes,  111 
Neoeseetion  in  pregnancy,  1,-,;! 

'"  "-e^fj^U   of  eclampsia, 

Ventilation!',    ,|,e    lvi„o..i„ 
..      .  room,  (jr.o    "     " 

\ernix  caseosa,  101 

\er.s,on  after  craniotomv,,Ian- 
,  .     ,        Ser  oi;  iJSC,    ' 
'|'|>'>lar,  !)4(i,  947 

i'liiications  for,  94C> 
pi-eparation  foi>,  947 

;^"■l'■softheoperati,.n,947 
I'nie  to  operate,  947 
eepiialic,  942-944 

eondiiii.ns  for,  944 

'•'>ntra-in.iicati<ins  for  94;! 
indications  for,  94-' 

«te|'soi;  the  o,,erati„i,.  1,44  !  v 

t'>'fa-in,licatio;,sf,„.9.  !       U^ 
<lanf,'ers  of,  94;{  '   ^ 

external,  944,  94.", 

I'oiilra-indieations  fur,  944 

04 


100i» 


Version,  external,   in.Iicaiio„s  -  villi      . 

f..r,  9/4  .\.'"  •  I'laecntal,  90 

I'i'eparaiinn  tor  94",  .\"^''.''i'<  "'"  ovum,  71 

'^.'•■I'^'-fiheopeWuiou  04-,  ^ ','""" "Jr  in  la l,„r,  (;;J7 

.    "II"' I'Miperate,  94.-,    ''  )"  "''l:'ii'"iMreatmenl   7'!'> 

;,';.'7'""i'itiMreatmen,72; 
"'  I'lvunancy,  |.-,.-,,  i.-,,,  \,.,:P 

ii'eaiinenl,  I,s;{       '    """ 
'"  ■■      !'•■'.  aiiaioiuv  of,  ;{7 
'""  «   "i;   ilurinir    'nv. 

nancv,  nn       '     "^ 
"uche  ol,  operation,  ,S70 
'  •^■''■^inj,'  of,  after  labor,  ;i,s;! 
t'dema  (if,  r),-,()  •      •' 

"•i'l'ation^.,,;  i„  ,„.,„,i,,,^^ 

ganu,,,,,n.  „f,  treatment  r.ol 
'".'"■^■■-  10,  following.  1Mb,',. 
,  fiealinent,  fi72 

'yniphanjritis  of  treatmeut, 

"'"■'■""•'itvs'T   of,    cono„„i,,,| 
<:'j'ii|''i«atin- labor' 

l"''"'i'ii«  of'.lurin.  pregnan- 
cy, 220 


'"  "'iH'rinr  position  of  ,i„, 

I'nnv,  4().S 
"•   ''"'i'  I'l-esentations  at  the 

I'l'ini,  4(i4 
'"    'i''«l^'''ted    or    impaeted 

eases,  9(i,S 
!;;rui.lnre  of  the  uterus,  (i|;i 
'"  "ansverse  presentations, 

internal.  94S 

'■lioice  of  hand.  9,-)(j  1 

•■ondiUoiis  for,  94,s  j 

dangers  of,  9-,()  1 

feet  in,  both,  9,-,(j  ! 
ioot  111,  choice  „/;  9r,o 

"*^"r,   in    dorso-anterior 

positions,  (),J4 
'••-''I'ote,   in  dorso-poMe- 
.      '"lor  positions,  9")4 
sin^'le,  'j.-,r, 

"iL"  operation,  preoara-  ,  '>'•  --*' 

'ions  lor,  9:17  '  V   i'"-'''""  "'  "''V^74 

operation  „f :  :   ^  'iivilis,  (194 

— L'xamiiiati(m,  9(i;{ 
—extraction,  ()(;.-, 

i'uiikdiale,     versus 

delay,  <)().-,  W . ,  ,  ,  , 

-iiitmduclion    of    the  '''■*''    ■■i''''oniii,al,    chaiiL'ev 

liand,  90,'j  ''""  


'ii'iKnosis  and  prognosis.  (;.)9 
**.vniptoms,  (lii.s  '■■"•'» 

'rt'alMieut,  720 


posture  of  the  patient 
9o9-9(i;}  ' 

<Ior.siil,  959 
knee-elbow,  9(i2 
latero-prone,  901 
,'j'_|Uattiii<.-,  9lia 
iiendelenbuiy,9(;-> 
Walcher,  901 
— «'izureofthefoot,9(i4 

— i^teps   of   I|n._   <„j;; 

— turniiiu',  904 
prepar.ition  for  .- 
—anesthesia,  9oS 
,        — antisejisis,  9o,S 

""'"•""";-,  ''"•    oi'eration,  j 

methods  of,  choice  of  94-) 
Pt'lvic,  indications  for  1)4") 


-■'■^'"".  podaiic,  indi;ui^-,s  ..  V :i'r"";r'".-'^-* 

lor,  912  ,,  •       "',  '""■     I  'a«eia  1.  29  ,'!( 


fur,  912 

varieties(,f  choice  of,  941 
\  ertex    presentations  deli„ed 
.WO.     (.See  P,r.,i>'. 
,,    .  f'ltionK.) 

^t'sical  calculus  of  pre^nancv 
,     .  -'00.  .-(01 

^r;:;!'''f,^''";"'"'- ovarian.  71 
•esses   l,|oo,|..     |Seey>V,„./.) 

""'''"'"■^'1. 'liseasesoi;  ,s;!7^ 
lieiiiorrhaye  from,  ,S2,S 
,      .    trealineni  of,  s;!() 

t;>;t'l'ide.  ihc,  sinu.turcof  ;!s 

""'    '■horionic,    7S,    ,s.-,    ,s,; 

91  '        ' 

ileKcner.illou  ,,f,  hv.ialidi- 

lorm,  2.">1 


due   to  pre.u-naiicv, 
Jol  •  ' 

uterine,  aiiatoiuv,  V) 
I  ,/'i«i'ial.  auatoinV,  4;!-45 
I  VVash,     lead-aud-opium.     fo... 
■  ,,-  ,  luul.'i,  720 

,    »» aters.    escnn.    ..r  . 

i  \'l  '^    ".'.   <omplete, 

•lilalation  of  ,«  •,(■. 
ler,  429 
;  I'''r'ial.   dilatation    of   os 

afier,  427 

«-'nly,  dilatation  of  OS  uith 
,.-       .       .original   429 
It  eaniiig,  ^77 

iirri;sl  of  lact.-.tion  after,  707 

'"    iii'i'ieurrent  .iiseases  of 

the    mother,    77;!- 

\y  "'"' 

\U't-nurse,  .selection  of  the,  0(18 

„  ,V.  1."'"  'anes,"  2;{4 


\\-     11...      '  '•••sciai.  :j<i   ; 

"imkels  disease.  844  84-5 

»»olflian  bodies,  02,  ll's-I').- 

'•I'fl,  llS-12;! 
^Voinan,  child-bearing,  insa,,. 
'l.v  in,  794 
pregnant,  posture  and  bear- 

'ii.y:  of,  202 

•'^urgical  operations  on,  ■>.-,! 

'olerance    of,   to  meclian- 

'eal    injuries,  249- 

^\'oun.Ls  afli^ctlng  normal  yes- 
tat  ion,  2-I9-2.J2 

XiiMioi-Adis,  oO;! 

>^o.vA  n:u.i(  U..V  of  ovum,  71 


m 


i;i 


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m 

m^ 

■  ' 

'  ■'  1 

-  i'l 

1 

1  i.;. 
if!;. 

1 

:;lj 

J  ■  ■  ■ 

PUBLISHED  BY 


W.  g.  gauRdet^,  925  Walnut  gbeet, 
sP^iladelpl^ia. 


;n 


JJR.  SAUNDERS,  In  presenting  to  the  profession  thefol- 
hls  1::  V'  °'  ''"'""="'°-'  "^-^  to  state  that  the  2 
m^dlo^r:  t  :*'"  *'"'"  ""^"^  °'  the  confidence  of 
and  bv  '""'-"""^^^  "^  "^«  high  standard  of  authorsWp 
Ld  IZl.  ^'"-"^""^  -   ^—P"-   PaPe.   printing 

The  works  indicated  in  the  Index  (see  next  page)  with 

mnally  through  travelling  solicitors,  but  they  can  be  oh 
tamed  ^,...,  fro,„  the  office  of  publication  (charges  of  sll 
me"t  Prepa.d,  by  remitting  the  quoted  prices.     Ll  *.!> 

All  the  other  books  advertised  in  this  catalogue  are 
commonly  for  sale  by  i,o,s.Ue.s  in  all  parts  of  the  Uni  ed 
S.  es,  bnt  any  book  will  be  sent  by  the  publisher  to  any 
address  (post-paid)  on  receipt  of  the  price  herein  given 


f 


!■ 


1 


,-i 


CONTENTS. 


Aiintomy. 

lliiyiirs,  Miiimnl  (>r  Aimldiiiy 

Niincri'ilf,  Aiiiiliiniy  and  .Ma'riiial  nf  l)lNi<«etiou,  , 
Muiiurvdu,  IJutviitiulH  ol'  Aiiutoiiiy, 


m 


Ba«'t4>rioloiry. 

Hall,  K•<Mllltilll^^  of  HarU'il(ili>t!y 

l''rollilii»:liJiiii,  LalHiiatciiy  (iiiiilc 

Mcl'mlanil,  Tuxt-KiHik  ol'  rathiiK»iiiu  llucterla,  . 

Ikttnny. 

Uustiii,  Lalwralory  KxitcInos  In  llutuny,  .... 


t'lifiiilNtr.v  uimI  PhyHlcM. 

Brockway,  KssiMitlals  111' riivMics, 

Wolir,  Ivsst'nlial.s  1)1' Clinnisiiy 

4'hll<lr<>n. 

*An  Anu^iiiMin  Tixl-Hdiik  of  l)lsi'aM's  of  Cliililron,  . 

(iiillilh,  Cari'dt' 111!' Italiy 

Towt'll,  KsHi'iiliah  111' DiNca-tOH  of  Childrun,  .   .   .  , 

Clliiifiil  <'linrlN.  etc. 

Keen,  Onrral ion  lllank, 

l.aln^, 'lrni|iirainn' Clnii'l 

TliiJums,  Dulaclialili'  Dii'i  l.isis,  dr., 

■lillKIIONiM. 

Culu'n  and  KshniT,  ICsNi'iilials  iif  l)iat;n>iNis,     .   .   . 

Mcliiiinilil,  Siii^'iial  liia);ni>sis  anil  Trt'alnn'nl,    .    . 

•Viurordt  mill  .stuai'l,  .Mciliral  I'iaKiiiisi.'t 

l>irti<tniiri«>N. 

•KcalinRand  llninlllon,  Now  I'mnnnniinK  Dictlon- 

aiv  111'  Mi'ilicine 

Mdi'loh,  Xnrse's  |)i(lii(nai'v  111"  Mi'dkal  TiTius,   .   . 
Saniulers'  I'ui'kot  Medical  Lexicon, 


Kitr. 

Ciluasun,  Ks.HunUals  or  Disoasos  111' Kur, 

KI<><*trlFity. 

Stewart  and  Lawran<'c,  1'ls.suntial.s  of  Medical  Elec- 
tricity,            .... 

Kiiilir,v4>IOK.V- 

Helaler,  a  'IVxt-Hook  of  KnilirynloKy 


Eye,  NoMe.  iiiitl  Throat. 

♦DcSclnvi'inil/.,  Diseases  of  Kvi' 

.Tarksnn  anil  (llca.siin,  Kssentfalsof  Dlsea-ses of  Kye, 

Niwe,  and  Tliiiial 

Kyle,  Manual  of  Diseases  of  Nose  and  Throat,    .  . 

<  Ji>n  i  t<t-u  r  1  iiiiry . 

Hvde,  Sv|iliilis  and  llu' Viiii'ival  Diseases 

Miirliii.'lvsseiilials  of  .Minor  .><nrgury,  Handaging, 
and  Venereal  Di.seast's, 

tJ.VIK'CMlOir.V. 

*Aii  .Vnierican 'i'ext-liook  iif  (iyio'iiilogy, 

f'ra^'in,  i;sseiitials  of  (iynei'iilogy, 

tiarri^nes.  DiseiKis  of  Women, 

Jjong,  .Syllalins  of  (iyneeology, 


Ui'e  IiiHiiriiiire. 

Kealinn.  How  to  Examine  for  Life  Insnrance,    .  . 
Miiterin  n«'«U<-n  iintl  TlicrnppiiticN. 

*An  .\nierii  an  IVxI-liook  of  .Vpplied  'I'lierapentics, 

Ccnia,  Notes  on  tin'  Newer  Hi'nn'ilies 

<irilfiii,  .Manual  of  .Materia  .Meiliea  iind  Tlieraiien 
lies, 

5Iorris,  Kssenlials  of  Materia  Meiliea,  etc.,   .    .   . 

Sannders'  I'oekel  .Meilieal  I'ornnilury, 

Stevens,  Mainnd  of  Tlierapenties,      

Tliorntoii,  Dosc-liook  and  I'reMriplioii-Writiiig, 
•Wurreu,  iHirgieal  I'athology  and  'I'lierapentics,   . 


2U 
17 


27 
It 
2!» 


t'J 


27 
'23 


■J" 


IB 

'.'0 
'ill 


2ri 

•2!) 
8 


9 

2S 


28 

28 
21) 

7 

2.'> 
12 

12 

2r, 


6 
24 

ir> 
17 


20 


.SO 
1,H 

12 

2:i 

20 
'20 
14 
10 


Me«iicnl  Jnrlnprndenee.  paor 

(liapniun.  Medical  .Inrisprndenie  and   roxieiiliigy,  14 

Si>niple,  lutsuntials  of  Legal  .Meilii'iin',  ell'.,   ,   ,   ,    .  2.1 

Me<ll<>liie. 

•An  Ainerlean  Text-Hook  of  I'rael lee 't 

l.oekwiiiHl,  .Manual  of  I'rai'llie  of  .Medieliie,       .    .  12 

Morris,  Kssentiuls  of  I'rai'liee  of  .Miilieine,  ,    .    .    .  21 

•Saninlera'   Ainerlcun   Vear-lliHik   of  .Medlelne  and 

Surgery, ;t2 

.Stevens,  Manual  of  I'ructlee  of  Medicine, 17 

NervoiiN  IllMoiiNeN  nnil  InNiinll.T. 

Ifnrr,  Mainial  of  Kervons  DNeases 12 

Shaw,  Essentials  of  Nervons  Diseases  uiid  Iiisunlty,  27 

.'WiirMliiir. 

All  Anieriian  Text-llook  of  Nnrsinu .10 

tirillith,  (are  of  the  lialiy 2!t 

Uuiuptoii,  Nursing:  its 'I'rini'lples  and  I'ladice,   .  1.5 

ObMtetrleN. 

•An  American  Text-Hook  of  Olisletrics, :io 

Ashton,  l';ssentials  of  Olislelries, 'ill 

Dorland.  .Mannal  of  Olistetrles |:| 

.lewetl,  Outlines  of  (llistelriis is 

Norris,  Syllahns  of  Uhsletrieal  l.ei'lnres 18 

Orthti|tn'ili«'N. 

Wilson,  rrevunling  and  t'orreeiing  Del'nrnillies,    .  15 

l>Htliol»iry. 

Sem)ile,  Ksscniinlsof  I'athology  ami  .Minhlil  .\nat- 

omy,  .       .   . 23 

*S<<nn,  I'atholo^v  and  Surgical  Treatment  of  Tninors,  2it 

Stengel,  Mami;il  of  I'allioliigy 12 

•\\'urreii,  Surgical  I'athology  and  Tlierapenlies,    .   .  lu 

Phnriiiiie.v. 

Say  re.  Essentials  of  Pharmacy,     26 

I*h,TNlolOK,V< 

♦An  Anieriian  Text-Hook  of  I'hysiology .10 

Hare,  I'^sseiitials  of  I'liysioloyy,     '22 

Itayniond,  .Manual  of  I'liysiidogy, l;{ 

Mkiii. 

Slelwagon,  E.ssentials  of  Diseases  of  I  he  Skin,  .   .    .  24 

Nil  rue  ry. 

An  .\iiierican  Text-Hook  of  Surgery ;i 

Heck,  Surgical  .Asepsis 12 

Dal  osta,  .Maiuial  of  Surgery, l:i 

Keen,  0|)eralioii  HIank.     .' l.'i 

McDonald,  Snrgleal  Diagnosis  and 'Ifiatment,    .   .  '2!) 

.Martin,  I'Xscntials  of  Surgery '22 

Martin,  Essentials  of  Minor  Surgery,  etc ^'i 

•Saunders'  American  Year-Hook  of  .Medicine  and 

Surgery .'(2 

•Sciin,  I'allioliigy  and  Surgical  Trealmeiil  of  Tiiiuors,  '29 

.Senn,  .Svllalius  of  Surgery 17 

•■Warren,  Surgical  Pathology  and  Therapeutics,  .   .  10 

Wilson,  Oithopicdic  Surgery, 1.5 

I'riiie. 

Wolir,  Es.seiitials  of  ICxamination  of  I'riiie,     .   .   .  '-'(! 

MiNcellHiieoiiN. 

•Gross,  .\utiiliiograpl\y  of, 9 

Saunders'  New  .Mil  Series  of  .Maniial.s 11-12 

Saunders'  (Question  (onipends 21 

Thomas,  Detaehalile  Diet  Lists,  etc., '29 


Practical,  Exhaustive,  Authoritative. 


PAOW 


It 

■Hi 


4 

Vi 
•Jl 

112 
17 


SAUNDERS' 

NEW  AID  SERIES  OF  MANUALS. 


''■■ 


FDR 


12 
27 


:io 

15 


;m 
2;» 
i:i 
i« 

18 


lllllt- 


iii>r», 


15 


23 
2» 
12 
lU 


26 


30 
22 
l:l 


21 


111"  and 


Imuns, 


:i 
12 
l;i 
ir. 
2'.t 
22 
2'i 

32 
29 
17 
10 
15 


9 

.11-12 

21 

29 


STUDENTS  AND   PRACTITIONERS. 


Mr.  Saindkrs  is  pleased  to  announce  that  he  has  ready  his  NEW 
AID  SSRIES  OF  MANUALS  for  Students  and  Practitioners.    As 

publisher  of  the  Standard  Series  of  Question  Compenus,  and  through  inti- 
mate relations  with  leading  members  of  the  medical  profession,  Mr.  Saunders  has 
been  enabled  to  study  progressively  the  essential  desiderata  in  practical  "self- 
helps"  for  students  and  physicians. 

This  study  has  manifested  that,  while  the  published  "Question  Compends" 
earn  the  highest  appreciation  of  students,  whom  they  serve  in  reviewing  their 
studies  preparatory  to  examination,  there  is  special  need  of  thoroughly  reliable 
handbooks  on  the  leading  branches  of  Medicine  and  Surgery,  each  subject  being 
compactly  and  authoritatively  written,  and  exhaustive  in  detail,  without  the  intro- 
duction of  cases  and  foreign  subject-matter  which  so  largely  expand  ordinary  text- 
books. 

The  Saunders  Aid  Series  will  not  merely  be  condensations  from 
present  literature,  but  will  be  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative 
American  Colleges.  This  nerv  series,  therefore,  will  form  an  admirable  col- 
lection of  advanced  lectures,  which  will  be  invaluable  aids  to  students  in  reading 
and  in  comprehending  the  contents  of  "  recommended  "  works. 

Each  Manual  will  further  be  distinguished  by  the  beauty  of  the  new  type ;  by 

the  qjality  of  the  paper  and  printing  ;  by  the  copious  use  of  illustrations ;  by  the 

attractive  binding  in  cloth;   and  by  the  extremely  low  price  at  which 

they  will  be  sold. 

II 


i^ 


I  r  ■ 
..'ii 


li 


!f 


Saunders'  New  Aid  Series  of  Manuals. 


VOLUMES  HOW  BEADY, 


i    /i 


PHYSIOLOGY,  by  Joseph  Howard  Raymond,  A.  M.,  M.  D.,  Professor  of  Physi- 
ology  and  Hygiene  and  Lecturer  on  Gynecology  in  tlie  Long  Island  College  Hos- 
pital ;  Director  of  Physiology  in  the  Hoagland  Laboratory ;  formerly  Lecturer  on 
Physiology  and  Hygiene  in  the  Brooklyn  Normal  School  for  Physical  Education ; 
Ex-Vice-Presidentof  the  American  Public  Health  Association;  Ex-Health Clommis- 
sioner,  City  of  Brooklyn,  etc.    Illustrated.    $1.25  net. 

SURGERY,  General  and  Oporative,  by  John  Chalmers  DaCosta,  M.  D.,  Demon- 
strator of  Surgery,  JefTersir.  Medical  College,  Philadelphia;  Chief  Assistant  Sur- 
geon, .Jefferson  Medical  College  Hospital ;  Surgical  Registrar,  Philadelphia  Hospital, 
etc.     188  illustrations  and  13  plates.     (Double  number.)    $2.50  net 

DOSE-BOOK   AND   MANUAL   OF    PRESCRIPTION-WRITING,  by  E.  Q. 

Thornton,  M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia.    Illustrated.    Price,  cloth,  $1.25  net. 

SURGICAL  ASEPSIS,  by  Carl  Bkck,  M.  D.,  Surgeon  to  St.  Mark's  Hospital  and 
to  the  New  York  German  Poliklinik,  etc.     Illustrated.    Price,  cloth,  $1.25  net. 

MEDICAL  JURISPRUDENCE,  by  Henry  C.  Chapman,  M.  D.,  Professor  of  Insti- 
tutes of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of 
Philadelphia;  Member  of  the  College  of  Physicians  of  Philadelphia,  of  the  Acade- 
my of  Natural  Sciences,  of  the  American  Philosophical  Society,  and  of  the  Zoologi- 
cal Society  of  Philadelphia.    $1.25  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES,  by  James  Nevins  Hyde, 
M.  D.,  Professor  of  Skin  and  Venereal  Diseases  in  Rush  Medical  College,  Chicago. 
Profusely  Illustrated.     (Double  number.)     ¥2.50  net. 

PRACTICE  OK  MEDICINE,  by  George  Roe  Lockwood,  M.  D.,  Professor  of 
Practice  of  the  Woman's  Medical  College  and  of  the  New  York  Infirmary;  Instruc- 
tor of  Physical  Diagnosis  of  the  Medical  Department  of  Columbia  College;  Attend- 
ing Physician  to  the  Colored  Hospital:  Pathologist  to  the  French  Hospital; 
Member  of  the  New  York  Academy  of  Medicine,  of  the  Pathological  Society,  of 
the  Clinical  Society,  etc    Illustrated.     (Double  number.)    $2.50  net 

VOL  UMES  IN  PRE  PAR  A  TION  FOR  EARL  Y  PUBLIC  A  TION, 

MANUAL  OF  OBSTETRICS,  by  W.  A.  Newman  Dorland,  M.  D.,  Demon- 
strator of  Obstetrics,  University  of  Pennsylvania;  Chief  of  Gynecological  Dispen- 
sary, Pennsylv.ania  Hospital ;  Member  of  Philadelphia  Obstetrical  Society,  etc. 
Profusely  illustrated. 

MATERIA  MEDICA,  by  Henry  A.  Griffin,  A.  B.,  M.D.,  Assistant  Physician  to 
the  Roosevelt  Hospital,  Out-jiatient  Department,  New  York  City. 

NOSE  AND  THROAT,  by  D.  Braoen  Kyle,  M.D.,  Chief  Laryngologist  of  the  St. 
A^riies  Hospital,  Philadelphia;  Hiicteriologist  of  the  Orthopii'dic  Hospital  and 
Infirmary  for  Nervous  Diseases;  Instructor  in  Clinical  Microscoi)y  and  Assistant 
Demonstrator  of  Pathology  in  the  .lefferson  Medical  College  etc. 

NERVOUS  DISEASES,  by  Chaulk'*  W.  Burr,  M.  D.,  (liiii.al  Professor  of  Nervous 
Diseases,  Medico-Chirurgical  College,  Philadelphia;  Pathologist  to  the  OrthopaHlic 
Hospital  and  Infirmary  for  Nervous  Diseases;  \'isiting  Physician  to  the  St.  .loseph 
Hospital,  etc. 

MANUAL  OF  ANATOMY,  by  rnviNO  S.  ITaynes,  M.  D.,  Adjunct  Professor  of 
Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department  of  the  University  of 
the  City  of  New  York,  etc. 

MANUAL  OF  PATHOLOGY,  by  Alfred  Stenoel,  M.  D.,  Instructor  in  Clinical 
Medicine,  Medical  Department  University  of  Pennsylvania,  etc. 

***  Tlicre  will  1k'  jiiilili.slu'd  in  tlie  .saini' sfrics,  at  dose  intervals,  carefully-prepared  works  on 
the  subjeeth  of  Chiklren,  (Jyneetilogy,  Hygiene,  etc.,  by  prominent  speeinlists. 


lii' 


CA  TALOGUE  OF  MEDICAL    WORKS. 


»3 


A    MANUAL    OF    PHYSIOLOGY.      By 

Joseph  H.  Raymond,  A.  M.,  M.  D.,  Professor 
of  Physiology  and  Hygiene,  and  Lecturer  on 
Gynecology  in  the  Long  Island  College  Hos- 
pital ;  Director  of  Physiology  in  the  Hoagland 
Laboratory  ;  formerly  Lecturer  on  Physiology 
and  Hygiene  in  the  Brooklyn  Normal  School 
for  Physical  Education  ;  Ex- Vice-President  of 
the  American  Public  Health  Association  ;  Ex- 
Health  Commissioner  City  of  Brooklyn,  etc. 
Illustrated.     Price,  Cloth,  $1.25  net. 

A  work  for  the  student  and  practitioner,  rep- 
resenting in  a  concise  form  the  ex'.^ting  state  of 
Phybioiogy  and  its  methods  of  inve^-ii  ;ation,  based  upon  Comparative  and  Patho- 
logical Anatomy,  Clinical  Medicine,  Physics,  and  Chemistry,  as  well  as  upoi? 
experimental  research. 


specimen  Illustration. 


to 


A  MANUAL  OF  SURGERY,  General  and 
Operative.  By  John  Chalmkks  DaCosta, 
M.  1).,  Demonstrator  of  Surgery,  Jefferson 
Medical  College,  Philadelphia ;  Chief  Assist- 
ant Surgeon,  Jefferson  Medical  College  Hos- 
pital ;  Surgical  Registrar,  Philadelphia  Hos- 
pital, etc.  One  very  handsome  volume  of 
over  700  pages,  with  a  large  number  of  illus- 
trations. (Double  number.)  Price,  Cloth, 
52.50  net. 


\  new  manual  of  the  Princijiles  and  Practice  of 
Surgery,  intended  to  meet  the  demands  of  students 
and  working  practitioners  for  a  medium-sized  work 
which  will  f-ni'^otb-  all  the  newer  methods  of  pro- 
cedure det  ;i_i!  ■^•^  the  larger  textbooks.     The  work 

has  been  written  in  a  concise,  practical  manner,  and  especial  attention  has  been 
given  o  ih^  most  recent  methods  of  treatment.  Illustrations  are  freely  used  to 
elucidai.'i  the  te.xt. 


specimen  Illustration. 


I'dic 
leph 

of 
of 

.•ill 

ks  oa 


A  MANUAL  OF  OBSTETRICS.  By  W.  A.  Newman  Dori.and,  M.  D., 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Chief  of  (gyneco- 
logical Dispensary,  Pennsylvania  Hosjjital ;  Member  of  Philadelphia  Obstet- 
rical Society,  etc.      Profusely  illustrated.     (In  pre])aiati()n.) 

This  work,  whit  h  is  thoroughly  practical  in  its  teachings,  is  intended,  as  its 
title  implies,  to  be  a  working  text-book  for  the  stutlent  and  of  value  to  the  prac- 
titioner as  a  (onveiiient  handbook  of  reference.  .Mthough  concisely  written, 
nothing  of  importance  is  omitted  that  will  give  a  clear  and  succinct  knowledge 
of  the  subject  as  it  stands  to-day.  Illustrations  are  freely  used  throughout  the 
text. 


\ 


14 


IV.  B.  SAUNDERS'  ILLUSTRATED 


DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING. 

By  E.  Q.  Thornton,  M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Med- 
ical College,  Philadelphia.     Price,  Cloth,  $1.25  net. 

But  little  attention  is  generally  given,  in  \vorks  on  Materia  Medica  and  Thera- 
peutics, to  the  methods  of  combining  remedies  in  the  form  of  prescriptions,  and 
this  manual  has  been  written  especially  for  students  in  the  hope  that  it  may  serve 
to  give  a  thorough  and  comprehensive  knowledge  of  the  subject. 

The  work,  which  is  based  upon  the  last  (1890)  edition  of  the  Pharinacof^a-ia, 
fully  covers  the  subjects  of  Weights  and  Measures,  Prescriptions  (form  of  writing, 
general  directions  to  pharmacist,  grammatical  construction,  etc.),  Dosage,  Incom- 
patibles.  Poisons,  etc. 


MEDICAI.JURISPRUDENCE  AND 
TOXICOLOGY.  By  Hknrv  C.  Chap- 
man, M.  D.,  Professor  of  Institutes  of 
Medicine  and  Medical  Jurisprudence  in 
the  Jefferson  Medical  College  of  Phila- 
delphia ;  Member  of  the  College  of  Phy- 
sicians of  Philadelphia,  of  the  Academy 
of  Natural  Sciences  of  Philadelphia,  of 
the  American  Philosophical  Society,  and 
of  the  Zoological  Society  of  Philadel- 
phia. 232  pages,  with  36  illustrations, 
some  of  which  are  in  colors.  Price, 
$1.25   net. 


specimen  Illustration. 


For  many  years  there  has  been  a  demand  from  members  of  the  medical  and 
legal  professions  for  a  medium-sized  work  on  this  most  important  branch  of  medi- 
cine. The  nece.ssarily  proscribed  limits  of  the  work  permit  only  the  consideration 
of  those  parts  of  this  extensive  subject  which  the  experience  of  the  author  as 
coroner's  physician  of  the  city  of  Philadelphia  for  a  period  of  six  years  leads  him 
to  regard  as  the  most  material  for  practical  purposes. 

Particular  attention  is  drawn  to  the  illustrations,  many  being  produced  in 
colors,  thus  conveying  to  the  layman  a  far  clearer  idea  of  the  more  intricate 
cases. 

"  The  salient  ])oints  are  clearly  delined,  and  ascertained  facts  are  laid  down  with  a  clearness 
that  is  une(|uivocal.'' — St.  Louis  .Mciiical  aud  Surgical  Journal. 


LABORATORY  GUIDE  FOR  THE  BACTERIOLOGIST.   By 

Lan(;i)()N  Froi  iiiN'fiH am,  M.  I).  \'.,  .Vssistant  in  ISactL'riology  antl  N'eterinarv 
Science,  Sheffield  Scientific  School,  Vale  University.  Illustrated.  Pri(o, 
C'loth,   75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  and 
microscopical  study  are  fully  described  and  arranged  as  sim])ly  and  concisely  as 
possible.     The  book  is  especially   intended   for  use  in  laboratory  work. 


CATALOGUE   OF  MEDICAL    WORKS. 


NURSING:  ITS  PRINCIPLES  AND  PRACTICE.  By  Isabel  Adams 
Hampton,  Oraduate  of  the  New  York  Training  School  for  Nurses  attached  to 
Bellevue  Hospital ;  Superintendent  of  Nurses,  and  Principal  of  the  Training 
School  for  Nurses,  Johns  Hopkins  Hospital,  Baltimore,  Md.  ;  late  Superin- 
tendent of  Nurses,  Illinois  Training  School  for  Nurses,  Chicago,  111.  In  one 
very  handsome  i2mo  volume  of  484  pages,  jjrofusely  illustrated.  Price, 
Cloth,  $2.00  net. 

This  entirely  new  work  on  the  important  subject  of  nursing  is  at  once  compre- 
hensive and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suit- 
able alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  deside- 
ratum with  thost.'  intrusted  with  the  management  of  hos])itals  and  the  instruction 
of  nurses  in  training  schools.  It  is  also  of  especial  value  to  the  graduated  nurse 
who  desires  to  accjuire  a  practical  working  knowledge  of  the  care  of  the  sick  and 
the  hygiene  of  the  sick-room. 

METHODS  OF  PREVENTING  AND  CORRECTING  DEFORM- 
ITIES OF  THE  BONES  AND  JOINTS  :  A  Handbook  of  Prac- 
tical Orthopedic  Surgery.  By  H.  Augustus  Wilson,  M.  D.,  Professor 
of  General  and  Orthopedic  Surgery,  Philadelphia  Polyclinic  ;  Clinical  Pro- 
fessor of  Orthopedic  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
(In  preparation.) 

The  aim  of  the  author  is  to  provide  a  book  of  moderate  size,  containing  com- 
prehensive details  that  will  enable  general  ])ractitioners  to  understand  thoroughly 
the  mechanical  features  of  the  many  forms  of  congenital  and  accpiired  deformities 
of  th(>  bones  and  joints. 

The  mechanical  functions  that  are  impaired  will  be  considered  first  as  to  pre- 
vention as  of  primary  importance,  and  following  this  will  be  described  the  methods 
of  correction  that  have  been  proved  practical  by  the  author.  Operative  procedures 
will  be  considered  from  a  mechanical  as  well  as  a  surgical  standpoint.  Prominence 
will  be  given  to  the  mechanical  recpiirements  for  braces  and  artificial  limbs,  etc., 
with  description  of  the  methods  for  constructing  the  simplest  forms,  whether  made 
of  plaster  of  Paris,  felt.  Leather,  paper,  steel,  or  other  materials,  together  with  the 
methods  of  readjustment  to  suit  the  changes  occurring  during  the  progress  of  the 
case.     A  very  large  number  of  original  illustrations  will  be  used. 


AN    OPERATION    BLANK,  with   Lists   of  Instruments,  etc.   re- 
quired  in   Various  Operations.      Prepared  by  W.  W.  Kf.en,  M.  D., 
LL.l).,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  College, 
Philadelphia.      Price   per    Pad,   containing    Blanks   for   fifty   operations,    50 
cents  net. 
A  convenient  blank  (suitable  for  all  operations),  giving  com])lete  instructions 
regarding  necessary  jjreparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

At  the  back  of  pad  is  a  list  of  instruments  used — viz.  general  instruments,  etc., 
retpiired  for  all  operations  ;  and  special  instruments  for  surgery  of  the  i)rain  and 
spine,  mouth  and  throat,  abdomen,  rectum,  male  and  female  genito-urinary  organs, 
the  bones,  etc. 

The  whole  forming  a  neat  ])ail,  arranged  for  hanging  on  the  wall  of  a  surgeon's 
office  or  in  the  hos[)ital  o[)erating-room. 


i6 


W.  B.  SAUNDERS'  ILLUSTRATED 


1 1  "  i 


DISEASES  OF  WOMEN.  By  Henry  J.  Garrigues,  A.  M.,  M.  D.,  Pro- 
fessor of  Obstetrics  in  the  New  York  Post-(iraduate  Medical  School  and  Hos- 
pital ;  Gynaecologist  to  St.  Mark's  Hospital,  and  to  the  German  Dispensary, 
etc.,  New  York  City.  In  one  very  handsome  octavo  volume  of  about  700 
pages,  illustrated  by  numerous  wood-cuts  and  colored  plates.  Prices :  Cloth, 
JI4.00  net;  Sheep,  ;S!5.oo  net. 


specimen  Illustration, 

A  PRACTICAL  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  knowle  jge 
of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by  the 
author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chapters  on 
Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based  uuon  the 
large  hospital  and  private  jjractice  of  the  author.  The  text  is  elucidated  by  a 
large  number  of  illustrations  and  colored  plates,  many  of  them  being  original,  and 
forming  a  complete  atlas  for  studying  e»i/>ryo/(>x\\'  and  the  anatomy  of  the  female 
goiitalia,  besides  exemi)li tying,  whenever  needed,  morbid  conditions,  instrimients, 
apparatus,  and  operations. 

EXCERPT    OF   CONTENTS. 

I)evelo|)inent  of  the  Female  (Jeiiitals. — Anatomy  of  the  Female  Pelvic  Orp;ans. —  I'liysiology. — 
Puberty. — Menstruation  and  Ovulation. — Copulation. —  Fecundation. — The  Climacteric. — F'tiolofjy 
in  (ieneral. — FAaminations  in  Ciener.al, — Treatment  in  Ciencr;;! — Abnormal  Men.struation  and  Nle- 
trorrluvia. — Leucorrhea. — Diseases  of  the  Vulva. — Diseases  of  the  Perineum. — Diseases  of  the 
X'agina. —  Di.sea.ses  of  the  Uterus. — Diseases  of  the  F"allo|>ian  Tubes. — Diseases  of  the  Ovaries. — 
Diseases  of  the  Pelvis. — Sterility. 

The  reception  accorded  to  this  work  has  been  most  flattering.  In  the 
short  period  Avhich  has  elapsed  since  its  issue,  it  has  been  adopted  and 
recommended  as  a  text-book  by  more  than  60  of  the  Medical  Schools  and 
Universities  of  the  United  States  and  Canada. 

"  One  of  the  be.st  text-l)ooks  for  students  and  nractitioners  which  has  been  [)ubli.shed  in  the 
F'.n^lish  language  ;  it  is  condensed,  clear,  and  coniprehen.sive.  The  i.rofound  learning  and  gre.it 
clinical  experience  of  the  distinguished  author  lind  expre.s.sion  in  this  book  in  a  nio.st  attractive  and 
instructive  form.  Voinig  |)riiclitioners,  to  whom  experienced  consultants  may  not  be  available,  will 
find  in  this  book  invalualile  counsel  and  help." 

TiiAi).  A.  Hkamy,  M.D,  I,I,.I)., 
Professor  of  Clinical  Gynecoloi^w  Midital  Colli'i:;e  of  Ohio  ;   Gyiiicoloffist  to  the  Good 

Samaritan  and  lo  the  Cincinnati  Hospitals. 


CATALOGUE  OF  MEDICAL    WORKS. 


17 


ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTICAL 
DISSECTION,  containing  "Hints  on  Dissection."  By  Charles  H. 
Nancrkde,  M.  L).,  Professor  of  Surgery  and  Clinical  Surgery  in  the  Uni- 
versity of  Michigan,  Ann  Arbor  j  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy  ;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  Post  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price :   Extra  Cloth  or  Oilcloth  for  the  dissection-room,  §2.00  net. 

No  pains  nor  expense  have  been  spared  to  make  this  work  the  most  exhaustive 
yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  published,  either  in 
America  or  in  Europe.  The  colored  plates  are  designed  to  aid  the  student  in 
dissecting  the  muscles,  arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been 
specially  drawn  and  engraved,  and  an  -Xijpendix  added  containing  60  illustrations 
rej)resenting  the  structure  of  the  entire  human  skeleton,  the  whole  being  ba.sed 
on  the  eleventh  edition  of  (iray's  Anatomy. 

A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M.,  M.  I).,  Instructor  of  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania, and  Demonstrator  of  Pathology  in  the  Woman's  Medical  College  of 
Philadelphia.  Specially  intended  for  students  preparing  for  graduation  and 
hospital  examinations.      Post  8vo,  502  pages.     Illustrated.     Price,  $2.50. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rai)idly  during  the 
last  (juarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disjjosal,  to  master  elaborate  treatises  or  to  cull  from  them  that 
knowledge  which  is  absolutely  essential.  From  an  extended  experience  in  teach- 
ing, the  author  has  been  enableil.  by  classification,  to  group  allied  symptoms, 
and  by  the  judicious  elimination  of  theories  and  redundant  explanations  to 
bring  within  a  comparatively  small  compass  a  complete  outline  of  the  practice  of 
medicine. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  The  American  Text-book 
of  Surgery.  By  Nicholas  Senn,  M.  D.,  Ph.  D.,  Professor  of  Surgery  in 
Rush  Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.     Price,  $2.00. 

This,  the  latest  work  of  its  eminent  author,  himself  one  of  the  contributors  to 
the  "  .-Vmerican  Text-book  of  Surgery,"  will  i)rove  of  exceptional  value  to  the 
advanced  student  who  has  adopted  that  work  as  his  text-book.  It  is  not  only  the 
syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an  epitome  or 
supplement  to  the  larger  work. 

A  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
The  American  Text-Book  of  Gynecology.     By  J.  W.  I.om;,  M.  D., 

Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Virginia, 

etc.      Price,  Cloth  (interleaved),  Si. 00  net. 

Hased  u|)(i>i  the  teacliitiR  mul  mitlni<ts  laid  cii.wii  in  ilie  lar^'t-r  work,  tills  will  not  only  lie  luse- 
ful  as  a  supplcnuMUary  voUimc.  bin  to  those  who  do  not  already  possess  the  Textlkiok  it  will  also 
have  an  independent  valne  as  an  aid  to  the  practitioner  in  trynecolot^ical  work,  and  to  the  stndent 
as  a  Riiide  in  the  lecture  room,  as  the  subject  is  presented  lu  a  manner  at  once  systematic,  clear, 
succinct,  and  practical. 


i8 


IV.  B.  SAUNDERS'  ILLUSTRATED 


SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  J5y  Richard  C.  Norkis, 
A.  M.,  M.  D.,  Demonstrator  of  Obstetrics  in  the  University  of  Pennsylvania. 
Third  edition,  thoroughly  revised  and  enlarged.  Crown  8vo.  Price,  Cloth, 
interleaved  for  notes,  $2.00  net. 

"This  work  is  so  far  sui)erior  to  others  on  the  same  .subject  that  we  take 
pleasure  in  calling  attention  briefly  to  its  excellent  features.  It  covers  the  subject 
thoroughly,  and  will  prove  invaluable  both  to  the  student  and  the  practitioner. 
'I'hc  author  has  introduced  a  number  of  valuable  hints  which  would  only  occur 
to  one  who  was  himself  an  experienced  teacher  of  obstetrics.  The  subject-matter 
is  clear,  forcible,  and  modern.  We  are  especially  jjloased  with  the  ])ortion  devoted 
to  the  practical  duties  of  the  accoucheur,  care  of  the  child,  etc.  'I'hc  paragraphs 
on  antiseptics  are  admirable  ;  there  is  no  doubtful  tone  in  the  directions  given. 
No  details  are  regarded  as  unimportant ;  no  minor  matters  omittetl.  W  c  \enture 
to  say  that  even  the  old  practitioner  will  find  uselul  hints  in  this  direction  which 
he  cannot  afford  to  despise." — Alciiical  Record. 

OUTLINES  OF  OBSTETRICS:  A  Syllabus  of  Lectures  Delivered 
at  Long  Island  College  Hospital.  By  Ch.^ri.i.s  Jkwktt,  A.  M.,  M.  ]),, 
Prolessor  of  Obstetrics  and  Pediatrics  in  the  College,  and  Obstetrician  to  the 
Hospital.  Edited  by  H.ar(ili)  F.  Jkwett,  M.  D.  Post  8vo,  264  pages. 
Price,  $2.00. 

This  book  treats  only  of  the  general  facts  and  principles  of  obstetrics :  these 
are  stated  in  concise  terms  and  in  a  systematic  and  natural  order  of  seciuence, 
theoretical  discussion  being  as  far  as  possible  avoided  ;  the  subject  is  thus  i)re- 
sented  in  a  form  most  easily  grasped  and  remembered  by  the  student.  Si)ecial 
attention  has  been  devoted  to  practical  (luestions  of  diagnosis  and  treatment,  and 
in  general  {particular  jjrominence  is  given  to  facts  whicli  tiie  student  most  needs  to 
know.  The  condensed  form  of  statement  and  the  orderly  arrangement  of  topics 
adajjt  it  to  the  wants  of  the  busy  practitioner  as  a  means  of  refreshing  his  know- 
ledge of  the  subject  and  as  a  handy  manual  for  daily  reference. 

NOTES  ON  THE  NEWER  REMEDIES:  their  Therapeutic  Appli- 
cations and  Modes  of  Administration.  By  David  Cerna,  M.D.,  Ph.D., 
Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in  the  Lhiiver- 
sity  of  Pennsylvania.     Post  8vo,  253  pages.      Price,  $1.25. 


:.  .^  J 


SECOND    EDITION,   RE-WRITTEN    AND    GREATLY    ENLARGED. 

The  work  takes  up  in  atphal)etical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  ai)plications,  administration,  aiKi  chem- 
ical formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics  now 
in  existence. 

Chemists  are  so  multiplying  compounds,  that,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  l)e  carried  tar  enough  to  determine  the  prac- 
tical imi)ortance  of  the  new  agents. 

"  K.spocially  valuable  becau.sc  of  its  conipletoncs.s,  it.s  accuracy,  it.s  systematic  consideration  of 
the  properties  and  therajiy  of  many  remedies  of  which  doctors  generally  know  l)ut  little,  e.\])ressed 
in  a  brief  yet  terse  manner." — Chicago  Clinical  Revinu. 


CA  TALOGUE  OF  MEDICAL    WORKS. 


»9 


LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  tiie  Philadelphia  College 
of  Pharmacy.     With  over  75  plates.     Price,   Cloth,  $2.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  tho.se  used  in  medicine.  Illustrations 
have  freely  been  used  to  elucidate  the  te.xt,  and  a  comjjlete  inde.x  to  facilitate  refer- 
ence has  been  added. 

The  folding  charts  which  supplement  the  subjects  will  be  found  useful  in  con- 
nection with  the  study  of  the  text. 


Trailing  Arbutus  (Epigea  repens). 
Sfccimen  Illustration. 

SAUNDERS'  POCKET  MEDICAL  LEXICON;  or,  Dictionary  of 
Terms  and  Words  used  in  Medicine  and  Surgery.  By  John  M. 
KE.vriNG,  M.  D.,  Editor  of  "Cyclopaedia  of  Diseases  of  Children,"  etc.; 
Author  of  the  "New  Pronouncing  Dictionary  of  Medicine,"  and  Henry 
Hamilton,  Author  of  "A  New  Translation  of  Virgil's  .Kneid  into  English 
Verse;"  Co-Author  of  a  "New  Pronouncing  Dictionary  of  Medicine." 
A  new  and  revised  edition.  32mo,  2S2  ])ages.  Prices:  Cloth,  75  cents; 
Leather  Tucks,  ^^i.oo. 

This  new  and  comprehensive  work  of  rcfercnie  is  the  outcome  of  a  demand  for 
a  more  modern  hand-book  of  its  class  than  those  at  present  on  the  market,  which, 
dating  as  they  do  from  1X55  to  i<S,S4,  arc  of  but  trifling  use  to  the  student  by  their 
not  containing  the  hundreds  of  new  words  now  used  in  current  literature,  espe- 
cially those  relating  to  lOlectricity  and  Bacteriology. 

"Remarkably  accurate  in  tenninology,  accentualiou,  ami  delinition."— /o/r;;/^/  of  Aineriatn 
Medical  Asscnittioii. 

"  Uriof,  yet  complete  ....  it  contains  the  very  latest  nomenclature  in  even  the  newest  depart- 
ments of  medicine."— .)/c(//Wj/  Keconi. 


MO 


W.  B.  SAUNDERS'  ILLUSTRATED 


SAUNDERS*  POCKET  MEDICAL  FORMULARY.  Hv  William 
M.  PowKLL,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1750  Formulas,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  convenient 
pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves  for  additions; 
with  an  Appendix  containing  Fosological  Table,  FormuUt  and  Doses  for 
Hypodermic  Medication,  Poisons  and  their  Antidotes,  Diameters  of  the 
Female  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet  List  for  Various  Dis- 
eases, Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia 
from  Drowning,  Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive 
Fevers,  Weights  and  Measures,  etc.  Third  edition,  revised  and  greatly 
enlarged.  Handsomely  bound  in  morocco,  with  side  index,  wallet,  and  flap. 
Price,  $1.75  net. 

"  This  liule  l)ook,  tliat  can  be  convenitMitly  carried  in  the  ])ocket,  contains  an  immense  amount 
of  material.  It  is  very  useful,  and  as  the  name  of  tlie  autiior  of  each  jirescription  is  given  is 
unusually  reliable." — A'aii  York    lejical  Rnord. 

MANUAL  OF  MATERIA  MEDICA  AND  THERAPEUTICS.     By 

.\.  A.  Stevens,  A.  M.,  M.  D.,  Instructor  of  i'hysical  Diagnosis  in  the  Uni- 
versity of  Pennsylvania,  and  Demonstrator  of  Pathology  in  the  Woman's 
Medical  College  of  Philadelphia.     435   pages.      Price,  CMoth,  ;f!2.25. 

This  wholly  new  volume,  which  is  based  on  the  1.S90  edition  of  the  Pharma- 
copa'ia,  comprehends  the  following  sections:  Physiological  Action  of  Drugs; 
Drugs;  Remedial  Measures  other  than  Drugs:  Ap|)lied  Therapeutics;  Incom- 
patibility in  Prescriptions;  'i'able  of  Doses;  Index  of  Drugs;  and  Index  of  Dis- 
eases ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 

HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  John  M. 
Ke.vi'ini;,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of  Phila- 
delphia ;  Vice-President  of  the  American  P;ediatric  Society ;  P^x- President 
of  the  Association  of  Life  Insurance  Medical  Directors.  Royal  8vo,  211 
pages,  with  two  large  }>hototype  illustrations,  and  a  plate  prepared  by  Dr. 
McClellan  from  special  dissections ;  also,  numerous  cuts  to  elucidate  the  text. 
Price,  in  Cloth,  $2.00  net. 

"  This  is  bv  far  the  most  useful  book  which  has  yet  ajjpeared  on  insurance  examination,  a  sub- 
ject of  growing  interest  and  importance.  Not  the  lea.st  valuable  portion  of  the  volume  is  Part  II., 
which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four  representative 
companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected  by  the  directors  of 
the  companies,  tht-v  Ibrm  the  latest  instructions  obtainable.  If  for  these  alone  the  book  should  lie 
at  the  right  hand  of  every  physician  interested  in  this  special  branch  of  medical  science." — The 
Medical  Neivs,  Philadelphia. 


TEMPERATURE    CHART.      Prepared   by    I).    I".   L.mne,   M.  D.      Size 

8  ■  13^2  inches:.     Price,  jjer  pad  of  25  charts,  50  cents. 

A  convenienlli'  arranged  chart  for  recording  Temperature,  with  columns  for  daily  aniounls  of 
Urinary  and  l-'ecal  Kxcretions,  Food,  Remarks,  etc.  On  the  back  of  each  chart  is  given  in  full  the 
method  of  Brand  in  the  treatment  of  Typhoid  Fever. 


SAUNDERS'  QUESTION  COMPENDS. 

Arranged  in  Question  and  Answer  Form. 


THE  LATEST,  CHEAPEST,  AND  BEST  ILLUSTRATED  SERIES 
OP  COMPENDS  EVER  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature 


WITH 


Students  and  Practitioners  in  every  City  of  the  United  States 

and  Canada. 


THE   REASON   ^VHY 

They  are  the  advance  guard  of  "Student's  Helps  "—that  no  HKLP;  they  are  the  leaders  in 
tlieir  special  line,  -veil  and  aitthoyitati-'ely  •i<rittcn  hv  able  men,  'c/w,  as  teac/iers  in  the  large  col- 
leges, know  exactly  what  is  luanteil  !>y  a  stiiilent  pre[>ariug  for  his  examinations.  The  judgment 
exercised  in  the  selection  of  authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen 
from  the  ranks  of  Demonstrators,  ()ui/-masters,  and  Assistants,  most  of  them  have  become  Pro- 
fessors and   Lecturers  in  their  respective   colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250  pages,  profusely 
illustrated,  and  elegantly  printed  in  clear,  readable  tyjie,  on  tine  paper. 

The  entire  .series,  numliering  twenty-three  subjects,  has  been  kept  thoroughly  revised  and 
enlarged  when  necessary,  many  of  tliem  bein;j;  in  their  fourth  and  fifth  editions. 

TO   SUM   UP. 

Although  there  are  numerous  other  Quizi.es,  Manuals.  .Vids,  etc.  in  the  market,  none  of  them 
approach  the  "  Blue  Series  of  (,)uestion  C'ompends ;"  and  the  claim  is  made  for  the  following  points 
of  excellence  : 

1.  Professional  distinction  and  rejiutation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Size  of  type  and  (luality  of  |)aper  and  binding. 


* 


Any  of  these  Compends  will  be  mailed  on  receipt  of  price. 

21 


aa 


ly.  n.  S.l(\V/)/;/?S'  ILLUSTRATED 


%  i 


ESSENTIALS  OF  PHYSIOLOGY.  |{y  M.  A.  Hakk,  M.  I).,  I'rofessor 
of  I'licnipLnitic  s  and  Materia  Mcdiia  in  the 
Jdlcrson  Medical  College  of  Philadelphia; 
Physician  to  St.  Agnes'  Hospital  and  to  the 
Medical  Dispensary  of  the  Children's  Hos- 
pital; Laureate  of  the  Royal  Academy  of 
Medicine  in  lielgiiun,  of  the  Medical  Society 
of  London,  etc.  I'hird  edition,  revised  and 
enlarged  by  the  addition  of  a  series  of  hand- 
some plate  illustrations  taken  from  the  cele- 
brated "  bones  Nervorum  Capitis"  of  .Vr- 
nold.  Crown  .Svo,  2_:;o  i)ages,  numerous 
illustrations.  Price,  Cloth,  Sioo  net ;  inter- 
leaved for  notes,  51.2^^  net. 


S/>t-chnrn  Jlluslyiiti^m. 
;uuh(ii-  lias  lUiiie  lii.s  work  thoroiii'lilv  ami  well. 


Spt\  itih-il  Utu\tratioH. 


"  .Vii  exccf<linj,'ly  u.stful  litllc  CdiiipciKl.      'I 
The  plates  of  tliL-  cranial   iicrvis  from  .Vnuild  an-  .siipcrl)." — Ji'iirnal  of  Amcricun  .^fediiul  Asm 
eta  t  ion. 

2.  ESSENTIALS  OF  SURGERY,  containing  also.  Venereal  l~)iseases,  Surg- 

ical Landmarks,  Minor  and  ()])erative  Surgery,  and  a  Complete  Description, 
together  with  full  Illustrations,  of  the  Lland- 
kerchief  and  Roller  liandage.  l>y  IOdwakk 
M.VKTiN,  A.  M.,  .\L  ]).,  Clinical  Professor  of 
(ienito-Urinary  Diseases,  Instructor  in  Operative 
Surgery,  and  Lecturer  on  Minor  Surgery,  Uni- 
versity of  Pennsylvania;  Surgeon  to  tiie  Howard 
Hosj)ital ;  .Assist.Tnt  Surgeon  to  the  University 
Hospital,   etc.      Fifth  edition.   Crown   .Svo,   334 

pages,  profusely  illustratcil.  Considerably  enlargetl  by  an  Appendix  contain- 
ing full  directions  and  jirescriptions  for  the  preparation  of  the  various  mate- 
rials used  in  Antiseptic  Surgery  ;  also,  several  hundred  recipes  covering  the 
medical  treatment  of  surgical  affections.  I'rice,  Cloth,  $1.00  j  interleaved  for 
notes,  $1.25. 

"Written  to  a.ssist  the  student,  it  will  he  of  undoubted  value  to  the  ))raetitioiier,  containing;  as 
it  does  tile  essence  of  suri^ical  work."  —  A'ii,iA<;/  M(i/i<(!/  <iihf  Sinxi<<i/  Joiiriia/. 

3.  ESSENTIALS  OF  ANATOMY,  including  the  Anatomy  of  the 

Viscera.  Hy  Chaklks  J5.  Xaxckkui;,  AL  D.,  Professor  of  Surgery  and  of 
Clinical  Surgery  in  the  University  of  Michigan,  .Ann  .Arbor  ;  Corresponding 
Member  of  the  Royal  Academy  of  Medicine,  Rome,  Italy  ;  late  Surgeon  to 
the  Jefferson  Medical  College,  etc.  Fifth  edition.  Crown  iSvo,  380  pages, 
icSo  illustrations.  Fnlarged  by  an  .Xjipendix,  containing  over  sixty  illus- 
trations of  the  Osteology  of  the  Human  Body.  The  whole  based  upon  the 
last  (eleventh)  edition  of  Cray's  Anatomy.  Price,  Cloth,  Si. 00  ;  interleaved 
for  notes,  $1.25. 

"  Truly  such  a  book  as  no  student  can  afford  to  be  without." — American  Pvactilioner  and  A'e-vi. 
"  The  questions  have  been  wisely  selected,  and  the  answers  accurately  and  concisely  given." — 
University  Medical  Mai^azinc. 


.  <r 


CArALOGUE  OF  MEDICAL    WORKS. 


n 


4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND 
INORGANIC,  containing  also,  (Jufstions  on  Mcilical  I'liysics,  C'hcniical 
I'liysiology,  Analytic  al  l'ro(  esses,  Irinalysis,  and  Toxicology.  15y  Lawkknh', 
WoMK,  M.  !).,  Demonstrator  of  Chemistry,  Jefferson  Medical  College; 
Visiting  Physician  to  the  derman  Hospital  of  Philadelphia ;  Member  of 
Philadelphia  College  of  Pharmacy,  etc.  Fourth  and  revi.scd  edition,  with  an 
Appendix,  Crown  Svo,  21  j  pages.  i'rice,  Cloth,  ;j!i.oo;  interleaved  for 
notes,  ;>;i.23. 

" 'I'lu!  .scope  of  tliis  work  is  c(;rl:iiiily  i'i|iuil  to  tliat  of  the  IksI  course  of  lectures  on   Medica! 
Chcniistrv."  —  Pluii in,utiiti,ol  J-.id. 


5.  ESSENTIALS   OF   OBSTETRICS.      My 

W.  Iv\STKKi.v  .XsiiToN',  M.  I).,  Profcssor  of  ( lyn- 
aicology  in  the  Medico-Chinirgical  College  of 
Philadeli)hia ;  Obstetrician  to  the  Philadelphia 
Hospi  al.  Third  edition,  thoroughly  revised 
and  enlarged,  Crown  .Svo,  244  pages,  75  illus- 
trations. Price,  Cloth,  ;^i.oo;  interleaved  for 
notes,  j;i.25. 

"  An  excellent  little  volume  conlaiiiinf;  correct  and  practical 
knowledge.  \v\  admirable  compiiid,  and  the  he.st  eonden.salion 
we  have  .seen." — Soiif/nrn  Pi cufi/ioiirr. 

"Of  extreme  value  to  .students,  and  an  excellent  little  hook 
to  freshen  u|)  the  memory  of  the  practitioner." — C/iiajf;;o  Medical 


Tillies. 


Spt'ci)iirn  Illustration. 


ESSENTIALS  OF  PATHOLOGY 
AND  MORBID  ANATOMY,  liy 
C.  !•;.  Akm.vnij  Si'.Mi'i.K,  P).  A.,  M.  H.  Can- 
tab. L.  S.  A.,  M.  R.  C.  P.  Pond.,  Physician 
to  the  Northeastern  Hospital  for  C'hildren, 
Hackney;  I'rofessjr  of  N'ocal  and  Aural 
Physiology,  and  ivxaminer  in  Acoustics  at 
Trinity  College,  l^ondon,  etc.  Crown  Svo, 
174  pages,  illustrated,  (sixth  thousand).  Price, 
Cloth,  ;>i.oo  ;   interleaved  for  notes,  $1.25. 

"A  valuable  little  volume — truly  a  iiinlliim  in  par-v."  —  Cinciiiimti  Medicci/  A'cius. 


S/>t  citiu-n  lihtsti'iitioti. 


7.  ESSENTIALS  OF  MATERIA  MEDICA,  THERAPEUTICS, 
AND  PRESCRIPTION-WRITING.  By  Hknuv  Morris,  M.  I)., 
I-ate  Demonstrator,  Jefferson  Medical  College;  Fellow  College  of  Physicians, 
Philadelphia;  Co-Editor  Biddle's  Materia  Medica;  Visiting  Physician  to  St. 
Joseph's  Hospital,  etc.  Fourth  edition.  Crown  Svo,  250  pages.  Price, 
Cloth,  $1.00;   interleaved  for  notes,  $1.25. 

'■  ^Jne  of  the  best  compends  in  this  -series.  Conci.se,  pithy,  and  clear,  well  suited  to  the  pur- 
pose   .ir  which  it  is  ])repared." — Medial!  and  Surgical  Reporter. 

"  The  subjects  are  treated  in  such  a  unique  and  attractive  manner  that  they  cannot  fail  to 
impress  the  mind  and  instruct  in  a  lasting  manne.." — Buffalo  Medical  and  Surgical  Journal. 


IMAGE  EVALUATION 
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24 


IV.  B.  SAUNDERS'  ILLUSTRATED 


8,  9.  ESSENTIALS  OF  PRACTICE  OF  MEDICINE.  By  Henry 
Morris,  M.  D.,  Author  of  "Essentials  of  Materia  Medica,"  etc.,  with  an 
Appendix  on  the  Clinical  and  Microscopical  Examination  of  Urine,  by  Law- 
rence Wolff,  M.  D.,  Author  of  "Essentials  of  Medical  Chemistry,"  etc. 
Colored  (Vogel)  urine  scale  and  numerous  fine  illustrations.  Third  edi- 
tion, enlarged  by  some  three  hundred  essential  formulae,  selected  from 
the  writings  of  the  most  eminent  authorities  of  the  medical  profession. 
Collected  and  arranged  by  William  M.  Powell,  M.  D.,  author  of 
"Essentials  of  Diseases  of  Children."  Crown  8vo,  460  pages.  Price, 
Cloth,  $2.00. 

"  The  teacliing  is  sound,  the  presentation  graphic,  matter  as  full  as  might  be  desired,  and  the 
style  attractive." — American  Practitioner  and  News. 

"  A  lirst-class  jiractice  of  medicine  iwiled  down,  and  giving  the  real  essentials  in  as  few  words 
as  is  consistent  with  a  tiiorough  understanding  of  the  subject.'' — Medical  Brief. 

10.  ESSENTIALS  OF  GYN^ffiCOL- 
OGY.  By  Edwin  B.  Cragin,  M.  D., 
Attending  Gynecologist,  Roosevelt  Hos- 
pital, Out-Patients'  Department ;  Assistant 
Surgeon,  New  York  Cancer  Hospital,  etc. 
Fourth  edition,  revised.  Crown  8vo,  198 
pages,  62  fine  illustrations.  Price,  Cloth, 
lli.oo  ;  interleaved  for  notes,  $1.25.  V 

"  This  is  a  most  excellent  addition  to  this  scries  of 
question  compends  The  style  is  concise,  and  at  the 
same  time  the  sentences  are  well  rounded.  This  renders 
the  book  far  more  easy  to  read  than  most  compends, 
and  adds  distinctly  to  its  value." — Medical  and  Surg- 
ical Reporter. 

IX.  ESSENTIALS  OF  DISEASES 
OF  THE  SKIN.  By  Henry  W. 
Stelwa(;on,  M.  D.,  Clinical  Lecturer 
on  Dermatology  in  the  Jefferson  Med- 
ical College,  Philadelphia;  Physician 
to  the  Skin  Service  of  the  Northern 
Dispensary ;  Dermatologist  to  Phila- 
delphia Hospital ;  Physician  to  Skin 
Department  of  the  Howard  Hospital ; 
Clinical  Professor  of  Dermatology  in 
the  Woman's  Medical  College,  Phila- 
delphia, etc.  Third  edition.  Crown 
8vo,  270  pages,  86  illustrations,  many 
of  which  are  original.  Price,  Cloth, 
$1.00  net;  interleaved,  $1.25  net. 

"  An  immen.se  amount  of  literature  has  been  gone  over  and  judiciously  cf  ndensed  by  the 
writer's  skill  and  experience." — Medical  Record. 

"  The  book  admirably  answers  the  purpose  for  which  it  is  written.  The  experience  of  the 
reviewer  has  taught  him  that  just  such  a  book  is  needed." — Neru  York  Medical  Journal. 


Specimen  Illustration. 


Specimen  Illu-tration. 


CATALOGUE  OF  MEDIO :L    WORKS. 


25 


12.  ESSENTIALS  OF  MINOR  SURGERY, 
BANDAGING,  AND  VENEREAL  DIS- 
EASES. By  EuwARD  Martin,  A.  M.,  M.  D., 
Author  of  "  Essentials  of  Surgery,"  etc.  Second  edi- 
tion. Crown  8vo,  thoroughly  revised  and  enlarged, 
78  illustrations.  Price,  Cloth,  ^i.oo;  interleaved  for 
notes,  $1.25. 

"Characterized  by  the  same  literary  excellence  that  has  distin- 
guished |)revious  numbers  of  this  series  of  compends." — American 
Practitioner  and  A'nus. 

"  The  best  condensation  of  the  subjects  of  which  it  treats  yet  placed 
before  the  profession." — Medical  News,  Philadelphia. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE, 
TOXICOLOGY,  AND  HYGIENE.     By  C.  E. 

Armand  Semple,  M.  D.,  Author  of  "Essentials  of 
Pathology  and  Morbid  Anatomy."  Crown  8vo,  212 
pages,  130  illustrations.  Price,  Cloth,  ;^i.oo;  inter- 
leaved for  notes,  1(1.25. 

"  The  leading  ponits,  the  essentials  of  this  too  much  neglected  por- 
tion of  medical  science,  are  here  summed  up  systematically  and 
clearly."  —  Southern  Practitioner. 


I\>   ->, 


.S/>('< /■;«£'«  ///us/ration. 


w^^^^SS^ 

i 

If^^^^IB^ 

s 

ll^^g 

m 

Sfecimen  Illustration. 


14. 


ESSENTIALS  OF  REFRACTION  AND  DISEASES  OF  THE 
EYE.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor  of  Disea.ses  of  the 
Eye  in  the  Philadelphia  Polyclinic  and  College  for  (Graduates  in  Medicine ; 
Member  of  the  American  Ophthalmological  Society ;  Fellow  of  the  College 
of  Physicians  of  Philadelphia ;  Fellow  of  the  American  Academy  of  Medi- 
cine, etc. ;  and  ESSENTIALS  OF  DISEASES  OF  THE  NOSE 
AND  THROAT.  By  E.  Baldwin  Gleason,  M.  D.,  Surgeon  in  charge 
of  the  Nose,  Throat,  and  Ear  Department  of  the  Northern  Dispensary  of 
Philadelphia ;  formerly  Assistant  in  the  Nose  and  Throat  Dispensary  of  the 
Hospital  of  the  University  of  Pennsylvania,  and  Assistant  in  the  Nose  and 
Throat  Department  of  the  Union  Dispensary,  etc.  Two  volumes  in  one. 
Second  edition.  Crown  8vo,  294  pages,  124  illustrations.  Price,  Cloth, 
lii.oo;  interleaved  for  notes,  $1.25. 


'%57>wrffTTT# 


specimen  Illustrations. 


"  .\  valuable  Ixiok  to  the  beginner  in  these  branches,  to  the  student,  to  the  busy  practitioner, 
and  as  an  adjunct  to  more  thorough  reading.  The  authors  are  capable  men,  and  as  successful 
teachers  know  what  a  student  most  needs" — JVe^v  York  Medical  Reco  d. 


26 


ty.  B.  SAUNDERS'  ILLUSTRATED 


15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.  By  William 
M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women,  at  Atlantic  City,  N.  J.  ;  late  Physician  to  the  Clinic  for  the  Dis- 
eases of  Children  in  the  Hospital  of  the  University  of  Pennsylvania  and  St. 
Clement's  Hospital ;  Instructor  in  Physical  Diagnosis  in  the  Medical  Depart- 
ment of  the  University  of  Pennsylvania.  Crown  8vo,  216  pages.  Price, 
Cloth,  jjSi.oo;  interleaved  for  notes,  $1.25. 

"  This  work  is  gotten  up  in  the  clear  and  attractive  style  that  characterizes  the  Saunilers' 
Series.  It  contains  in  appropriate  form  the  jjist  of  ail  liie  l)est  worlis  in  the  department  to  wliich 
it  relates." — American  Practitioner  and  Niius. 

"  The  book  contains  a  series  of  ini|)ortant  <|ucstions  and  answers,  which  the  student  will  lind 
of  great  utility  in  the  examination  of  children." — Annals  of  Gynacology. 

16.  ESSENTIALS  OF  EXAMINATION 

OF  URINE.  By  Lawrenck  Wolff, 
M.  D.,  Author  of  "  P>ssentials  of  Medical 
Chemistry,"  etc.  Colored  (Vogel)  urine 
scale  and  numerous  illustrations.  Crown 
8vo.     Price,  Cloth,  75  cents. 

"  A  little  work  of  decided  value." — University  Medical 
Magazine. 

"  A  goo<l  manual  for  students,  well  written,  and  an- 
swers, categorically,  many  questions  beginners  are  sure  to 
ask." — Afedical  Renn-d. 

"  The  questions  have  been  well  chosen,  and  the  an- 
swers are  clear  and  brief.  The  book  cannot  fail  to  Ix;  use- 
ful to  students." — Medical  and  Siiri;ical  Reporter. 

17.  ESSENTIALS  OF  DIAGNOSIS.  By  Solomon 
SoLis-CoHKN,  M.  D.,  Professor  of  Clinical  Medicine  and 
Applied  Therapeutics  in  the  Philadelphia  Polyclinic,  and 
Augustus  A.  Eshner,  M.  D.,  Instructor  in  Clinical  Medi- 
cine, Jefferson  Medical  College,  Philadelphia.  Crown 
8vo,  382  pages,  55  illustrations,  some  of  which  are  col- 
ored, and  a  frontispiece.     Price,  ;?i.5o  net. 

"  A  good  book  for  the  student,  properly  written  from  their  standpoint, 
and  confines  itself  well  to  its  text." — Medical  Record. 

"  Concise  in  the  treatment  of  the  sulyect,  terse  in  expression  of  fact. 
.  .  .  The  work  is  reliable,  and  represents  the  acce|)ted  views  of  clinicians 
of  to-day." — American  Journal  of  Medical  Sciences. 

"  The  subjects  are  explained  in  a  few  well-selected  words,  and  the  required  ground  has  been 
v*v  thoroughly  gone  over." — International  Afedical  Magazine. 


Specimen  Illustration. 


\ 


18.  ESSENTIALS  OF  PRACTICE  OF  PHARMACY.  By  Lucius  E. 
Sayre,  M.  D.,  Professor  of  Pharmacy  and  Materia  Medica  in  the  University 
of  Kansas.  Second  edition,  revised  and  enlarged.  Crown  8vo,  200  pages. 
Price,  Cloth,  $1.00;  interleaved  for  notes,  $1.25. 

"Covers  a  great  deal  of  ground  in  small  compass.  The  matter  is  well  digested  and  arranged. 
The  research  questions  are  a  valuable  feature  of  the  Ixwk." — Albany  Medical  Annals. 

"The  best  quiz  on  Pharmacy  we  have  yet  examined." — National  Drug  Register. 

"  The  veterpn  pharmacist  can  peruse  it  with  pleasure,  because  it  emphasizes  his  grasp  upon 
knowledge  already  gleaned." —  Western  Drug  Record. 


f 


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20.  ESSENTIALS  OF  BACTERIOLOGY: 
A  Concise  and  Systematic  Introduction 
to  the   Study  of  Micro-organisms.      \\y 

M.  V.  Bali,,  M.  D.,  Assistant  in  Microscopy, 
Niagara  University,  Buffalo,  N.  Y.  ;  late  Resi- 
dent Physician,  (ierman  Hospital,  Philadelphia, 
etc.  Second  edition  revised.  Crown  8vo,  200 
pages,  81  illustrations,  some  in  colors,  and  5 
plates.  Price,  Cloth,  $1.00;  interleaved  for 
notes,  $1.25. 

"  The  amount  of  material  conden.se(l  in  this  hule  Ixink  is 
so  great,  and  so  accurate  are  the  furmuKv  and  methods,  tliat  it 
will  l)e  foun<l  useful  as  a  lalxjm'ory  hand-book." — Medical Ne%vs. 

"  Hacteriology  is  the  keynote  of  future  medicine,  and  every  |)hysician  who  expects  succe.ss 
must  familiarize  himself  vith  a  knowledge  of  germ-life — the  agents  of  disea.se.  'I'liis  little  hook, 
with  its  beautiful  illustratinns,  will  give  the  students,  in  brief,  the  results  of  years  of  study  and 
research  unaided." — Pacific  Record  of  Medicine  and  Surgery. 

21.  ESSENTIALS  OF  NERVOUS  DIS- 
EASES AND  INSANITY,  their  Symp- 
toms and  Treatment.  By  John  C.  Shaw, 
M.  D.,  Clinical  Professor  of  Diseases  of  the  Mind 
and  Nervous  System,  Long  Island  College  Hos- 
pital Medical  School ;  Consulting  Neurologist  to 
St.  Catherine's  Hospital  and  to  the  Long  Island 
College  Hospital  ;  formerly  Medical  Superin- 
tendent King's  County  Insane  Asylum.  Second 
edition.  Crown  8vo,  186  pages,  48  original 
illustrations,  mostly  selected  from  the  .Vuthor's 
private  practice.  Price,  Cloth,  $1.00;  inter- 
leaved for  notes,  $1.25. 

"Clearly  and  intelligently  written." — Boston  Medical  and  Siiri^ical  Journal. 

"  A  valuable  addition  to  this  .series  of  eomi)end.s,  and  one  that  cannot  fail  to  be  appreciated  by 
all  physicians  and  students." — Medical  Brief. 

"  Dr.  Shaw's  Primer  is  excellent.  The  engravings  are  well  executed  and  very  interesting." — 
Times  and  Register. 

22.  ESSENTIALS  OF  PHYSICS.  By  Fred.  J. 
Brockwav,  M.  D.,  Assistant  Demonstrator  of  Anat- 
omy in  the  College  of  Physicians  and  Surgeons,  New 
York.  Crown  8vo,  320  pages,  155  fine  illustrations. 
Price,  Cloth,  $1.00  net ;  interleaved  for  notes,  $1.25 
net. 

"The  publi.sher  has  again  shown  himself  as  fortunate  in  his  edi- 
tor as  he  ever  has  l)een  in  the  attractive  .style  and  make-up  of  bis 
compends." — American  Practitioner  and  Xe^vs. 

"  Contains  all  that  one  need  know  of  the  subject,  is  well  written, 
and  is  copiously  illustrated." — Medical  Record. 

"  The  author  has  dealt  with  the  subject  in  a  manner  that  will  make  the  theme  not  only  com- 
paratively easy,  but  also  of  interest." — Medical  News. 


V-  •" 


Sf'iJntin  Illustration. 


Specimen  Ittuslralhn. 


— »KIif^T 


28 


CATALOGUE  OF  MEDICAL    WORKS. 


i 


23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.  By  D.  D.  Stew- 
art, M.  D.,  Demonstrator  of  Diseases  of  the  Nervous  System,  and  Chief  of 
the  Neurological  Clinic  in  the  Jefferson  Medical  College ;  Physician  to  St. 
Mary's  Hospital,  and  to  St.  Christopher's  Hospital  for  Children,  etc.,  and 
E.  S.  Lawrv^-nce,  ]V^D.,  Chief  of  the  Electrical  Clinic,  and  Assistant 
Demonstrator  of  Diseases  of  the  Nervous  System  in  the  Jefferson  Medical 
'••'^College,  etc.  Crown  8vo,  148  pages,  65  illustrations.  Price,  Cloth,  $1.00; 
interleaved  for  notes,  $1.25.. 

•|  Clearly  written,  and  affords  a  safe  guide  to  the  beginner  in  this  subject."— J/f</;Va/  and 
Surgical  Journal . 

"  The  subject  is  presented  in  a  lucid  and  jileasing  manner." — Medical  Record. 

"  A  little  work  on  an  imiiortant  subject,  which  will  prove  of  great  value  to  medical  students 
and  trained  nurses  who  wish  to  study  the  scientific  as  well  as  the  practical  points  of  electricity.'-  - 
The  Hospital,  London,  England. 

"  The  selection  and  arrangement  of  material  are  done  in  a  skilful  manner.  It  gives,  in  a 
condensed  form,  the  princiijles  and  science  of  electricity  and  their  application  in  the  practice  of 
medicine." — Annals  of  Surgery. 


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specimen  iltustialion. 


24.  ESSENTIALS  OF  DISEASES  OF 
THE  EAR.  By  E.  B.  Gleason,  S.  B., 
M.  D.,  Clinical  Professor  of  Otology,  Med- 
ico-Chirurgical  College,  Philadelphia;  Sur- 
geon in  Charge  of  the  Nose,  Throat,  and 
Ear  Department  of  the  Northern  Dispen- 
sary of  Philadelphia  ;  formerly  Assistant  in 
the  No.se  and  Throat  Dispensary  of  the 
Hospital  of  the  University  of  Pennsylvania, 
and  Assistant  in  the  Nose  and  Throat  De- 
partment of  the  Union  Dispensary.  89 
illustrations.  Price,  Cloth,  $1.00;  inter- 
leaved for  notes,  ^1.25. 

This  latest  addition  to  the  Saunders  Compend 
Series  accurately  represents  the  modern  aspect  of 

otological  science.     While  small  in  compass,  it  is  logically  and  capably  written ;  it 
comprises  upward  of  150  pages,  with  89  illustrations,  mostly  from  original  sources. 

NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing  Treat- 
ment, containing  Descriptions  of  the  Principal  Medical  and  Nursing  Terms 
and  Abbreviations ;  of  the  Instruments,  Drugs,  Disea.ses,  Accidents,  'I'reat- 
ments.  Physiological  Names,  Operations,  Foods,  Appliances,  etc.  encountered 
in  the  ward  or  in  the  sick-room.  Compiled  for  the  use  of  nurses.  B^ 
HoNNOR  Morten,  Author  of  "How  to  Become  a  Nurse,"  "Sketches  ot 
Hospitiii  Life,"  etc.     i6mo,  140  pages.     Price,  Cloth,  $1.00. 

This  lit'ile  volume  is  intended  merely  as  a  small  reference-book  which  can  be 
consulted  ut  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation  to  the 
nurse  to  en;;ble  her  to  comprehend  a  case  until  she  has  leisure  to  look  up  larger 
and  fuller  works  on  the  subject. 


By  D.  D.  Stew- 
em,  and  Chief  of 

Physician  to  St. 
"hildren,  etc.,  and 
ic,  and  Assistant 
Jefferson  Medical 
ce,  Cloth,  iiSi.oo; 

)ject." — Medical  and 

H-ord. 

to  medical  students 
ints  of  electricity."-  - 

nner.     It  gives,  in  a 
)n  in  the  practice  of 


—  R 


'*■.. 


illustialion. 


ipably  written  ;  it 
original  sources. 


lursing  Treat- 

d  Nursing  Terms 
Occidents,  Treat- 
etc.  encountered 
of  nurses.  B\l 
"  "Sketches  ot 


Dk  which  can  be 
planation  to  the 
0  look  up  larger 


;>^ 


